While exercise of all types is beneficial, strength training is probably the most important single exercise modality. It’s also the mode most likely to be neglected by people in their health regimen. For example, Unfortunately, while around 60% of people achieve the minimum recommended amounts of cardiovascular exercise, only 20-30% of people achieve the minimum recommended two resistance training sessions per week.^1-3 Research from Portugal and Australia suggests that a majority of people are not even aware of what the physical activity guidelines are.^{3, 4} In those following exercise regimes, the greatest health benefits are seen in those who include resistance training and especially in those who exercise more than 3 times per week.⁵

Because of the importance of strength training and its health benefits, it has been suggested that the focus for exercise should be on increasing overall metabolic stress from higher intensity forms of exercise (e.g. >70% maximum heart rate or using heavy relative loads) and that progressive resistance training should be the focus for fat loss.⁶

Moderate-intensity aerobic exercise has been shown to effectively reduce body weight (by around 2 kg over 6-12 months) and reduces waist circumference,⁷ however, compared with aerobic exercise alone, resistance + aerobic exercise results in greater reductions in fat mass, LDL cholesterol, and greater increases in lean mass.⁸ In a 2015 meta-analysis by James Clark in the Journal of Diabetes and Metabolic Disorders, diet + exercise had the greatest effect on fat loss but diet + resistance training had a greater effect than diet plus aerobic exercise OR diet + aerobic + resistance exercise. Resistance training also had a greater independent effect than aerobic or aerobic + resistance.⁶ The finding that diet + resistance outperforms diet + resistance + aerobics seems counterintuitive as the greatest benefits to health are from combining strength and aerobic training, however, the effect may be because many studies fail to either observe or recommend adequate, progressive approaches to resistance training and thus, combined interventions may be limiting the volume and efficacy of resistance training. Therefore, a combination is likely to be most beneficial BUT it is imperative that minimum thresholds for resistance/strength training are included in an exercise regime and that it is progressive and consistent.

These results combined suggest that a healthy diet is essential for healthy weight maintenance and body composition, but exercise improves results and that the greatest effects from exercise are seen from resistance training.

Resistance exercise is also known to improve bone health, in particular, bone mineral density and there are associations between strength, muscle mass, and bone density.⁹ Strength training (and exercise that includes impact) improves bone mineral density in peri- and post-menopausal women,¹⁰ and combined aerobic and resistance training improves bone health in people with diabetes.¹¹ It is recommended to use loads of 70-90% of 1-repetition maximum for more than 2 sets per exercise, using 1-3 minutes rest intervals over 2-3 sessions per week to improve lean body mass, bone mineral density, and reduce the risk of osteoporosis.⁹

Combining exercise provides the greatest benefits

While strength training provides the greatest ‘bang for buck’ of all the exercise modalities, combining aerobic and resistance training improves aerobic fitness, overall health, and quality of life more than individual modalities like yoga, cardiovascular training, or strength training alone in healthy people and diverse conditions including HIV/AIDS and kidney disease.^{12, 13}

How to Incorporate Strength Training for Health

The research points towards certain critical factors that help to maximise longer-term results. These include exercise regimens that ¹⁴:

• Are person-centred
• Contain choice and flexibility
• Shift mindset away from seeing people as ‘patients’ who ‘must’ exercise to people who have lived experiences that can meaningfully contribute to exercise programs.
• Establish healthy relationships with people and their whanau and environment
• Highlight the value of engaging in exercise.
• Include resistance and aerobic elements.
• Have a minimum of two sessions per week.
• Are inclusive and informal.

As part of a healthy diet, lifestyle, and exercise strategy, plans should include

• A MINIMUM of 2 resistance training sessions per week
• Resistance training sessions should use loads of 70-90% of 1RM for more than 2 sets per exercise with 1–3-minute (+) rest intervals.
• Note: Additional health benefits are noted with greater than 5 hours of moderate-intensity activity per week.^{9, 15}
• Additionally, at least 2 exercises should be performed that target the entire body, or greater exercise combinations to affect all the major muscle groups and/or movement patterns (i.e., varieties or pushing, pulling, squatting, lunging, and lifting exercises, and possibly bracing, twisting, and anti-rotation)

Caveat: Doing ‘good’ is better than not doing ‘perfect’

Any movement or physical activity is better than nothing. Even moderate exercise like regular walking,¹⁶ stair walking, bodyweight exercise,¹⁷ or abbreviated training regimens like high-intensity interval training, are beneficial to a range of health outcomes.¹⁷ However, the biggest bang-for-buck is likely to come from incorporating progressive strength training into your routine.

Focus on building the habit of strength movement…and the ‘skill’ of strength

If you aren’t already in a regular habit of exercise, it is important to focus on building sustainable habits of strength movement rather than attempting to find or follow the ‘perfect’ exercise regime. Short bouts of exercise initially might help people to develop a habit of health, allowing them to both adhere and increase activity over time.¹⁸ A recent (2020) study published in Preventative Medicine Reports, demonstrated that a lower exercise recommendation led participants to feel that their activity level was more adequate, which in turn predicted greater engagement in physical activity and perceived health. This more adaptive mindset predicted greater self-efficacy and participation in physical activity the following week. The authors concluded. “Rather than inducing complacency, recommendations prescribing a relatively lower (vs. higher) amount of physical activity may be more effective at promoting physical activity and health by inducing adaptive mindsets.”

Ann effective way to build the habit of movement and build strength as a skill is to accumulate exercise by either doing brief workouts daily (rather than traditional, extended weightlifting sessions) or even doing ‘micro workouts’ throughout the day. The research suggests that there isn’t much difference between accumulating exercise (over a day) vs completing a standard session once per day, so long as the same amount of work completed overall is the same. Some studies have even shown improved weight loss and LDL-cholesterol from accumulated training vs once-daily sessions.¹⁹

Summary

• Include at least 2 resistance training sessions per week
• Resistance training could include weight training or bodyweight exercise (including gymnastics, yoga, etc.) so long as the ‘skill of strength’ is built through consistency and the loads applied are progressive
• A ‘minimum effective dose’ regimen is likely to include at least 2 sessions per week (as above) including at least 2 large compound movements conducted for ≥10 total repetitions (i.e., 2 sets of 5 repetitions, 5 sets of 2 repetitions, 3 sets of 4 repetitions etc.)
• Remember that strength is a skill
  • Cardiovascular fitness and metabolic conditioning are quicker and easier to attain
  • The building and maintenance of strength (and muscle mass) conversely takes consistency and practise over a long timeframe

Example abbreviated strength training plans

Bodyweight

Performed 2-5 times per week, for 2-5 sets of up to 25 repetitions (under 6 repetitions if focussed on MED strength and/or if fatigued)

• Bodyweight squat
• Pushup
• Pullup
• Hip thrust or back bridge
• Plank

Home resistance

Performed 3 x per week for 3-5 sets of 3-5 repetitions

• Snatch or Clean variation (if able)
• Squat
• Press
• Row
• Deadlift
• Assistance work if desired

Ultra-abbreviated regimen

Performed 2-5 times per week, 2 sets, ~5 repetitions

• Press
• Deadlift

References

1.         Shakespear-Druery J, De Cocker K, Biddle SJH, Gavilán-Carrera B, Segura-Jiménez V, Bennie J. Assessment of muscle-strengthening exercise in public health surveillance for adults: A systematic review. Preventive Medicine. 2021;148:106566.

2.         Song M, Nam S, Buss J, Lee S-J. Assessing the prevalence of meeting physical activity recommendations among U.S. healthcare workers: Data from the 2015 National Health Interview Survey. Archives of Environmental & Occupational Health. 2020;75(7):422-30.

3.         Berry NM, Nolan R, Dollman J. Associations of awareness of physical activity recommendations for health and self-reported physical activity behaviours among adult South Australians. Journal of Science and Medicine in Sport. 2016;19(10):837-42.

4.         Martins J, Cabral M, Elias C, Nelas R, Sarmento H, Marques A, et al. Physical activity recommendations for health: knowledge and perceptions among college students. Retos: nuevas tendencias en educación física, deporte y recreación. 2019(36):290-6.

5.         Wu N, Bredin SSD, Guan Y, Dickinson K, Kim DD, Chua Z, et al. Cardiovascular Health Benefits of Exercise Training in Persons Living with Type 1 Diabetes: A Systematic Review and Meta-Analysis. Journal of Clinical Medicine. 2019;8(2):253.

6.         Clark JE. Diet, exercise or diet with exercise: comparing the effectiveness of treatment options for weight-loss and changes in fitness for adults (18–65 years old) who are overfat, or obese; systematic review and meta-analysis. Journal of Diabetes & Metabolic Disorders. 2015;14(1):31.

7.         Thorogood A, Mottillo S, Shimony A, Filion KB, Joseph L, Genest J, et al. Isolated Aerobic Exercise and Weight Loss: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. The American Journal of Medicine. 2011;124(8):747-55.

8.         García-Hermoso A, Ramírez-Vélez R, Ramírez-Campillo R, Peterson MD, Martínez-Vizcaíno V. Concurrent aerobic plus resistance exercise versus aerobic exercise alone to improve health outcomes in paediatric obesity: a systematic review and meta-analysis. British Journal of Sports Medicine. 2018;52(3):161.

9.         Pimenta LD, Massini DA, Santos Dd, Vasconcelos CMT, Simionato AR, Gomes LAT, et al. Bone Health, Muscle Strength and Lean Mass: Relationships and exercise recommendations. Revista Brasileira de Medicina do Esporte. 2019;25:245-51.

10.       Sañudo B, de Hoyo M, del Pozo-Cruz J, Carrasco L, del Pozo-Cruz B, Tejero S, et al. A systematic review of the exercise effect on bone health: the importance of assessing mechanical loading in perimenopausal and postmenopausal women. Menopause. 2017;24(10):1208-16.

11.       Viggers R, Al-Mashhadi Z, Fuglsang-Nielsen R, Gregersen S, Starup-Linde J. The Impact of Exercise on Bone Health in Type 2 Diabetes Mellitus—a Systematic Review. Current Osteoporosis Reports. 2020;18(4):357-70.

12.       Neto MG, Saquetto MB, Alves IG, Martinez BP, Vieira JPB, Brites C. Effects of Exercise Interventions on Aerobic Capacity and Health-Related Quality of Life in People Living With Hiv/Aids: Systematic Review and Network Meta-Analysis. Physical Therapy. 2021.

13.       Gomes Neto M, de Lacerda FFR, Lopes AA, Martinez BP, Saquetto MB. Intradialytic exercise training modalities on physical functioning and health-related quality of life in patients undergoing maintenance hemodialysis: systematic review and meta-analysis. Clinical Rehabilitation. 2018;32(9):1189-202.

14.       Middleton R, Moxham L, Parrish D. Diabetes, older people and exercise: recommendations for health promotion programs. Australian Nursing and Midwifery Journal. 2016;23(9):32.

15.       Piercy KL, Troiano RP. Physical Activity Guidelines for Americans From the US Department of Health and Human Services. Circulation: Cardiovascular Quality and Outcomes. 2018;11(11):e005263.

16.       Sydora BC, Turner C, Malley A, Davenport M, Yuksel N, Shandro T, et al. Can walking exercise programs improve health for women in menopause transition and postmenopausal? Findings from a scoping review. Menopause. 2020;27(8):952-63.

17.       Füzéki E, Banzer W. Physical Activity Recommendations for Health and Beyond in Currently Inactive Populations. International Journal of Environmental Research and Public Health. 2018;15(5):1042.

18.       Byrne H, Caulfield B, De Vito G. Self-directed exercise programmes in sedentary middle-aged individuals in good overall health; a systematic review. Preventive Medicine. 2018;114:156-63.

19.       Murphy MH, Lahart I, Carlin A, Murtagh E. The Effects of Continuous Compared to Accumulated Exercise on Health: A Meta-Analytic Review. Sports Medicine. 2019;49(10):1585-607.