J Physiol 600.

5 (2022) pp 1013–1026 1013

TOPICAL REVIEW

Low-volume high-intensity interval training for

cardiometabolic health
Angelo Sabag1 , Jonathan P. Little2 and Nathan A. Johnson3
1
NICM Health Research Institute, Western Sydney University, Westmead, Australia
2
School of Health and Exercise Sciences, University of British Columbia, Kelowna, British Columbia, Canada
3
Faculty of Medicine and Health, The University of Sydney, Sydney, Australia

Edited by: Ian Forsythe & Scott Powers

The Journal of Physiology

Abstract High-intensity interval training (HIIT) is characterised by short bouts of high-intensity

submaximal exercise interspersed with rest periods. Low-volume HIIT, typically involving less
than 15 min of high-intensity exercise per session, is being increasingly investigated in healthy
and clinical populations due to its time-efficient nature and purported health benefits. The
findings from recent trials suggest that low-volume HIIT can induce similar, and at times greater,
improvements in cardiorespiratory fitness, glucose control, blood pressure, and cardiac function

Angelo Sabag is an Accredited Exercise Physiologist and Postdoctoral Research Fellow at Western
Sydney University. In 2019, Angelo completed his PhD under the supervision of Associate Professor
Nathan Johnson, where he explored the efficacy of novel exercise therapies, such as low-volume high
intensity interval training, for the management of cardiometabolic health in adults with type 2 diabetes.
Nathan Johnson is an Associate Professor in Exercise Physiology at the University of Sydney. His research
focuses on the interaction between physical activity and fat metabolism in health and disease and aims
to find practical solutions and innovative approaches, particularly exercise, for managing dangerous body
fats and cardiometabolic health without weight loss.

© 2021 The Authors. The Journal of Physiology © 2021 The Physiological Society DOI: 10.1113/JP281210
1014 A. Sabag and others J Physiol 600.5

when compared to more traditional forms of aerobic exercise training including high-volume
HIIT and moderate intensity continuous training, despite requiring less time commitment
and lower energy expenditure. Although further studies are required to elucidate the precise
mechanisms of action, metabolic improvements appear to be driven, in part, by enhanced
mitochondrial function and insulin sensitivity, whereas certain cardiovascular improvements are
linked to increased left ventricular function as well as greater central and peripheral arterial
compliance. Beyond the purported health benefits, low-volume HIIT appears to be safe and
well-tolerated in adults, with high rates of reported exercise adherence and low adverse effects.
(Received 5 January 2021; accepted after revision 16 March 2021; first published online 24 March 2021)
[Correction made on 1 June 2021, after first online publication: co-author’s name corrected from ‘Johnathan P. Little’ to
‘Jonathan P. Little’.]
Corresponding author Angelo Sabag: NICM Health Research Institute, Western Sydney University, Locked Bag 1797,
Penrith, NSW 2751, Australia. Email: a.sabag@westernsydney.edu.au

Abstract figure legend Low-volume high-intensity interval training (HIIT) is safe and effective for improving cardio-
respiratory fitness, cardiac function, blood glucose levels, and blood pressure. Typical low-volume HIIT protocols involve
one four-minute interval or ten one-minute intervals at intensities between 80-100% of maximal oxygen uptake.

Introduction both efficacious and time-efficient, are being increasingly

Physical activity, including structured ‘exercise,’ is
considered a cornerstone therapy for the management
of cardiometabolic health (Pérez-Martínez et al. 2017).
Although the effect of exercise, independent of dietary
change, on weight loss remains equivocal (Shaw et al.
2006; Swift et al. 2014), undertaking regular exercise has
been shown to improve an array of cardiometabolic risk
factors such as excess abdominal adiposity (Sabag et al.
2017), dyslipidemia (Mann et al. 2014), hypertension
(Cornelissen & Smart, 2013), hyperglycemia (Umpierre
et al. 2013), and especially low cardiorespiratory fitness
(Lin et al. 2015). In fact, low cardiorespiratory fitness has
emerged as a key risk factor for obesity-related diseases
such as the metabolic syndrome, type 2 diabetes, and
cardiovascular disease (Wei et al. 1999; LaMonte et al.
2005; Ross et al. 2016). Furthermore, it has been argued
that cardiorespiratory fitness may even be considered
a clinical vital sign, as increases in maximal oxygen
consumption (VO2max ) between 3.5 ml/kg/min to
7 ml/kg/min have been reported to considerably lower
the incidence of adverse cardiovascular events by ∼10%
to 30% (Ross et al. 2016).
Despite the beneficial effect of exercise on cardio-
metabolic health being well-known in the scientific
community and amongst the general public, exercise
adoption and adherence continues to be a challenge for
many people. In fact, over 35% of adults from high-income
countries are considered physically inactive (i.e., not
meeting the recommended physical activity guidelines)
(Guthold et al. 2018). While individual perceived benefits
and barriers to exercise serve as strong predictors of
exercise-adoption (Chao et al. 2000), ‘lack of time’ is an
often-cited perceived barrier to exercise adoption (Booth
et al. 1997). As such, alternate exercise therapies, which are
investigated.
High-intensity interval training
High-intensity interval training (HIIT) is characterised by
bouts of high-intensity exercise interspersed with active
or passive rest periods. Recent findings suggest that when
compared to more traditional forms of aerobic exercise,
such as moderate intensity continuous training (MICT),
HIIT has been shown to elicit similar and at times greater
improvements in outcomes such as cardiorespiratory
fitness despite often requiring less time commitment and
lower energy expenditure (Sultana et al. 2019). In light
of findings such as these, it is unsurprising that the
popularity of HIIT has increased amongst the general
public (Thompson, 2019) and in the scientific community.
In fact, there appears to be an ever-growing body of
literature surrounding the effects of HIIT on various
indices of health, including in clinical populations (Taylor
et al. 2019).
Classifications. Although commercial gyms and online
outlets may include various exercise modalities (aerobic
exercise, resistance training, or concurrent aerobic and
resistance exercise) under the umbrella of ‘HIIT,’ the
scientific literature typically refers to HIIT as intense
aerobic-based interventions (Weston et al. 2014;
Taylor et al. 2019). Furthermore, HIIT can be further
sub-categorised into low- and high-volume HIIT, as
well as ‘sprint interval training’ (SIT). Both low- and
high-volume HIIT are characterised by high-intensity
efforts, usually between 80 and 100% VO2max or pre-
dicted maximum heart rate (HRmax ), interspersed with
light recovery exercise or no exercise between intervals

© 2021 The Authors. The Journal of Physiology © 2021 The Physiological Society
J Physiol 600.5 Low-volume HIIT for cardiometabolic health
Table 1. Classification of common HIIT variations
Intensity
Low-volume HIIT 80% to 100% of VO2max or HRmax
High-Volume HIIT 80% to 100% of VO2max or HRmax ∗
SIT > 100% maximal work rate/ VO2max ∗ , ‘all out’
Table informed by Gibala et al (Gibala et al. 2014), Sultana et al (Sultana et al. 2019) and Taylor et al (Taylor et al. 2019). HIIT,
high-intensity interval training; SIT, sprint interval training; VO2max , maximal oxygen uptake; HRmax , maximal heart rate; ∗ , or
equivalent.
(Weston et al. 2014). It is becoming increasingly accepted
that low-volume HIIT involves interventions in which
the total time spent in active intervals (i.e. not including
rest periods) is less than 15 min, whereas high-volume
HIIT requires total time spent in active intervals to be
greater than 15 min (Taylor et al. 2019). SIT interventions
are characterised by ‘all-out’ or supramaximal (> 100%
maximal work rate or VO2max ) efforts lasting between
∼8–30s, which require large non-oxidative energy
contributions, interspersed with light recovery exercise
or no exercise between intervals. Although low-volume
HIIT and SIT share some features, differentiating these
two interventions comes down to the intensity - with
low-volume HIIT being performed below, and SIT
being performed above, the work-rate associated with
maximal aerobic capacity. As a consequence of the
higher intensity, SIT bouts are typically shorter because
it becomes increasingly difficult to sustain supramaximal
intervals for longer than ∼30s. These interval training
classifications have been summarised in Table 1 using
definitions reported elsewhere (Gibala et al. 2014; Sultana
et al. 2019; Taylor et al. 2019).
While low-volume HIIT is being researched intensively,
it is unclear whether this form of exercise training is
superior, comparable, or inferior to more traditional
forms of exercise training such as MICT for managing
cardiometabolic health. Consequently, this review aims
to critically evaluate the available evidence, including
mechanistic and randomised studies, to determine the
efficacy of low-volume HIIT for improving cardio-
metabolic health.
Efficacy of low-volume HIIT for cardiometabolic
health
Randomised trials. One of the earliest trials to investigate
the efficacy of low-volume HIIT on cardiometabolic
health was undertaken by Tjønna and colleagues, in which
participants, who were overweight but otherwise healthy,
were randomised to either high-volume HIIT (4 × 4-min
© 2021 The Authors. The Journal of Physiology © 2021 The Physiological Society
1015
Cumulative
Interval Interval
Repetitions Duration Duration∗ Work: Rest
∗ 1 to 10 60–240s < 15 min 1:1 to 1:2
≥4 60–240s ≥ 15 min 1:1 to 1:2
≥4 8–30s < 10 min 1:1 to 1:9
at 90% HRmax ) or low-volume HIIT (1 × 4-min at
90% HRmax ) three times per week for 10 weeks 2013.
The findings showed that both the high-volume and
low-volume interventions improved cardiorespiratory
fitness, blood pressure, and fasting blood glucose levels
despite the 1 × 4-min intervention requiring less than
half the time commitment of the 4 × 4-min intervention,
with both interventions achieving only a small amount of
weight loss (mean −1.8 kg and −2.1 kg for 1 × 4-min
HIIT and 4 × 4-min HIIT, respectively). A recent study by
Poon and colleagues involving adult men with overweight
and obesity showed that low-volume HIIT (10 × 1-min
at 80–90% HRmax ) led to similar improvements in cardio-
respiratory fitness when compared to higher volume
MICT (Poon et al. 2020), however, neither intervention
significantly improved blood pressure, blood lipid levels,
or glucose control. Despite their comparable effects, only
the MICT intervention led to statistically significant body
weight loss (−0.8 kg and −1.7 kg for low-volume HIIT
and MICT, respectively).
Following the early success of low-volume HIIT in
non-clinical populations, multiple studies have recently
assessed the suitability and efficacy of low-volume HIIT
in higher risk populations, such as those with metabolic
syndrome or type 2 diabetes. A study by Ramos and
colleagues showed low-volume HIIT (1 × 4-min at
85–95% HRpeak ), high-volume HIIT (4 × 4-min at
85–95% HRpeak ), and MICT each reduced the severity
of metabolic syndrome, measured as a reduction in
metabolic syndrome z-score, with comparable degrees
of efficacy between interventions despite only achieving
small body weight loss (−1.4 kg, −1.1 kg and −1 kg
for low-volume HIIT, high-volume HIIT, and MICT,
respectively) (Ramos et al. 2017). The metabolic
syndrome z-score consists of key cardiometabolic
outcomes including fasting blood glucose, high-density
lipoprotein cholesterol, triglycerides, mean arterial
pressure, waist circumference, and body mass index
(BMI). By incorporating metabolic syndrome z-scores,
the authors were able to show the efficacy of low-volume
HIIT, and exercise more broadly, on clinically important
1016 A. Sabag and others
outcomes for individuals with or at risk of metabolic
dysfunction.
Metabolic dysfunction-associated fatty liver disease
(MAFLD) affects nearly 70% of individuals with
type 2 diabetes and is characterised by high levels of
intrahepatic fat, in the absence of significant alcohol
consumption, which negatively affects hepatic insulin
signalling pathways and increase glucose and fatty acid
production (Williams et al. 2011; Loomba et al. 2012). Oh
and colleagues investigated the effects of aerobic exercise
in sedentary men with MAFLD and showed that 12 weeks
of thrice weekly low-volume HIIT (3 × 3-min at 80–85%
VO2max ) led to similar improvements in intrahepatic
fat levels as MICT (−13.7% and −14.3%, respectively)
despite requiring less than half the time commitment, half
the energy expenditure and not eliciting body weight loss
(Oh et al. 2017).
There is also emerging evidence suggesting the efficacy
of low-volume HIIT in individuals with more severe
metabolic abnormalities such as those with type 2
diabetes. A randomised controlled trial by Winding
and colleagues showed that 11 weeks of thrice weekly
low-volume HIIT (10 × 1-min at 95% of peak power
output) led to similar or greater improvements in cardio-
respiratory fitness, body composition, and glucose control
in adults with type 2 diabetes when compared with higher
volume MICT despite requiring ∼45% less training time
and ∼35% less energy expenditure (Winding et al. 2018).
As these improvements occurred with only ∼1 kg of mean
weight loss in both exercise groups, other mechanisms
beyond simple weight loss likely explain these benefits.
The authors reported that improvements in glucose
control following low-volume HIIT were associated
with improved hepatic insulin sensitivity as endogenous
glucose production, measured by tracers during a mixed
meal tolerance test, decreased. Furthermore, the authors
reported that exercise compliance was similar between
groups (91% and 94% for, low-volume HIIT and MICT,
respectively) and that no participants experienced injuries
or hypoglycaemic events, thus further supporting the
efficacy and safety of low-volume HIIT in populations
with more severe metabolic abnormalities such as type
2 diabetes. These findings were in accordance with our
recent study, which showed that 12 weeks of thrice weekly
low-volume HIIT (1 × 4-min at 90%VO2peak ) significantly
improved intrahepatic fat, glucose control (Sabag et al.
2020), and arterial stiffness (Way et al. 2020) in the
absence of body weight loss (−0.6 kg and −0.3 kg for
low-volume HIIT and MICT, respectively), in inactive
adults with obesity and type 2 diabetes. Similar to the
study by Winding and colleagues, our study also reported
no adverse events resulting from low-volume HIIT, and
compliance between the two exercise interventions was
similar (93% and 98% for MICT and HIIT, respectively).
The findings of these and further studies have been
J Physiol 600.5
summarised in Table 2 and the reported benefits of regular
low-volume HIIT on cardiometabolic health are presented
in Figure 1.
Mechanisms of action
As evidenced by multiple randomised trials pre-
viously described, low-volume HIIT appears to be
an effective therapy for the management of cardio-
metabolic health in clinical and non-clinical populations,
including in the absence of clinically significant weight
loss. Notwithstanding the ever-accumulating evidence
regarding its efficacy, the precise mechanism by which
low-volume HIIT improves cardiometabolic health,
despite requiring less time and energy than MICT,
remains elusive.
Metabolic. Muscle insulin resistance, a hallmark feature
of type 2 diabetes, is associated with mitochondrial defects
in which reduced fat oxidation capacity and/or incomplete
β-oxidation result in the accumulation of metabolic
by-products such as ceramides and diacylglycerides
(DAG), which impair insulin receptor signalling through
various mechanisms (Kelley & Mandarino, 2000).
One such way is through the sustained activation of
serine/threonine kinases such as protein kinase C
(PKC) (Morino et al. 2006), which leads to inhibitory
phosphorylation of insulin-receptor substrate 1 (IRS1)
(Sanyal et al. 2001). Phosphorylation of IRS1 inhibits
the kinase activity and activation of phosphoinositide
3-kinase (PI3K) and protein kinase b (Akt) leading to
impaired insulin-stimulated glucose transporter type 4
(GLUT4) translocation and subsequent glucose uptake
(Timmers et al. 2008; Li et al. 2015). As the capacity
to oxidise and utilise fuel is directly related to exercise
performance, it is unsurprising that individuals with type
2 diabetes often suffer from impaired exercise capacity,
which contributes to the diminished reliance on intra-
myocellular triglycerides in favour of earlier shifts to
carbohydrate oxidation at lower intensities relative to
individuals with normal glucose tolerance (Ghanassia
et al. 2006).
Regular exercise has been shown to improve
mitochondrial oxidative capacity and increase
mitochondrial content, which may be mediated
bidirectionally through increases in cardiorespiratory
fitness (van Tienen et al. 2012). This may also be true
for low-volume HIIT, as Hood and colleagues showed
that a total of six sessions of low-volume HIIT (10 × 1
at ∼80–95% HRR) performed over two weeks, increased
muscle oxidative capacity by ∼35% in previously inactive
but otherwise healthy adults (Hood et al. 2011). This
finding was replicated in individuals with more severe
metabolic abnormalities when Little and colleagues
© 2021 The Authors. The Journal of Physiology © 2021 The Physiological Society
J Physiol 600.5 Low-volume HIIT for cardiometabolic health 1017

Table 2. Summary of randomised trials of low-volume HIIT on cardiometabolic health

Study Low-volume HIIT

Study Name population Intervention Comparison Primary Findings

Metabolic
(Tjønna et al. 26 inactive LV-HIIT running (n = 13) HV-HIIT running (n = 13) 3/7 for Comparable
2013). adult males 3/7 for 10 weeks. 10 weeks. improvements in
with Warm up: 10 min at 70% Warm up: 10 min at 70% HRmax . VO2max, blood
overweight. HRmax . Work: 4 × 4-min at 90% HRmax pressure, fasting
Work: 1 × 4-min at 90% (3-min recovery intervals at 70% glucose between
HRmax . HRmax ). interventions. HV-HIIT
Cool down: 5 min Cool down: 5-min (intensity NR). led to greater
(intensity NR). Total exercise time: 40 min. improvements in
Total exercise time: Total energy expenditure: NR. cholesterol and body
19 min. fat than LV-HIIT.
Total energy expenditure:
NR.
(Ramos et al. 65 adults with LV-HIIT cycling or running HV-HIIT cycling or running (n = 22) Comparable
2017) metabolic (n = 21) 3/7 for 3/7 for 16 weeks. improvements in
syndrome. 16 weeks. Warm up: 10 min at 60–70% metabolic syndrome-z
Warm up: 10 min at HRpeak . score between
60–70% HRpeak . Work: 4 × 4-min at 85–95% HRpeak Interventions.
Work: 1 × 4-min at (3-min recovery intervals at Metabolic z-score
85-95% HRpeak . 60–70% HRpeak ). comprised of a
Cool down: 3 min. Cool down: 3 min. combination of blood
Total exercise time: Total exercise time: 38 min. pressure, lipid profile,
17 min. Total energy expenditure: fasting glucose levels,
Total energy expenditure: 1003 ± 360 kcal (per week). waist circumference,
412 ± 121 kcal (per MICT cycling or running (n = 22) and BMI.
week). 5/7 for 16 weeks.
Warm up: NR.
Work: 30 min at 60–70% HRpeak .
Cool down: NR.
Total exercise time: 30 min.
Total energy expenditure:
959 ± 300 kcal (per week).
(Oh et al. 61 sedentary LV-HIIT cycling (n = 20) 3/7 MICT cycling (n = 13) 3/7 for Comparable
2017) men with for 12 weeks. 12 weeks. improvements in
obesity and Warm up: NR. Warm up: NR. intrahepatic fat
MAFLD. Work: 3 × 3-min at Work: 40 min at 60–65% VO2max . between interventions.
80–85% VO2max (2-min Cool down: NR. Only LV-HIIT improved
recovery intervals at Total exercise time: 40 min. hepatic stiffness.
50% VO2max ). Total energy expenditure: 360 kcal Fat mass significantly
Cool down: NR. (per session). decreased in MICT and
Total exercise time: RT (n = 19) 3/7 for 12 weeks. RT. Lean mass
13 min. 7 exercises including: sit-ups, leg increased in LV-HIIT
Total energy expenditure: presses, leg extensions, leg curls, and RT.
180 kcal (per session). chest presses, seated rows, and
pull-downs. No further details
provided.
Total exercise time: NR.
Total energy expenditure: 180 kcal
(per session).
(Continued)

© 2021 The Authors. The Journal of Physiology © 2021 The Physiological Society
1018 A. Sabag and others J Physiol 600.5

Table 2. (Continued)

Study Low-volume HIIT

Study Name population Intervention Comparison Primary Findings

(Winding et al. 29 adults with LV-HIIT running (n = 11) MICT cycling (n = 10) 3/7 for LV-HIIT led to
2018) type 2 3/7 for 11 weeks. 11 weeks. significantly greater
diabetes. Warm up: 5 min at 40% Warm up: 5 min at 40% Wpeak . improvements in
Wpeak . Work: 40 min at 50% VO2max . VO2peak than MICT and
Work: 10 × 1-min at 95% Cool down: NR. CON. Only LV-HIIT led
Wpeak . (1-min recovery Total exercise time: 45 min. reduced blood glucose
at 20% Wpeak ). Total energy expenditure: levels and insulin
Cool down: NR. 312 ± 83 kcal (per session). resistance. Both LV-HIIT
Total exercise time: CON (n = 8) 11 weeks. and MICT reduced
25 min. Details regarding control bodyweight when
Total energy expenditure: intervention NR. compared to CON,
200 ± 38 kcal (per however only LV-HIIT
session). reduced visceral fat.
(Abdelbasset 47 adults with LV-HIIT cycling (n = 16) 3/7 MICT cycling (n = 15) 3/7 for Comparable
et al. 2020) obesity, for 8 weeks. 8 weeks. improvements in
type 2 Warm up: 5 min. Warm up: 5 min. intrahepatic fat and
diabetes, Work: 3 × 4-min at Work: 50 min at 60 −70% HRmax . visceral fat between
and NAFLD. 80–85% VO2max (2-min Cool down: 5 min. interventions.
recovery at 50% Total exercise time: 60 min.
VO2max ). Total energy expenditure: NR.
Cool down: 5 min. CON (n = 16) 8 weeks.
Total exercise time: Usual care.
26 min.
Total energy expenditure:
NR.
(Poon et al. 24 inactive LV-HIIT running (n = 12) MICT running (n = 12) 3/7 for Comparable
2020) adult males 3/7 for 8 weeks. 8 weeks. improvements in
with Warm up: 5 min at 60% Warm up: 5 min at 70% HRmax . VO2max , and body fat
overweight. HRmax . Work: 50 min at 65–70% HRmax . loss between
Work: 10 × 1-min at Cool down: 5 min at 50% HRmax . interventions.
80–90% HRmax (1-min Total exercise time: 60 min. Only MICT led to
recovery at 50% HRmax ). Total energy expenditure: significant reductions
Cool down: 5 min at 50% 553 ± 32 kcal (per session). in body weight, waist
HRmax . circumference, and
Total exercise time: blood glucose levels.
29 min.
Total energy expenditure:
279 ± 21 kcal (per
session).
(Sabag et al. 35 inactive LV-HIIT cycling (n = 12) 3/7 MICT cycling (n = 12) 3/7 for Comparable
2020) † adults with for 12 weeks. 12 weeks. improvements in
obesity and Warm up: 10 min at 50% Warm up: 5 min at 50% VO2peak . VO2max and HbA1c
type 2 VO2peak . Work: 45 min at 60% VO2peak . between LV-HIIT and
diabetes. Work: 1 × 4-min at 90% Cool down: 5 min at 50% VO2peak . MICT. Only LV-HIIT led
VO2peak . Total exercise time: 55 min. to significant
Cool down: 5 min 50% Total energy expenditure: NR. improvements in
VO2peak . CON (n = 12) 0.5/7 for 12 weeks. intrahepatic fat when
Total exercise time: Warm up: 5 min at 50% VO2peak . compared to CON.
19 min. Work: fitball exercise and upper
Total energy expenditure: and lower body stretches.
NR. Cool down: 5 min at 50% VO2peak .
Total exercise time: 25 min.
Total energy expenditure: NR.
(Continued)

© 2021 The Authors. The Journal of Physiology © 2021 The Physiological Society
J Physiol 600.5 Low-volume HIIT for cardiometabolic health 1019

Table 2. (Continued)

Study Low-volume HIIT

Study Name population Intervention Comparison Primary Findings

(Ryan et al. 31 inactive LV-HIIT running/cycling/ MICT running/cycling/ Comparable

2020) adults with rowing/elliptical (n = 16) rowing/elliptical (n = 12) 4/7 for improvements in
obesity. 4/7 for 12 weeks. 12 weeks. VO2max , intrahepatic
Warm up: 3 min at ∼65% Warm up: NR fat, and peripheral
HRmax . Work: 45 min at 70% HRmax . insulin sensitivity
Work: 10 × 1-min at 90% Cool down: NR between interventions.
HRmax (1-min recovery Total exercise time: 45 min.
at 50% HRmax ). Total energy expenditure: 250 kcal
Cool down: 3 min at (per session).
∼65% HRmax .
Total exercise time:
26 min.
Total energy expenditure:
150 kcal (per session).
Cardiovascular
(Matsuo et al. 42 sedentary LV-HIIT cycling (n = 14) 5/7 MICT cycling (n = 14) 5/7 for Comparable
2014) males. for 8 weeks. 8 weeks. improvements in
Warm up: 3 min. Warm up: 2 min. VO2max between
Work: 3 × 3-min at Work: 40 min at 60–65% VO2max . LV-HIIT and SIT. LV-HIIT
80–90% VO2max (2-min Cool down: 3. induced significantly
recovery intervals at Total exercise time: 45 min. greater improvements
50% VO2max ). Total energy expenditure: 360 kcal in VO2max than MICT.
Cool down: 3 min. (per session). Only LV-HIIT and SIT
Total exercise time: SIT cycling (n = 14) 5/7 for 8 weeks. improved stroke
18 min. Warm up: 2 min. volume.
Total energy expenditure: Work: 7 × 30-s at 130% VO2max
180 kcal (per session). (15-s recovery intervals).
Cool down: 3 min.
Total exercise time: 10 min.
Total energy expenditure: 100 kcal
(per session).
(Wilson et al. 16 adults with LV-HIIT (n = 11) 3/7 for CON (n = 5) for 3 months. LV-HIIT significantly
2019) type 2 3 months. Participants were instructed to improved VO2peak .
diabetes. Warm up: NR. maintain their usual lifestyle for LV-HIIT improved left
First month work: the duration of the intervention ventricular stroke
10 × 1-min at 90% period. volume response to
HRpeak (1-min rest exercise and cardiac
periods). reserve.
Second month work:
5 × 2-min at 90% HRpeak
(2-min rest periods).
Third month work:
4 × 3-min at 90% HRpeak
(2-min moderate
intensity recovery
intervals).
Cool down: NR.
Total exercise time:
20 min.
Total energy expenditure:
NR.
(Continued)

© 2021 The Authors. The Journal of Physiology © 2021 The Physiological Society
1020 A. Sabag and others J Physiol 600.5

Table 2. (Continued)

Study Low-volume HIIT

Study Name population Intervention Comparison Primary Findings

(Way et al. 35 inactive LV-HIIT cycling (n = 12) 3/7 MICT cycling (n = 12) 3/7 for Comparable
2020) † adults with for 12 weeks. 12 weeks. improvements in
obesity and Warm up: 10 min at 50% Warm up: 5 min at 50% VO2peak . VO2peak , central
type 2 VO2peak . Work: 45 min at 60% VO2peak . arterial stiffness, and
diabetes. Work: 1 × 4-min at 90% Cool down: 5 min at 50% VO2peak . systolic blood pressure
VO2peak . Total exercise time: 55 min. between LV-HIIT and
Cool down: 5 min at 50% Total energy expenditure: NR. MICT.
VO2peak . CON (n = 12) 0.5/7 for 12 weeks.
Total exercise time: Warm up: 5 min at 50% VO2peak .
19 min. Work: fitball exercise and upper
Total energy expenditure: and lower body stretches.
NR. Cool down: 5 min at 50% VO2peak .
Total exercise time: 25 min.
Total energy expenditure: NR.
LV-HIIT, low-volume high-intensity interval training; HV-HIIT, high-volume high-intensity interval training; SIT, sprint interval training;
MICT, moderate intensity continuous training; CON, control; VO2max , maximal oxygen uptake; VO2peak , peak oxygen uptake; HRmax ,
maximal heart rate; HRpeak ; peak heart rate; Wpeak ; peak power output; †, separate outcomes reported from the same trial.

showed that six sessions of low-volume HIIT (10 × 1
at 90% HRmax ) performed over two weeks, led to
increased mitochondrial protein content and elevated
mitochondrial enzyme capacity in adults with type 2
diabetes (Little et al. 2011). As mitochondrial oxidative
capacity is associated with insulin resistance (Fabbri
et al. 2017), this mechanism may partly explain how
regular low-volume HIIT ameliorates insulin resistance
in pre-clinical and clinical populations (Figure 2).
Another pathway by which low-volume HIIT can
improve glucose control is through exercise-induced
increases in GLUT4 content. Little and colleagues showed
that six sessions of low-volume HIIT increased GLUT4
content by an average of ∼369% (Little et al. 2011).
As glycogen and glucose oxidation rates increase with
exercise intensity (van Loon et al. 2001), and because
increases in GLUT4 translocation are regulated by
glycogen content in addition to insulin (Derave et al.
2000), this may partly explain previous reports that
showed a single bout of HIIT led to greater and longer
lasting effects on postprandial glucose metabolism
when compared to a work-matched moderate intensity
exercise protocol in adults with overweight/obesity
(Little et al. 2014). In line with the acute effects of
low-volume HIIT on muscle insulin sensitivity being
largely driven by glycogen depletion/repletion, Ryan
and colleagues recently demonstrated that 12 weeks
of low-volume HIIT (10 × 1-min at ∼90% HRmax )

Figure 1. Reported benefits of regular

low-volume HIIT on cardiometabolic
health

© 2021 The Authors. The Journal of Physiology © 2021 The Physiological Society
J Physiol 600.5 Low-volume HIIT for cardiometabolic health 1021

increased muscle insulin sensitivity measured by
hyperglycaemic-euglycemic clamp at 1 day but not 4 days
following the last bout of training. These improvements
appeared temporally related to enhanced storage and
resynthesis of muscle glycogen, as resting skeletal muscle
glycogen concentration was increased compared to
pre-training at 4 days, but not 1 day, following training
(Ryan et al. 2020). While this study showed similar
improvements following traditional MICT (45 min at
∼70% HRmax ), the low-volume HIIT protocol required
∼40% less time (26 min vs. 45 min) and energy (∼150 kcal
vs. ∼250 kcal). These data indicate that beyond the
traditional understanding of glycogen depletion and
resynthesis being a primary mediator of post-exercise
improvements in insulin sensitivity, it also appears that
the basal capacity of skeletal muscle to increase storage of
glycogen may also contribute to the longer-term insulin
sensitising effects of exercise.
As highlighted earlier, the accumulation of metabolic
by-products such as DAG have been shown to impair
insulin signalling pathways through the sustained
activation of PKC, which leads to ensuing impairments
in the insulin signalling pathway (Szendroedi et al. 2014).
Interestingly, despite the findings from a recent study
by Parker and colleagues, which showed that a single
session of high-volume HIIT (4 × 4-min at 95% HRpeak )
significantly lowered the phosphorylation of PKC, it is
unclear whether these exercise-related improvements are
associated with the reduction of DAG and other metabolic
by-products or through other mechanisms. For example,
Ryan and colleagues showed that although 12 weeks of
low-volume HIIT improved peripheral insulin sensitivity,
skeletal muscle lipid species were not improved (Ryan
et al. 2020). Consequently, further research is required
to elucidate the mechanisms underlying exercise-related
improvements in skeletal muscle insulin sensitivity.
Furthermore, it is important to note that many of the
mechanistic improvements following low-volume HIIT
are not necessarily exclusive to this modality and may
be seen following other aerobic exercise interventions.
However, low-volume HIIT can elicit such improvements
at volumes much lower than traditional exercise inter-
ventions thus highlighting its utility.
Cardiovascular. It is well established that individuals
with metabolic dysfunction have an increased risk of
cardiovascular morbidity and mortality (Isomaa et al.
2001). Although the aetiology of cardiovascular disease
within this context is not completely understood, existing
evidence suggests that metabolic syndrome may be pre-
cursor to cardiovascular disease (Wilson et al. 2005).
While further research is required to determine the
association between metabolic dysfunction severity and
cardiovascular disease progression, one of the most

Figure 2. Schematic model of skeletal muscle insulin resistance and effect of low-volume HIIT on various
pathways
Intracellular processes leading to skeletal muscle insulin resistance. Adapted from Snel et al. (2012), and Watt
and Hoy (2012). Solid lines indicate direct pathways. Broken lines indicate inhibitory effect. Green arrows next to
exercise bikes indicate positive effects of HIIT, with the direction of arrows determining whether specific signalling
pathways are increased or decreased. HIIT improves glucose control and skeletal muscle insulin resistance through
various mechanisms such as by increasing mitochondrial content and function, inhibiting phosphorylation of PKC,
by increasing GLUT4 content, and through increased glycogen resynthesis and storage capacity. HIIT, high-intensity
interval training; FFA, free fatty acid; FATP, fatty acid transport protein; CD36, cluster of differentiation 36; LC-CoA,
long chain co-enzyme A; DAG, diacylglycerol; PKC, protein kinase C; IR, insulin receptor; IRS1, insulin receptor
substrate 1; PI-3K, phosphatidylinositol 3-kinase; AKt, Protein Kinase B; GLUT4, glucose transporter 4.

© 2021 The Authors. The Journal of Physiology © 2021 The Physiological Society
1022 A. Sabag and others
common initial presentations of cardiovascular disease in
type 2 diabetes is heart failure (Dinesh Shah et al. 2015).
In fact, recent findings suggest that type 2 diabetes may
accelerate the progression of left ventricular dysfunction
(LVD), including reduced left ventricular ejection fraction
and abnormal mitral inflow patterns, to heart failure
(Rørth et al. 2018).
Despite exercise intolerance, contributed by both
central and peripheral factors, being common in
individuals with metabolic dysfunction, (Wahl et al. 2018),
aerobic exercise remains a primary therapy for cardio-
metabolic disease management, including in populations
with severe cardiovascular abnormalities such as heart
failure with reduced ejection fraction (Tucker et al. 2019).
While the precise mechanisms by which aerobic exercise,
including HIIT, ameliorates cardiovascular dysfunction
requires further elucidation, a landmark study by Wisløff
and colleagues showed that when compared to MICT,
high-volume HIIT (4 × 4-min intervals at 90–95%
HRpeak ) led to superior improvements in left ventricular
ejection fraction and the reversal of left ventricular
remodelling in participants with heart failure (Wisløff
et al. 2007). The utility of HIIT was further highlighted
in a recent prospective study involving patients with
heart failure and reduced ejection fraction (Hsu et al.
2019). The findings of the study showed that participants
who completed 36 sessions of HIIT (5 × 3-min at 80%
VO2peak ) over two to three months, significantly improved
cardiorespiratory fitness, left ventricular ejection fraction,
and reversed pathological left ventricular remodelling.
Although there are currently limited data, recent findings
indicate that low-volume HIIT may also improve LVD,
including in populations with type 2 diabetes. For
example, Wilson and colleagues reported that thrice
weekly low-volume HIIT (intervention details reported
in Table 2) for three months improved diabetes-related
cardiac impairments, such as systolic and diastolic left
ventricular function (Wilson et al. 2019). While the
current literature indicates that low-volume HIIT may be
an effective therapy in adults with cardiac abnormalities,
further randomised controlled studies are required to
determine how these interventions compare to traditional
aerobic exercise therapies and standard care.
Beyond the preservation and improvement of cardiac
function, ameliorating age-related stiffening of the arteries
is considered an important therapeutic target for cardio-
vascular health (Tanaka, 2019). Central arterial stiffness,
a strong predictor of future cardiovascular events and
all-cause mortality (Vlachopoulos et al. 2010), reflects the
ability of large elastic arteries, such as the aorta, to expand
and recoil with cardiac pulsation and relaxation (Arnett
et al. 1994). Importantly, aerobic exercise has been shown
to improve arterial stiffness in an intensity-dependent
manner (Ashor et al. 2014). Furthermore, this may
also be true for low-volume HIIT as a recent report
J Physiol 600.5
has shown that 12 weeks of thrice weekly low-volume
HIIT (1 × 4 at 90% VO2peak ) significantly improved
central arterial stiffness when compared to control
(−0.3 m/s and +0.8 m/s for low-volume HIIT and
placebo, respectively) in adults with type 2 diabetes
(Way et al. 2020). Furthermore, in this study both
exercise interventions improved systolic blood pressure
(−7 mmHg and −11 mmHg for low-volume HIIT and
MICT, respectively). Collectively, these findings highlight
that low-volume HIIT may be a useful therapy for the
amelioration of type 2 diabetes disease-related central
and peripheral cardiovascular impairments. While these
results are promising, further studies incorporating larger
sample sizes are required to establish whether low-volume
HIIT elicits comparable or superior improvements in
cardiovascular health when compared to MICT.
Feasibility and safety of low-volume HIIT
Feasibility. It has been argued that variations of HIIT,
such as SIT (Table 1), are not suitable for inactive
populations due to poor affective responses, low
self-efficacy, and increased challenges to self-regulation
(Hardcastle et al. 2014). However, there is a relative
lack of data to confirm that HIIT leads to poor affective
responses or that these supposed responses impede
exercise adoption and/or adherence. In fact, a recent
meta-analysis showed that HIIT was superior to MICT
for improving affective and enjoyment responses to
exercise, quantified by the Physical Activity Enjoyment
Scale, and for the Exercise Enjoyment Scale (Oliveira et al.
2018). Such results should be considered carefully as these
tools aim to quantify how enjoyable individuals perceive
exercise to be rather than whether or not the individual
will engage in or sustain physical activity/exercise.
While there are limited long-term studies assessing the
efficacy of low-volume HIIT for long-term exercise
adherence, a recent randomised trial by Jung and
colleagues showed that low-volume HIIT may in fact
be more sustainable than MICT in adults with prediabetes
(Jung et al. 2015). After completing 10 sessions of super-
vised low-volume HIIT (10 × 1-min at 90% HRpeak ) or
MICT, participants were asked to train using low-volume
HIIT or MICT approaches (depending on which group
they were randomised to) three times per week for
four weeks. Those randomised to the low-volume HIIT
group showed greater exercise adherence than those
randomised to MICT (89% vs. 71% prescribed session
attendance for low-volume HIIT and MICT, respectively).
A follow-up trial with a larger sample size and similar
design demonstrated increased free-living activity in
participants randomized to both HIIT and MICT, with
similar improvements in cardiorespiratory fitness in
both groups after one year of independent exercise
© 2021 The Authors. The Journal of Physiology © 2021 The Physiological Society
J Physiol 600.5 Low-volume HIIT for cardiometabolic health
(Jung et al. 2020). These findings are in accordance with
a previous study by Shepherd and colleagues in which
previously inactive but otherwise healthy individuals
participated in thrice weekly group-based high-volume
HIIT for 10 weeks (Shepherd et al. 2015). The participants
randomised to the HIIT group demonstrated significantly
greater exercise adherence than those randomised to
MICT (83% vs. 61% prescribed session attendance for
HIIT and MICT, respectively) (Shepherd et al. 2015).
Together, these reports suggest that HIIT, including
low-volume HIIT, may be adopted and adhered to at
equal or greater rates than MICT, however further studies
are required to fully characterise long-term adherence
to HIIT (> 6 months) and to determine if adherence is
impacted by health status.
Safety. There is strong evidence demonstrating the
efficacy and safety of supervised HIIT in healthy, pre-
clinical, and clinical populations. A recent randomised
controlled trial showed that HIIT was safe and efficacious
for improving cardiovascular health in adult men who
had previously undergone coronary artery bypass grafting
(Ghardashi-Afousi et al. 2018). Furthermore, a systematic
review of 23 studies involving 1117 participants under-
going cardiac rehabilitation, showed that HIIT (including
low- and high-volume HIT, and SIT) was associated
with a low rate of major CV-related events, with only
one event reported in over 17 083 training sessions
(Wewege et al. 2018). Importantly, the vast majority of
studies involving clinical populations employed various
precautionary practises including the use of appropriate
pre-exercise screening tools and exercise monitoring and
supervision where required. Furthermore, basic exercise
prescription principles, such as progressive overload
(McNicol et al. 2009), may further increase the safety and
adherence of low-volume HIIT, as many studies involving
HIIT-based interventions often incorporated some form
of progressive overload, whether it be by increasing the
amount (Jung et al. 2015) or duration of intervals (Sabag
et al. 2020).
Conclusion
There is an ever-growing body of evidence supporting the
utility of low-volume HIIT for improving cardiometabolic
health in both clinical and general populations. The
available evidence from randomised trials indicates that
when compared to higher volume continuous training,
low-volume HIIT leads to similar, and sometimes
greater, cardiometabolic improvements despite lower
energy expenditure and time requirement. Further
studies involving long-term interventions are required to
determine whether low-volume HIIT is sustainable in the
long-term.
© 2021 The Authors. The Journal of Physiology © 2021 The Physiological Society
1023
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Wilson GA, Wilkins GT, Cotter JD, Lamberts RR, Lal S & Additional information
Baldi JC (2019). HIIT improves left ventricular exercise
response in adults with type 2 diabetes. Med Sci Sports Exerc Competing interests
51, 1099–1105.
A.S., J.P.L., and N.A.J. declare that they have no conflict of inter-
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vascular disease and type 2 diabetes mellitus. Circulation
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