the role of physical activity in the prevention and …dynamic aerobic endurance training...

The 1st World Congress on Controversies in

Obesity, Diabetes and Hypertension (CODHy)

Berlin, October 26-29 2005

The role of physical activity in the

prevention and management of

hypertension and obesity

R. Fagard, MD, PhD2,

Hypertension and Cardiovascular Rehabilitation Unit,

University of Leuven K.U.Leuven, Belgium

- Epidemiological studies

- Update on intervention studies:

Physical exercise and blood

pressure

updated meta-analyses of

randomized controlled trials

- Recommendations

Epidemiological studies (1)

• Several large epidemiological studies which allowed for

age and anthropometric characteristics have reported an

inverse relationship between blood pressure and either

habitual physical activity or physical fitness. The

difference in blood pressure between the most and the

least physically active or fit usually amounted to no

more than 5 mmHg

• In addition, longitudinal observational studies found that

physical activity and fitness are inversely related to the

later development of hypertension

Epidemiological studies (2)

• However, it remains difficult to ascribe these

findings to physical activity or fitness per se

because of possibly interfering confounding

factors

• Therefore, well-controlled intervention studies

with random allocation to exercise or control are

mandatory to further explore the relationship

between exercise and blood pressure, and other

cardiovascular risk factors

Physical exercise and blood pressue

according to type of physical exercise

• Dynamic aerobic endurance training:

training programs that involve large muscle groups in dynamic activities, designed specificallyto increase aerobic endurance performance

• ‘Resistance’ training:

training programs that involve strength, weight, static and/or isometric training, designedspecifically to increase muscular strength, powerand/or endurance

Effects of endurance training on blood

pressure, blood pressure regulating

mechanisms and cardiovascular

risk factors

Cornelissen VA, Fagard RH

Hypertension 2005; 46: 667-675

Our aim was to perform a comprehensive meta-

analysis of the literature on the effects of dynamic

aerobic endurance training on:

- resting blood pressure,

- ambulatory blood pressure,

- hemodynamic and neurohumoral mechanisms, and

- cardiovascular risk factors, including

anthropometric characteristics, blood lipids and

insulin sensitivity

(Cornelissen & Fagard, Hypertension 2005)

Dynamic aerobic endurance training

Selection of studies

• Randomized controlled trials, involving dynamic

aerobic endurance exercise training of at least 4

weeks duration

• Parallel group and/or cross-over design

• Adult normotensive and/or hypertensive subjects

• Exclusion of cardiovascular (and other) diseases

• Reporting of (changes of) blood pressure

• Published in peer-reviewed journal


Selected studies

• Number of studies: 72

• Number of subjects:

– randomized: 3936 (median n per study: 32; range: 8-357)

– analysed: 3394 (overall: 88.7%; range : 51-100%)

• Number of study groups: 105

• Demographic characteristics:

– Gender: ~ 57% men

– Age: median of group averages: 46.6 yr; range 21-83 yr


Characteristics of the training program

Values are median and range of study groups

* Excluding warm-up and cool-down periods

There are no significant differences among the three groups according to

baseline blood pressure

mainly walking, jogging,

running, and/or cycling

Mode

65 (30-87)Net intensity (%)

40 (15-63)Time/session* (min)

3 (1-7)Frequency (n/week)

16 (4-52)Total duration (weeks)


General characteristics

-49210875992178N of trained

subjects

Subgroups according to baseline BP

Values are unweighted means

§ Overall P-value for comparison of blood pressure subgroups

* P ≤ 0.05 compared with optimal blood pressure group

<0.0527.8*26.325.426.5BMI (kg/m2)

NS73.971.171.972.4Heart rate (b/min)

NS29.231.531.531.0Peak VO2

(ml/min/kg)

<0.00152.7*47.8*38.347.0Age (yr)

-314628105N of study groups

P§Hypertension(High)NormalOptimalAll

Overall results

Values are means, weighted for the number of trained participants

§ Overall P < 0.001 and among group P = NS for all variables

§§ Baseline body mass index: 26.5 kg/m2

-1.4 (-1.8; -1.0)30.930Body fat (%)

-1.2 (-1.5; -0.9)75.280Weight (kg)§§

-4.8 (-5.7; -3.9)72.764Heart rate (b/min)

+4.0 (+3.5; +4.5)31.181Peak VO2 (ml/min/kg)

Net change (95% CL)§BaselineN



Results: Anthropometric characteristics


* Baseline body mass index: 26.5 kg/m²

§ Overall % change in 14 study groups: -2.3% (-3.3;-1.3); P < 0.001

< 0.05-0.0092 (-0.018;-0.0004)0.908Waist-to-hip ratio§

< 0.001-2.8 (-4.0;-1.7)91.39Waist circumference (cm)§

< 0.001-1.4 (-1.8;-1.0)30.930Body fat (%)

< 0.001-1.2 (-1.5;-0.9)75.280Weight (kg)*

PNet change (95% CL)BaselineN


Overall results on blood pressure (mmHg)


§ Overall P < 0.001 for resting BP, and < 0.01 for ambulatory BP

§§ 24 h BP in 2 trials which only reported 24 h BP

-3.3 (-5.8; -0.9)

-3.5 (-5.2; -1.9)

134.8

85.6

11

11

- systolic

- diastolic

Daytime ambulatory BP§§

-3.0 (-4.0; -2.0)

-2.4 (-3.1; -1.7)

128.1

81.6

104

102

Resting blood pressure

- systolic

- diastolic


(Van Hoof et al, Am J Cardiol 1989; 63 : 945-949)

Overall results on haemodynamics


Overall results on daytime and night-time

blood pressure (mmHg)

Daytime BP

-3.3 (-5.8;-0.9)**134.811-systolic

-3.5 (-5.2;-1.9)**85.611-diastolic

Night-time BP

-0.6 (-2.8; +1.6)116.46-systolic

-1.0 (-2.5; +0.5)71.46-diastolic

Net change

(95% CL)

BaselineN

Values are means, weighted for the number of trained participants; ** P ≤ 0.01

Dynamic aerobic endurance trainingResults on blood pressure in BP subgroups (mm Hg)

-6.9 (-9.1; -4.6)+

-4.9 (-6.5; -3.3)+

145.4

92.3

30

30

Hypertension

- systolic

- diastolic

Values are means, weighted for the number of trained participants§ *P ≤ 0.05; ** P ≤ 0.01; + P ≤0.001

-1.7 (-3.1; -0.3)*

-1.7 (-2.6; -0.7)+

127.2

80.3

46

44

(High)Normal

- systolic

- diastolic

-2.4 (-4.2; -0.6)**

-1.6 (-2.4; -0.7)*

114.3

73.0

28

28

Optimal BP

- systolic

- diastolic


DYNAMIC AEROBIC ENDURANCE TRAINING

Results according to baseline body mass index (25 kg/m²)

Mean weighted net changes (1)

N Lean N Overweight

Peak VO2

(ml/min/kg)

25 + 3.5 (+2.6; + 4.4)

33 + 3.9 (+3.2; +4.6)

Heart rate

(b/min)

20 - 4.9 (-6.6; -3.2)

25 - 4.4 (-5.7; -3.2)

BMI

(kg/m²)

27 - 0.15 (-0.33; + 0.03)

37 - 0.45 (-0.60; -0.31)

Values are weighted means (95% CL)

DYNAMIC AEROBIC ENDURANCE TRAINING

Results according to baseline body mass index (25 kg/m²)

Mean weighted net changes (2)

N Lean N Overweight

Blood pressure (mm Hg)

- systolic

- diastolic

27

27

- 3.3 (-5.1; -1.6)

- 2.5 (-3.5; -1.6)

37

37

- 3.3 (-4.7; -1.9)

- 2.5 (-3.7; -1.2)


DYNAMIC AEROBIC

ENDURANCE TRAINING AND

BLOOD PRESSURE

Mechanisms

Haemodynamic and basic mechanisms of

training-induced changes in blood pressure

Dynamic aerobic endurance trainingMechanisms of the training-induced changes

in blood pressure

• Change in weight/BMI ?

• Sympathetic nervous system?

• Renin-angiotensin-aldosterone system?

• Insulin sensitivity?

• Endothelial function?

• Prostaglandins?

• …

Net change in BP vs net change in BMI

Systolic BP Diastolic BP

Fagard, Med Sci Sports Exerc 1999; 31 : S624-S630


Plasma norepinephrine (PNE) and renin activity (PRA)

< 0.05

< 0.001

P

Values are means, weighted for the number of trained

participants

- 20 (-35; -4.7)10PRA

- 29 (-40; -18)16PNE

Net % change

(95% CL)§

N

(Van Hoof et al, Am J Cardiol 1989; 63 : 945-949)


Insulin sensitivity

-0.15 (-0.20;-0.11)+

-2.73(-3.55;-1.92)+

5.0

89.3

18Glucose (mmol/L)

(mg/dL)


**P ≤ 0.01; + P ≤ 0.001

HOMA-index: [(glucose(mmol/L)*insulin(IU/L))/22.5]

-0.31 (-0.53;-0.094)**2.114HOMA-index

-1.4 (-2.2;-0.53)**11.619Insulin (IU/L)

Net change (95% CL)BaselineN


Blood lipids


= 0.07-9.74 (-21.3;+0.84)12439Triglycerides

(mg/dL)

NS

< 0.05

NS

-1.55 (-5.03;+1.74)

+1.24 (+0.19;+2.28)

-3.02 (-11.6;+5.80)

214

52.6

140

31

38

30

- total

- HDL

- LDL

Cholesterol

(mg/dL)



Conclusions

• Dynamic aerobic endurance training decreases blood

pressure through a reduction of systemic vascular

resistance, in which the sympathetic nervous system and

the renin-angiotensin system appear to be involved, and

favourably affects cardiovascular risk factors

• The training-induced blood pressure reduction is more

pronounced in hypertensives than in non-hypertensives

and is observed in lean and overweight subjects

Effect of resistance exercise on

resting blood pressure

A meta-analysis of randomized

controlled trials

Cornelissen VA, Fagard RH

Journal of Hypertension 2005; 23: 251-259

Resistance training and blood pressure


• Randomized controlled trials, involving strength, weight, static and/or isometric training (‘resistance’ training), designed specifically to increase muscularstrength, power and/or endurance, and lasting at least 4 weeks

• Parallel group and/or cross-over design

• Adult normotensive and/or hypertensive subjects


• Reporting (of changes) of blood pressure



Selected studies


• Number of subjects:

– randomized: 341 (median n per study: 26; range 20-84)

– analysed: 290 (overall: 85%; range: 63-100%)

• Number of study groups: 12 (normotension: 9; hypertension: 3)

• Demographic characteristics

– gender: 61% men

– age: range of group averages: 20-72 yr

Resistance training and blood pressureCharacteristics of the training programs

Values are median and range of study groups, or number of study

groups (N)

conventional (N=8)

circuit (N=3)

static (N=1)

Mode

70 (30-90)Intensity (% of 1 RM)

?Time/session (min)

3 (N=10); 2 (N=2)Frequency (n/week)

14 (6-26)Total duration (weeks)


Overall results

N: number of study groups


§ * P ≤ 0.05; ** P ≤ 0.01

- 0.94 (-1.6; -0.25)**430.16Body fat (%)

+ 0.33 (-2.7; +3.4)NS476.48Weight (kg)

+ 1.0 (-1.7; +3.7)NS870.710Heart rate (b/min)

+ 2.6 (+0.3; +4.8)*624.79Peak VO2

(ml/min/kg)

//5412Age

Net change (95% CL)§NBaselineN


Overall results on blood pressure (mmHg)

< 0.01-4.7 (-8.1; -1.4)80.912Diastolic

N: number of study groups


< 0.01-6.0 (-10.4; -1.6)131.612Systolic

Weighted for the inverse of the variance of ∆ BP

< 0.01-3.5 (-6.1; -0.9)81.112Diastolic

= 0.10-3.2 (-7.1; +0.7)131.012Systolic

Weighted for the number of trained participants



Conclusions

• Moderate intensity ‘resistance’ training

– is able to decrease blood pressure, and

– could become part of the non-pharmacological

intervention strategy to prevent and combat high

blood pressure

• However, additional studies are needed, especially in

the hypertensive population

Recommendations

RECOMMENDATIONS

• Exercise is a cornerstone therapy for the primary prevention, treatment and control of hypertension

• Based upon the current evidence the following exerciseprescription is recommended:

– frequency: on most, preferably all days of the week

– intensity: moderate intensity (40 - <60% of VO2 reserve)

– time: ≥≥≥≥ 30 min of continuous or accumulated physical activityper day

– type: primarily endurance physical activity supplemented byresistance exercise

American College of Sports Medicine Position Stand:

Exercise and Hypertension

Pescatello, Franklin, Fagard, Farquhar, Kelley & Ray

Medicine and Science in Sports and Exercise 2004; 36: 533-553

DYNAMIC AEROBIC

ENDURANCE TRAINING AND

BLOOD PRESSURE

Influence of training intensity

Net change in BP vs training intensity

Metaregression analysis

Fagard, Med Sci Sports Exerc 2001; 33 : S484-S492


Change in BP vs training intensity

Studies comparing different training intensities


Fagard, Med Sci Sports Exerc 2001; 33; S484-S492

DYNAMIC AEROBIC ENDURANCE

TRAINING

VS DIET (CALORIC RESTRICTION)

Fagard RH, Med Sci Sports Exerc 1999; 31: S624-S630

DYNAMIC TRAINING VS DIET


• Comparative trials of

– exercise vs diet, and/or

– exercise + diet vs diet alone

• Random group allocation


• Reporting of (changes of) blood pressure at rest



Selected studies


• Number of comparisons:

exercise vs diet: 11

exercise + diet vs diet: 11

• Number of subjects: 1,087


Baseline data

N Exercise Diet

Age (yr) 11 49.9

(45.9; 53.9)

49.3

(45.2; 53.4)

Peak VO2

(ml/min/kg)

10 31.6

(28.5; 34.8)

31.4

(28.3; 34.5)

BMI

(kg/m²)

11 28.3

(26.9; 29.6)

28.6

(27.1; 30.1)

SBP

(mm Hg)

11 125.6

(120.1; 131.1)

124.5

(118.8; 130.1)

DBP

(mm Hg)

11 81.8

(77.5; 86.1)

80.9

(77.0; 84.8)

Values are weighted means (95 % CL)


Mean weighted changes

N Exercise Diet P

Peak VO2

(ml/min/kg)

10 + 3.4

(+2.3; +4.4)

+ 1.0

(-0.2; +2.1)

< 0.01

BMI

(kg/m²)

11 - 0.42

(-0.67; -0.17)

- 1.58

(-2.18; -0.97)

< 0.01

SBP

(mm Hg)

11 - 3.6

(-5.2; -2.0)

- 5.9

(-7.7; -4.1)

< 0.01

DBP

(mm Hg)

11 - 2.7

(-3.8; -1.7)

- 4.2

(-5.9; -2.4)

< 0.05



Baseline data

N Exercise + diet Diet

Age (yr) 11 48.5

(45.4; 51.6)

48.7

(45.6; 51.8)

Peak VO2

(ml/min/kg)

9 29.7

(25.2; 34.2)

29.1

(24.3; 33.8)

BMI

(kg/m²)

11 28.6

(27.1; 30.1)

28.6

(27.0; 30.2)

SBP

(mm Hg)

11 129.4

(120.1; 138.7)

128.3

(120.1; 136.5)

DBP

(mm Hg)

11 83.1

(77.0; 89.2)

82.1

(76.6; 87.6)



Mean weighted changes

N Exercise + diet Diet P

Peak VO2

(ml/min/kg)

9 + 5.4

(+4.1; +6.6)

+ 0.8

(-0.03; +1.7)

< 0.001

BMI

(kg/m²)

11 - 2.04

(-2.73; -1.35)

- 1.66

(-2.37; -0.95)

< 0.001

SBP

(mm Hg)

11 - 7.1

(-9.9; -4.4)

- 6.8

(-9.8; -3.9)

0.84

DBP

(mm Hg)

11 - 5.5

(-7.5; -3.4)

- 4.2

(-6.0; -2.4)

0.14



Conclusions

- Exercise appears to be less effective than

diet in lowering body weight and blood

pressure

- The reduction of body weight was more

pronounced when diet was combined with

exercise than with diet alone, but there was

no greater reduction in blood pressure with

the combined intervention

EXERCISE AND HYPERTENSION

Recommendations: pharmacological therapy

• When drug therapy is indicated in physically active people it should, ideally– lower blood pressure not only at rest, but also during exertion– not adversely affect exercise capacity– decrease systemic vascular resistance

• Calcium channel blockers and ACE-inhibitors (or AT II receptor blockers) are currently the drugs of choice for the initiation of treatment in the exercising patient

• Diuretics and beta-blockers are not recommended; they may decreaseexercise performance, cause electrolyte disturbances and/or may beon the doping list for some sports

• Calcium channel blockers and ACE-inhibitors (or AT II receptor blockers) can be combined for better blood pressure control

• If a third drug is required, a low-dose thiazide-like diuretic, possiblyin combination with a potassium sparing agent, can be recommended

RecommendationsESC Study Group on Sports Cardiology

- Recommendations for competitive sports participation in

athletes with cardiovascular disease

Pelliccia A, Fagard R, Björnstad HH et al.

European Heart Journal 2005; 26: 1422-1445.

- ESC Study Group on Sports Cardiology Recommendations

for participation in leisure-time physical activities and

competitive sports for patients with hypertension

Fagard RH, Björnstad HH, Borjesson M et al.

European Journal of Cardiovascular Prevention and

Rehabilitation 2005; 12: 326-331.

the role of physical activity in the prevention and …dynamic aerobic endurance training...

Documents