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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
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- Epidemiological studies
- Update on intervention studies:
Physical exercise and blood
pressure
updated meta-analyses of
randomized controlled trials
- Recommendations
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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
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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
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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
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Effects of endurance training on blood
pressure, blood pressure regulating
mechanisms and cardiovascular
risk factors
Cornelissen VA, Fagard RH
Hypertension 2005; 46: 667-675
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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)
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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
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Dynamic aerobic endurance training
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
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Dynamic aerobic endurance training
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)
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Dynamic aerobic endurance training
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
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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
Dynamic aerobic endurance training
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Dynamic aerobic endurance training
Results: Anthropometric characteristics
Values are means, weighted for the number of trained participants
* 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
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Dynamic aerobic endurance training
Overall results on blood pressure (mmHg)
Values are means, weighted for the number of trained participants
§ 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
Net change (95% CL)§BaselineN
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(Van Hoof et al, Am J Cardiol 1989; 63 : 945-949)
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Overall results on haemodynamics
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Dynamic aerobic endurance training
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
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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
Net change (95% CL)§BaselineN
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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)
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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)
Values are weighted means (95% CL)
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DYNAMIC AEROBIC
ENDURANCE TRAINING AND
BLOOD PRESSURE
Mechanisms
Haemodynamic and basic mechanisms of
training-induced changes in blood pressure
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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?
• …
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Net change in BP vs net change in BMI
Systolic BP Diastolic BP
Fagard, Med Sci Sports Exerc 1999; 31 : S624-S630
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Dynamic aerobic endurance training
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
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(Van Hoof et al, Am J Cardiol 1989; 63 : 945-949)
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Dynamic aerobic endurance training
Insulin sensitivity
-0.15 (-0.20;-0.11)+
-2.73(-3.55;-1.92)+
5.0
89.3
18Glucose (mmol/L)
(mg/dL)
Values are means, weighted for the number of trained participants
**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
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Dynamic aerobic endurance training
Blood lipids
Values are means, weighted for the number of trained participants
= 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)
PNet change (95% CL)BaselineN
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Dynamic aerobic endurance training
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
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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
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Resistance training and blood pressure
Selection of studies
• 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
• Exclusion of cardiovascular (and other) diseases
• Reporting (of changes) of blood pressure
• Published in peer-reviewed journal
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Resistance training and blood pressure
Selected studies
• Number of studies: 9
• 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
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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)
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Resistance training and blood pressure
Overall results
N: number of study groups
Values are means, weighted for the number of trained participants
§ * 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
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Resistance training and blood pressure
Overall results on blood pressure (mmHg)
< 0.01-4.7 (-8.1; -1.4)80.912Diastolic
N: number of study groups
Values are means, weighted for the number of trained participants
< 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
PNet change (95% CL)BaselineN
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Resistance training and blood pressure
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
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Recommendations
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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
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DYNAMIC AEROBIC
ENDURANCE TRAINING AND
BLOOD PRESSURE
Influence of training intensity
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Net change in BP vs training intensity
Metaregression analysis
Fagard, Med Sci Sports Exerc 2001; 33 : S484-S492
Systolic BP Diastolic BP
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Change in BP vs training intensity
Studies comparing different training intensities
Systolic BP Diastolic BP
Fagard, Med Sci Sports Exerc 2001; 33; S484-S492
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DYNAMIC AEROBIC ENDURANCE
TRAINING
VS DIET (CALORIC RESTRICTION)
Fagard RH, Med Sci Sports Exerc 1999; 31: S624-S630
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DYNAMIC TRAINING VS DIET
Selection of studies
• Comparative trials of
– exercise vs diet, and/or
– exercise + diet vs diet alone
• Random group allocation
• Exclusion of cardiovascular (and other) diseases
• Reporting of (changes of) blood pressure at rest
• Published in peer-reviewed journal
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DYNAMIC TRAINING VS DIET
Selected studies
• Number of studies: 10
• Number of comparisons:
exercise vs diet: 11
exercise + diet vs diet: 11
• Number of subjects: 1,087
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DYNAMIC TRAINING VS DIET
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)
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DYNAMIC TRAINING VS DIET
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
Values are weighted means (95% CL)
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DYNAMIC TRAINING VS DIET
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)
Values are weighted means (95% CL)
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DYNAMIC TRAINING VS DIET
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
Values are weighted means (95% CL)
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DYNAMIC TRAINING VS DIET
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
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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
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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.