The role of physical activity in the prevention and management of hypertension and obesity

Transcription

1 The 1 st World Congress on Controversies in Obesity, Diabetes and Hypertension (CODHy) Berlin, October The role of physical activity in the prevention and management of hypertension and obesity R. Fagard, MD, PhD 2, Hypertension and Cardiovascular Rehabilitation Unit, University of Leuven K.U.Leuven, Belgium

2 Physical exercise and blood pressure - Epidemiological studies - Update on intervention studies: updated meta-analyses of randomized controlled trials - Recommendations

3 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

4 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

5 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 specifically to increase aerobic endurance performance Resistance training: training programs that involve strength, weight, static and/or isometric training, designed specifically to increase muscular strength, power and/or endurance

6 Effects of endurance training on blood pressure, blood pressure regulating mechanisms and cardiovascular risk factors Cornelissen VA, Fagard RH Hypertension 2005; 46:

7 Our aim was to perform a comprehensive metaanalysis 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)

8 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

9 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 : %) Number of study groups: 105 Demographic characteristics: Gender: ~ 57% men Age: median of group averages: 46.6 yr; range yr

10 Dynamic aerobic endurance training Characteristics of the training program Total duration (weeks) Frequency (n/week) Time/session* (min) Net intensity (%) Mode 16 (4-52) 3 (1-7) 40 (15-63) 65 (30-87) mainly walking, jogging, running, and/or cycling 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

11 Dynamic aerobic endurance training General characteristics Subgroups according to baseline BP All Optimal (High)Normal Hypertension P N of study groups N of trained subjects Age (yr) * 52.7* <0.001 Peak VO 2 (ml/min/kg) NS Heart rate (b/min) NS BMI (kg/m 2 ) * <0.05 Values are unweighted means Overall P-value for comparison of blood pressure subgroups * P 0.05 compared with optimal blood pressure group

12 Dynamic aerobic endurance training Overall results N Baseline Net change (95% CL) Peak VO 2 (ml/min/kg) (+3.5; +4.5) Heart rate (b/min) (-5.7; -3.9) Weight (kg) (-1.5; -0.9) Body fat (%) (-1.8; -1.0) Values are means, weighted for the number of trained participants Overall P < and among group P = NS for all variables Baseline body mass index: 26.5 kg/m 2

13 Dynamic aerobic endurance training Results: Anthropometric characteristics N Baseline Net change (95% CL) P Weight (kg)* (-1.5;-0.9) < Body fat (%) (-1.8;-1.0) < Waist circumference (cm) (-4.0;-1.7) < Waist-to-hip ratio (-0.018; ) < 0.05 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

14 Dynamic aerobic endurance training Overall results on blood pressure (mmhg) N Baseline Net change (95% CL) Resting blood pressure - systolic (-4.0; -2.0) - diastolic (-3.1; -1.7) Daytime ambulatory BP - systolic 11 - diastolic (-5.8; -0.9) -3.5 (-5.2; -1.9) Values are means, weighted for the number of trained participants Overall P < for resting BP, and < 0.01 for ambulatory BP 24 h BP in 2 trials which only reported 24 h BP

15 (Van Hoof et al, Am J Cardiol 1989; 63 : )

16 Overall results on haemodynamics

17 Dynamic aerobic endurance training Overall results on daytime and night-time blood pressure (mmhg) N Baseline Net change (95% CL) Daytime BP -systolic (-5.8;-0.9)** -diastolic (-5.2;-1.9)** Night-time BP -systolic (-2.8; +1.6) -diastolic (-2.5; +0.5) Values are means, weighted for the number of trained participants; ** P 0.01

18 Dynamic aerobic endurance training Results on blood pressure in BP subgroups (mm Hg) N Baseline Net change (95% CL) Optimal BP - systolic - diastolic (-4.2; -0.6)** -1.6 (-2.4; -0.7)* (High)Normal - systolic - diastolic (-3.1; -0.3)* -1.7 (-2.6; -0.7) + Hypertension - systolic - diastolic (-9.1; -4.6) (-6.5; -3.3) + Values are means, weighted for the number of trained participants *P 0.05; ** P 0.01; + P 0.001

19 DYNAMIC AEROBIC ENDURANCE TRAINING Results according to baseline body mass index (25 kg/m²) Mean weighted net changes (1) N Lean N Overweight Peak VO 2 (ml/min/kg) Heart rate (b/min) BMI (kg/m²) (+2.6; + 4.4) (-6.6; -3.2) (-0.33; ) (+3.2; +4.6) (-5.7; -3.2) (-0.60; -0.31) Values are weighted means (95% CL)

20 DYNAMIC AEROBIC ENDURANCE TRAINING Results according to baseline body mass index (25 kg/m²) Mean weighted net changes (2) Blood pressure (mm Hg) - systolic - diastolic N Lean N Overweight (-5.1; -1.6) (-3.5; -1.6) (-4.7; -1.9) (-3.7; -1.2) Values are weighted means (95% CL)

21 DYNAMIC AEROBIC ENDURANCE TRAINING AND BLOOD PRESSURE Mechanisms Haemodynamic and basic mechanisms of training-induced changes in blood pressure

22 Dynamic aerobic endurance training Mechanisms of the training-induced changes in blood pressure Change in weight/bmi? Sympathetic nervous system? Renin-angiotensin-aldosterone system? Insulin sensitivity? Endothelial function? Prostaglandins?

23 Net change in BP vs net change in BMI Systolic BP Diastolic BP Fagard, Med Sci Sports Exerc 1999; 31 : S624-S630

24 Dynamic aerobic endurance training Plasma norepinephrine (PNE) and renin activity (PRA) N Net % change P (95% CL) PNE (-40; -18) < PRA (-35; -4.7) < 0.05 Values are means, weighted for the number of trained participants

25 (Van Hoof et al, Am J Cardiol 1989; 63 : )

26 Dynamic aerobic endurance training Insulin sensitivity N Baseline Net change (95% CL) Glucose (mmol/l) (-0.20;-0.11) + (mg/dl) (-3.55;-1.92) + Insulin (IU/L) (-2.2;-0.53)** HOMA-index (-0.53;-0.094)** Values are means, weighted for the number of trained participants **P 0.01; + P HOMA-index: [(glucose(mmol/l)*insulin(iu/l))/22.5]

27 Dynamic aerobic endurance training Blood lipids N Baseline Net change (95% CL) P Cholesterol (mg/dl) - total (-5.03;+1.74) NS - HDL (+0.19;+2.28) < LDL (-11.6;+5.80) NS Triglycerides (mg/dl) (-21.3;+0.84) = 0.07 Values are means, weighted for the number of trained participants

28 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

29 Effect of resistance exercise on resting blood pressure A meta-analysis of randomized controlled trials Cornelissen VA, Fagard RH Journal of Hypertension 2005; 23:

30 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 muscular strength, 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

31 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: %) Number of study groups: 12 (normotension: 9; hypertension: 3) Demographic characteristics gender: 61% men age: range of group averages: yr

32 Resistance training and blood pressure Characteristics of the training programs Total duration (weeks) Frequency (n/week) Time/session (min) Intensity (% of 1 RM) Mode 14 (6-26) 3 (N=10); 2 (N=2)? 70 (30-90) conventional (N=8) circuit (N=3) static (N=1) Values are median and range of study groups, or number of study groups (N)

33 Resistance training and blood pressure Overall results N Baseline N Net change (95% CL) Age / / Peak VO 2 (ml/min/kg) (+0.3; +4.8)* Heart rate (b/min) (-1.7; +3.7) NS Weight (kg) (-2.7; +3.4) NS Body fat (%) (-1.6; -0.25)** N: number of study groups Values are means, weighted for the number of trained participants * P 0.05; ** P 0.01

34 Resistance training and blood pressure Overall results on blood pressure (mmhg) N Baseline Net change (95% CL) P Weighted for the number of trained participants Systolic (-7.1; +0.7) = 0.10 Diastolic (-6.1; -0.9) < 0.01 Weighted for the inverse of the variance of BP Systolic (-10.4; -1.6) < 0.01 Diastolic (-8.1; -1.4) < 0.01 N: number of study groups Values are means, weighted for the number of trained participants

35 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

36 Recommendations

37 RECOMMENDATIONS 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: Exercise is a cornerstone therapy for the primary prevention, treatment and control of hypertension Based upon the current evidence the following exercise prescription is recommended: frequency: on most, preferably all days of the week intensity: moderate intensity (40 - <60% of VO 2 reserve) time: 30 min of continuous or accumulated physical activity per day type: primarily endurance physical activity supplemented by resistance exercise

38 DYNAMIC AEROBIC ENDURANCE TRAINING AND BLOOD PRESSURE Influence of training intensity

39 Net change in BP vs training intensity Metaregression analysis Systolic BP Diastolic BP Fagard, Med Sci Sports Exerc 2001; 33 : S484-S492

40 Change in BP vs training intensity Studies comparing different training intensities Systolic BP Diastolic BP Fagard, Med Sci Sports Exerc 2001; 33; S484-S492

41 DYNAMIC AEROBIC ENDURANCE TRAINING VS DIET (CALORIC RESTRICTION) Fagard RH, Med Sci Sports Exerc 1999; 31: S624-S630

42 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

43 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

44 DYNAMIC TRAINING VS DIET Baseline data N Exercise Diet Age (yr) (45.9; 53.9) Peak VO (ml/min/kg) (28.5; 34.8) BMI (kg/m²) (26.9; 29.6) SBP (mm Hg) (120.1; 131.1) DBP (mm Hg) (77.5; 86.1) Values are weighted means (95 % CL) 49.3 (45.2; 53.4) 31.4 (28.3; 34.5) 28.6 (27.1; 30.1) (118.8; 130.1) 80.9 (77.0; 84.8)

45 DYNAMIC TRAINING VS DIET Mean weighted changes Peak VO 2 (ml/min/kg) BMI (kg/m²) SBP (mm Hg) DBP (mm Hg) N Exercise Diet P < 0.01 (+2.3; +4.4) (-0.2; +2.1) < 0.01 (-0.67; -0.17) (-2.18; -0.97) < 0.01 (-5.2; -2.0) (-7.7; -4.1) < 0.05 (-3.8; -1.7) (-5.9; -2.4) Values are weighted means (95% CL)

46 DYNAMIC TRAINING VS DIET Baseline data N Exercise + diet Diet Age (yr) (45.4; 51.6) Peak VO (ml/min/kg) (25.2; 34.2) BMI (kg/m²) (27.1; 30.1) SBP (mm Hg) (120.1; 138.7) DBP (mm Hg) (77.0; 89.2) Values are weighted means (95% CL) 48.7 (45.6; 51.8) 29.1 (24.3; 33.8) 28.6 (27.0; 30.2) (120.1; 136.5) 82.1 (76.6; 87.6)

47 DYNAMIC TRAINING VS DIET Mean weighted changes N Exercise + diet Diet P Peak VO 2 (ml/min/kg) BMI (kg/m²) SBP (mm Hg) DBP (mm Hg) (+4.1; +6.6) (-2.73; -1.35) (-9.9; -4.4) (-7.5; -3.4) (-0.03; +1.7) (-2.37; -0.95) (-9.8; -3.9) (-6.0; -2.4) < < Values are weighted means (95% CL)

48 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

49

50 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 decrease exercise performance, cause electrolyte disturbances and/or may be on 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, possibly in combination with a potassium sparing agent, can be recommended

51 Recommendations ESC 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: 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: