Sedentary Behavior, Exercise, and Cardiovascular Health

Physical activity and exercise to improve cardiovascular health for adults living with HIV

Pharmacologic advancements in the treatment of human immunodeficiency virus (HIV) has extended the life expectancy of people living with HIV (PLWH). An unfortunate side effect of HIV treatment, however, is an increased prevalence of dyslipidemia, glycemic dysregulation and abnormal distribution of body fat (lipodystrophy). Consequently, the risk of developing cardiovascular disease (CVD) is significantly increased in PLWH and ultimately a major cause of mortality. Physical activity and exercise training are interventions that have effectively protected against the development of CVD and, in the presence of CVD, has help mitigate morbidity and mortality. Early concerns over potential immunosuppressive effects of exercise in PLWH have largely been dispelled and in some cases exercise has been shown to strengthen markers of immune function. Interventions with aerobic exercise, resistance exercise, and their combination, particularly at higher intensities, are showing promising health outcomes in PLWH. This review will summarize the key cardiovascular and metabolic effects of antiretroviral therapy; the effects of the types and intensities of exercise on cardiorespiratory fitness, cardiometabolic markers, and muscle strength; and provide recommendations on strategies to apply exercise interventions in clinical settings.

The Impact of Obesity in Heart Failure

Obesity has reached worldwide epidemic proportions, adversely impacting health on a global scale. Overweight and obesity adversely impact cardiac structure and function, affecting systolic and diastolic ventricular function. Studies and meta-analyses have documented an obesity paradox in large heart failure cohorts, where overweight and obese individuals with established heart failure have a better short- and medium-term prognosis compared with lean patients; this relationship is strongly impacted by level of cardiorespiratory fitness. There are implications for therapies aimed at increasing lean and muscle mass, and weight loss, for the prevention and treatment of compared with in patients with concomitant obesity.

Effects of physical activity and smoking on cardio-ankle vascular index, respiratory muscle strength, and exercise performance in early normal weight adulthood: a cross-sectional study

Few studies have shown the impact of unhealthy habits on arterial stiffness, respiratory muscle strength and exercise performance in early normal weight adulthood. This study sought to determine the effects of physical activity and smoking on its parameters in normal weight male participants. Forty-eight participants were divided into four groups: physically inactive nonsmokers and smokers and physically active nonsmokers and smokers (n=12 in each group). All of the participants were measured for body composition, arterial stiffness, respiratory muscle strength and exercise performance. Two-way analysis of variance design was used to test the main and interaction effects of physical activity by group (smokers vs. nonsmokers). P-value of less than 0.05 was considered as a statistically significant difference. As a result, cardio-ankle vascular index and respiratory muscle strength were diminished in smokers and physically inactive participants, while body and visceral fat mass were increased in both those groups. Fat-free mass was lower in only physically inactive participants. This study also found the interaction effects on body fat and arterial stiffness. In conclusion, participants with healthy normal weight, but smoked and performed inappropriate physical activity, exhibited body composition imbalance, decreased respiratory muscle strength, exercise performance, and increased arterial stiffness. Therefore, smoking cessation and exercise in younger adults are appropriate ways of improving body composition, respiratory muscle strength, aerobic capacity and arterial stiffness instead of trying to control their weight by smoking.

Effects of Bluetooth-Enabled Desk Ellipticals on Office Work Performance: Rationale, Design, and Protocol for a Randomized Trial With Overweight and Obese Adults

Background

Workplaces that provide opportunities for physical activity without requiring extra time for activity could help counteract the obesity epidemic. Desk ellipticals can contribute to activity-supportive workplace environments; however, the feasibility of engaging employees in pedaling ellipticals during simultaneous office work has not been well evaluated.

Objective

We aim to present the rationale and methods from an ongoing randomized trial with overweight and obese employees that will evaluate (1) the effects of pedaling a compact desk elliptical on work performance and (2) the influence of different incentive types and schedules on desk pedaling quantity.

Methods

Overweight and obese medical center employees are being recruited in dyads for a 2 (gift card type: healthier food vs Amazon) by 3 (gift card schedule: immediate incentive contingent on individual pedaling quantity; immediate incentive partially contingent on dyads’ joint pedaling quantity; and delayed noncontingent pedaling incentive) cluster randomized within-subjects factorial trial. All participants receive a Bluetooth-enabled desk elliptical for 4 weeks and access to a mobile app that provides real-time pedaling feedback. The primary aims are to assess (1) change in employee work performance from pre- to postelliptical installation via employee and supervisor ratings and (2) effects of gift card type and schedule on quantity of objectively measured desk pedaling completed.

Results

Data collection is ongoing. We expect to complete main outcome analyses in 2020.

Conclusions

This trial represents one of the earliest attempts to assess the effects of desk pedaling and pedaling-incentive types in real-world offices. It could help bridge the research-to-practice gap by providing evidence on whether desk pedaling can be sustained without compromising work performance.

International Registered Report Identifier (IRRID)

DERR1-10.2196/16275

The Beneficial Role of Exercise Training for Myocardial Infarction Treatment in Elderly

Worldwide, elderly people have a higher prevalence of myocardial infarction (MI), which is associated with body function aging and a sedentary lifestyle. In addition to medication, exercise training is a well-established supplementary method to prevent and treat cardiovascular diseases (CVDs). Substantial evidence has shown the value of different intensity exercise programs in the prevention and treatment of MI, and exercise rehabilitation programs are also applicable to elderly patients with MI. Although exercise rehabilitation programs could significantly improve function, quality of life (QoL), and lower mortality and morbidity for people with MI, such programs are underused because their mechanisms are not accurately elucidated. To promote the application of exercise therapy for MI, this review summarizes the benefits and mechanisms of exercise rehabilitation for post-MI patients and provides rationalized proposals for outpatient cardiac rehabilitation.

Moderate Exercise in Spontaneously Hypertensive Rats Is Unable to Activate the Expression of Genes Linked to Mitochondrial Dynamics and Biogenesis in Cardiomyocytes

Hypertension (HTN) is a public health concern and a major preventable cause of cardiovascular disease (CVD). When uncontrolled, HTN may lead to adverse cardiac remodeling, left ventricular hypertrophy, and ultimately, heart failure. Regular aerobic exercise training exhibits blood pressure protective effects, improves myocardial function, and may reverse pathologic cardiac hypertrophy. These beneficial effects depend at least partially on improved mitochondrial function, decreased oxidative stress, endothelial dysfunction, and apoptotic cell death, which supports the general recommendation of moderate exercise in CVD patients. However, most of these mechanisms have been described on healthy individuals; the effect of moderate exercise on HTN subjects at a cellular level remain largely unknown. We hypothesized that hypertension in adult spontaneously hypertensive rats (SHRs) reduces the mitochondrial response to moderate exercise in the myocardium. Methods: Eight-month-old SHRs and their normotensive control-Wistar-Kyoto rats (WKYR)-were randomly assigned to moderate exercise on a treadmill five times per week with a running speed set at 10 m/min and 15° inclination. The duration of each session was 45 min with a relative intensity of 70-85% of the maximum O₂ consumption for a total of 8 weeks. A control group of untrained animals was maintained in their cages with short sessions of 10 min at 10 m/min two times per week to maintain them accustomed to the treadmill. After completing the exercise protocol, we assessed maximum exercise capacity and echocardiographic parameters. Animals were euthanized, and heart and muscle tissue were harvested for protein determinations and gene expression analysis. Measurements were compared using a nonparametric ANOVA (Kruskal-Wallis), with post-hoc Dunn's test. Results: At baseline, SHR presented myocardial remodeling evidenced by left ventricular hypertrophy (interventricular septum 2.08 ± 0.07 vs. 1.62 ± 0.08 mm, p < 0.001), enlarged left atria (0.62 ± 0.1 mm vs. 0.52 ± 0.1, p = 0.04), and impaired diastolic function (E/A ratio 2.43 ± 0.1 vs. 1.56 ± 0.2) when compared to WKYR. Moderate exercise did not induce changes in ventricular remodeling but improved diastolic filling pattern (E/A ratio 2.43 ± 0.1 in untrained SHR vs. 1.89 ± 0.16 trained SHR, p < 0.01). Histological analysis revealed increased myocyte transversal section area, increased Myh7 (myosin heavy chain 7) expression, and collagen fiber accumulation in SHR-control hearts. While the exercise protocol did not modify cardiac size, there was a significant reduction of cardiomyocyte size in the SHR-exercise group. Conversely, titin expression increased only WYK-exercise animals but remained unchanged in the SHR-exercise group. Mitochondrial response to exercise also diverged between SHR and WYKR: while moderate exercise showed an apparent increase in mRNA levels of Ppargc1α, Opa1, Mfn2, Mff, and Drp1 in WYKR, mitochondrial dynamics proteins remained unchanged in response to exercise in SHR. This finding was further confirmed by decreased levels of MFN2 and OPA1 in SHR at baseline and increased OPA1 processing in response to exercise in heart. In summary, aerobic exercise improves diastolic parameters in SHR but fails to activate the cardiomyocyte mitochondrial adaptive response observed in healthy individuals. This finding may explain the discrepancies on the effect of exercise in clinical settings and evidence of the need to further refine our understanding of the molecular response to physical activity in HTN subjects.

Portable Gentle Jogger Improves Glycemic Indices in Type 2 Diabetic and Healthy Subjects Living at Home: A Pilot Study

BACKGROUND

Physical inactivity is a high-risk factor for type 2 diabetes. Increased physical activity improves indices of glycemic control. Continuous glucose monitoring (CGM) allows the investigation of glycemic control during activities of daily living. A pilot study was undertaken to determine the effects of the portable Gentle Jogger (passive simulated jogging device (JD)) that decreases physical inactivity by effortlessly producing body movements on glycemic indices of healthy and type 2 diabetes subjects using CGM during activities of daily living.

METHODS

A single-arm, nonblinded study was carried out in 22 volunteers (11 type 2 diabetics and 11 healthy subjects), using continuous glucose monitoring (CGM) for 14 days. On day 4, subjects were provided with JD and instructed to use it a minimum of 3 times per day for 30 min for 7 days. CGM data was analyzed at baseline (BL) and during 2, 3, 4, 5, 6, and 7 days of JD (JD 2, 3, 4, 5, 6, 7) and 1-2-day post JD (Post JD1 and 2) and the following 24 hr indices computed mean glucose (mGLu), SUM of all glucose values, % coefficient of variation (%CV), area under the 24-hour curve (AUC), time spent above range (TAR, glucose 180-250 mg/dl), and time in range (TIR).

RESULTS

In healthy subjects, there were significantly lower values of mGlu and SUM compared to BL for all days of JD usage. In type 2 diabetics, mGlu, SUM, and AUC were significantly lower compared to BL, for all days of JD usage and Post JD1. TAR was significantly lower and TIR significantly improved during JD, in type 2 diabetics without change in %CV.

CONCLUSION

Gentle Jogger is a portable, passive movement technology that reduces physical inactivity while improving 24 hr glycemic control. It can be self-administered as a standalone device or as an adjunct to diabetic medications. This trial is registered with NCT03550105.

Determinants of Cardiorespiratory Fitness in Patients with Heart Failure Across a Wide Range of Ejection Fractions

Impaired cardiorespiratory fitness (CRF) in heart failure (HF) is influenced by a complex array of cardiac and extracardiac factors. The study aimed to identify clinical determinants of CRF measured as peak oxygen consumption (peak VO₂) in HF patients, and to determine a peak VO₂ prediction model using regression equations. Retrospective analysis of 200 HF patients who completed treadmill cardiopulmonary exercise testing and underwent Doppler echocardiography and/or biomarker analysis on the same day was performed. After univariate linear regression analysis, a multivariate peak VO₂ prediction model was developed using significant variables in a stepwise linear regression analysis. In subjects with repeated testing, Pearson's correlation was used to assess correlations between measured and predicted change in peak VO₂ (Δpeak VO₂) over time. Mean age was 57 years, with 55% being male. Stepwise linear regression was used to generate a weighted model for peak VO₂: 30.895 + (-0.112•age[years]) + (0.296•hemoglobin [g/dl]) + (-0.101•E/e'[unit change]) + (-0.202• body mass index [kg/m²]) + (-0.593• N-terminal pro-brain natriuretic peptide [log_N pg/ml])) + (-1.349•CRP [log mg/L]). Predicted peak VO₂ correlated strongly with measured peak VO₂ in HF with reduced ejection fraction and HF with preserved ejection fraction patients (r = +0.63, p <0.001; r = +0.64, p <0.001, respectively). Predicted Δpeak VO₂ correlated with measured Δpeak VO₂ (r = +0.23, p <0.001). In conclusion, in patients with HF across a wide range of left ventricular ejection fraction, age, systemic inflammation, oxygen carrying capacity, obesity, and elevated filling pressures are the strongest predictors of impaired CRF. The proposed CRF model allows prediction of peak VO₂ in HF patients and may be used to estimate peak VO₂ changes over time.

Sarcopenic Obesity in Heart Failure With Preserved Ejection Fraction

Heart failure with preserved ejection fraction (HFpEF) is a public health epidemic that is projected to double over the next two decades. Despite the high prevalence of HFpEF, there are currently no FDA approved therapies for health-related outcomes in this clinical syndrome making it one the greatest unmet needs in cardiovascular medicine. Aging and obesity are hallmarks of HFpEF and therefore there is a high incidence of sarcopenic obesity (SO) associated with this syndrome. The presence of SO in HFpEF patients is noteworthy as it is associated with co-morbidities, worsened cardiovascular health, hospitalizations, quality of life, and mortality. Furthermore, SO plays a central role in exercise intolerance, the most commonly reported clinical symptom of this condition. The aim of this review is to provide insights into the current knowledge pertaining to the contributing pathophysiological mechanisms and clinical outcomes associated with HFpEF-related SO. Current and prospective therapies to address SO in HFpEF, including lifestyle and pharmaceutical approaches, are discussed. The urgent need for future research aimed at better understanding the multifaceted physiological contributions to SO in HFpEF and implementing interventional strategies to specifically target SO is highlighted.

Pediatric Flatfeet-A Disease Entity That Demands Greater Attention and Treatment

Background: Pediatric flatfoot is a common deformity. Unfortunately, the common opinion has been that most children with this faulty foot structure will simply out-grow it, despite no radiographic evidence to support this claim. Every step on a deformed foot leads to excessive tissue strain and further joint damage. Many forms of conservative and surgical treatments have been offered. This study was aimed at investigating the effectiveness of non-surgical and surgical treatment options. Main Text: faulty-foot structure is the leading cause of many secondary orthopedic deformities. A wide range of treatments for pediatric flatfeet have been recommended from the "do-nothing" approach, observation, to irreversible reconstructive surgery. Most forms of conservative care lack evidence of osseous realignment and stability. A conservative surgical option of extra-osseous talotarsal joint stabilization provides patients an effective form of treatment without the complications associated with other irreversible surgical procedures. Conclusion: Pediatric flatfeet should not be ignored or downplayed. The sooner effective treatment is prescribed, the less damage will occur to other parts of the body. When possible, a more conservative corrective procedure should be performed prior to irreversible, joint destructive options.

High-Intensity Walking Time Is a Key Determinant to Increase Physical Fitness and Improve Health Outcomes After Interval Walking Training in Middle-Aged and Older People

OBJECTIVE

To examine the effects of interval walking training (IWT) on the estimated peak aerobic capacity (eV˙O_2peak) and lifestyle-related disease (LSD) score while focusing on exercise intensity and volume in middle-aged and older people.

PARTICIPANTS AND METHODS

Men and women (N=679; mean age, 65±7 SD years) completed 5-month IWT. Participants were instructed to repeat 5 or more sets of fast and slow walking for 3 minutes each at 70% or more and 40% eV˙O_2peak for walking, respectively, per day for 4 or more d/wk. This study was conducted from April 1, 2005, through February 29, 2008.

RESULTS

Interval walking training increased eV˙O_2peak by 14% and decreased LSD score by 17% on average (P<.001). During 5-month IWT, fast and slow walking times were 88±65 SD and 100±86 min/wk, respectively, but varied among participants. We divided participants into approximately 10 bins for 6 minutes each of fast and slow walking times per week up to 60 min/wk, and above this time, approximately 8 bins for 30 or 60 minutes each of fast and slow walking up to the maximal time. We found that both eV˙O_2peak and LSD score improved as fast walking time per week increased up to 50 min/wk (R²=0.94; P<.001 for eV˙O_2peak; R²=0.51; P=.03 for LSDS) but plateaued above this time. In contrast, improvement in neither eV˙O_2peak nor LSDS was positively correlated with slow or total walking time per week. Multiple regression analyses confirmed that fast walking time per week was the major determinant of improvements in eV˙O_2peak (P<.001) and LSD score (P=.001).

CONCLUSION

High-intensity walking time during IWT is a key factor to increase eV˙O_2peak and decrease LSD score in middle-aged and older people.

Socioecological and biological associations of lower levels of physical activity in 8-year-old children: a 2-year prospective study

OBJECTIVES

Evaluate if socioecological and biological factors, at the age of 8 years, are associated with lower level of physical activity (PA) 2 years later.

METHOD

In a study cohort of 199 children aged 7.8±0.6 years, we used questionnaires and physical measurements to evaluate biological (eg, sex), social (eg, parental PA) and environmental (eg, school settings) factors. Objective PA was measured 2 years later with accelerometers. General PA (GPA) was defined as mean counts per minute (cpm) and moderate to vigorous PA (MVPA) as min/day >3500 cpm. We used analysis of covariance to evaluate if socioecological factors at age 8 are associated with level of PA 2 years later.

RESULTS

Daily GPA was 690.5±216.6 cpm and the children spent 40.9±18.3 min on MVPA. Female sex is associated with -131.1 (-183.4, -78.7) cpm GPA, each 10 cm shorter body height with -48.7 (-94.8, -26.5), each unit higher body mass index (BMI) with -26.0 (-37.5, -14.5) and allocation to 60 min school PA/week with -73.8 (-131.5, -16.2) compared with allocation to 200 min school PA/week. Female sex is associated with -10.3 (-14.8, -5.7) min of MVPA and each unit higher BMI with -1.9 (-2.9, -0.9) min.

CONCLUSION

Female sex, shorter body height and higher BMI are at age 8 years associated with lower level of PA 2 years later. It appears possible to increase PA by daily school PA.

TRIAL REGISTRATION NUMBER

NCT00633828.

Lifestyle Interventions with a Focus on Nutritional Strategies to Increase Cardiorespiratory Fitness in Chronic Obstructive Pulmonary Disease, Heart Failure, Obesity, Sarcopenia, and Frailty

Cardiorespiratory fitness (CRF) is an independent predictor for all-cause and disease-specific morbidity and mortality. CRF is a modifiable risk factor, and exercise training and increased physical activity, as well as targeted medical therapies, can improve CRF. Although nutrition is a modifiable risk factor for chronic noncommunicable diseases, little is known about the effect of dietary patterns and specific nutrients on modifying CRF. This review focuses specifically on trials that implemented dietary supplementation, modified dietary pattern, or enacted caloric restriction, with and without exercise training interventions, and subsequently measured the effect on peak oxygen consumption (VO₂) or surrogate measures of CRF and functional capacity. Populations selected for this review are those recognized to have a reduced CRF, such as chronic obstructive pulmonary disease, heart failure, obesity, sarcopenia, and frailty. We then summarize the state of existing knowledge and explore future directions of study in disease states recently recognized to have an abnormal CRF.

Impact of therapeutic lifestyle changes in resistant hypertension

Hypertensive individuals are at an increased risk of developing heart disease and stroke. Adopting healthy lifestyles, such as being active on ≥4 days per week, weight-loss in the presence of obesity, consuming a diet rich in fruits and vegetables, and sodium below the recommended threshold, avoiding high alcohol consumption and refraining from smoking have been effective lifestyle therapies to prevent or control stage 1 hypertension (HTN). Among the 1 in 3 Americans who have HTN (systolic blood pressure ≥ 130 mmHg or diastolic blood pressure ≥ 80 mmHg), 16% are diagnosed with resistant HTN (RHT). Although there are comparatively fewer studies examining the blood pressure lowering effects of therapeutic lifestyle interventions in patients with resistant HTN, the available literature appears promising. This paper reviews key studies that quantify the blood pressure lowering effects of certain therapeutic lifestyles in patients with RHT and highlights areas needing more attention.

Physical activity without weight loss reduces the development of cardiovascular disease risk factors - a prospective cohort study of more than one hundred thousand adults

PURPOSE

Whether physical activity (PA) might have certain benefits for cardiovascular disease (CVD) primordial prevention even in the absence of clinically significant weight loss is of public health interest. In this study, we examined the independent and combined associations of simultaneous changes in PA and body weight with the subsequent development of major CVD risk factors in adults.

METHODS

This prospective analysis included 116,134 healthy men and women, aged ≥18 years, with at least 3 medical examinations from the Taiwan MJ Cohort. Two-year changes in PA and body weight between the first and second examination were linked to subsequent development of hypertension, hypercholesterolemia, atherogenic dyslipidemia, metabolic syndrome, type 2 diabetes mellitus (T2DM), and chronic inflammation, which were assessed by physical examinations and laboratory tests.

RESULTS

During an average follow-up of 5.7 ± 4.1 years after the second examination, 10,840 individuals developed hypertension, 10,888 hypercholesterolemia, 6078 atherogenic dyslipidemia, 13,223 metabolic syndrome, 4816 T2DM, and 2027 inflammation. Weight gain was associated with a subsequent higher risk of all CVD risk factors, with HR (95%CI) ranging from 1.11 (1.00-1.23) for inflammation to 1.74 (1.67-1.82) for metabolic syndrome, compared with participants who lost weight. A stable weight was also associated with a higher risk of all CVD risk factors except with inflammation. In combined analyses, participants who simultaneously gained weight and decreased PA levels had the highest risk compared with those who lost weight and increased PA. Increasing or maintaining PA reduced the increased subsequent risk of some CVD risk factors among participants who maintained a stable weight or gained weight. Among participants who lost weight, decreased PA was not associated with an increased risk.

CONCLUSIONS

Although weight loss is crucial for the prevention of CVD risk factors, increasing or maintaining PA is also important to prevent them among adults who gain or maintain their weight.

Promoting physical activity in primary and secondary prevention

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Mortality risk comparing walking pace to handgrip strength and a healthy lifestyle: A UK Biobank study

AIMS

Brisk walking and a greater muscle strength have been associated with a longer life; whether these associations are influenced by other lifestyle behaviours, however, is less well known.

METHODS

Information on usual walking pace (self-defined as slow, steady/average, or brisk), dynamometer-assessed handgrip strength, lifestyle behaviours (physical activity, TV viewing, diet, alcohol intake, sleep and smoking) and body mass index was collected at baseline in 450,888 UK Biobank study participants. We estimated 10-year standardised survival for individual and combined lifestyle behaviours and body mass index across levels of walking pace and handgrip strength.

RESULTS

Over a median follow-up of 7.0 years, 3808 (1.6%) deaths in women and 6783 (3.2%) in men occurred. Brisk walkers had a survival advantage over slow walkers, irrespective of the degree of engagement in other lifestyle behaviours, except for smoking. Estimated 10-year survival was higher in brisk walkers who otherwise engaged in an unhealthy lifestyle compared to slow walkers who engaged in an otherwise healthy lifestyle: 97.1% (95% confidence interval: 96.9-97.3) vs 95.0% (94.6-95.4) in women; 94.8% (94.7-95.0) vs 93.7% (93.3-94.2) in men. Body mass index modified the association between walking pace and survival in men, with the largest survival benefits of brisk walking observed in underweight participants. Compared to walking pace, for handgrip strength there was more overlap in 10-year survival across lifestyle behaviours.

CONCLUSION

Except for smoking, brisk walkers with an otherwise unhealthy lifestyle have a lower mortality risk than slow walkers with an otherwise healthy lifestyle.

Effects of Physical Activity, Exercise, and Fitness on Obesity-Related Morbidity and Mortality

Obesity is associated with increased prevalence of cardiovascular (CV) disease (CVD) risk factors, which may adversely impact CV structure and function and may increase the prevalence of most CVD, particularly heart failure (HF) and coronary heart disease (CHD). Physical activity (PA), exercise training (ET) and cardiorespiratory fitness (CRF) are all associated with marked reductions in most CVD, including HF and CHD. Additionally, PA/ET and, especially CRF, markedly alter the relationship between adiposity and subsequent major CVD outcomes and dramatically impact the "obesity paradox," which are all reviewed, including attention to the debate regarding "fitness versus fatness" for long-term prognosis, including in patients with established CVD.

Association between body mass index and fitness in Korean adults according to the lump mean value and Gaussian fitting

The aim of this study was to determine the body mass index (BMI) for the best fitness and effective exercise. This study analyzed data from the Korean national fitness assessment by the Korea Institute of Sport Science (2017). The fitness tests considered were sit-up, standing long jump (SLJ), 20-m multi-stage shuttle run (20-m MSSR), and 10-m shuttle run (10-m SR) tests. The BMIs for the best fitness and widths of the fitness distributions were calculated using the lump mean value and Gaussian fitting. The values of BMI (kg/m²) associated with the best sit-up, SLJ, 20-m MSSR, and 10-m SR scores were 23.4, 22.6, 22.2, and 22.6 for males and 19.0, 18.5, 18.6, and 18.6 for females. The widths (kg/m²) of the sit-up, SLJ, 20-m MSSR, and 10-m SR distributions were 3.65, 3.42, 3.73, and 2.86 for males and 4.84, 4.88, 4.45, and 4.35 for females. The results show that the BMI can be reduced the most and fitness can be increased effectively by the 20-m MSSR for males and the SLJ for females, which could be used to establish personal exercise aims.

Exercise reduces inflammatory cell production and cardiovascular inflammation via instruction of hematopoietic progenitor cells

A sedentary lifestyle, chronic inflammation and leukocytosis increase atherosclerosis; however, it remains unclear whether regular physical activity influences leukocyte production. Here we show that voluntary running decreases hematopoietic activity in mice. Exercise protects mice and humans with atherosclerosis from chronic leukocytosis but does not compromise emergency hematopoiesis in mice. Mechanistically, exercise diminishes leptin production in adipose tissue, augmenting quiescence-promoting hematopoietic niche factors in leptin-receptor-positive stromal bone marrow cells. Induced deletion of the leptin receptor in Prrx1-creER^T2; Lepr^fl/fl mice reveals that leptin's effect on bone marrow niche cells regulates hematopoietic stem and progenitor cell (HSPC) proliferation and leukocyte production, as well as cardiovascular inflammation and outcomes. Whereas running wheel withdrawal quickly reverses leptin levels, the impact of exercise on leukocyte production and on the HSPC epigenome and transcriptome persists for several weeks. Together, these data show that physical activity alters HSPCs via modulation of their niche, reducing hematopoietic output of inflammatory leukocytes.

Comparative efficacy of exercise and anti-hypertensive pharmacological interventions in reducing blood pressure in people with hypertension: A network meta-analysis

Aims

This analysis aims to estimate the comparative efficacy of anti-hypertensive medications and exercise interventions on systolic and diastolic blood pressure reduction in people with hypertension.

Methods

A systematic review was conducted focusing on randomised controlled trials (RCTs) of exercise interventions and first-line anti-hypertensives where blood pressure reduction was the primary outcome in those with hypertension. Network meta-analyses were conducted to generate estimates of comparative efficacy.

Results

We identified 93 RCTs ( N = 32,404, mean age in RCTs: 39–70 years) which compared placebo or usual care with first-line antihypertensives including angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, calcium channel blockers and thiazide-like diuretics and exercise interventions including aerobic training and dynamic resistance training. Of these, there were 81 (87%) trials related to medications ( n = 31,347, 97%) and 12 (13%) trials related to exercise ( n = 1057, 3%). The point estimates suggested that antihypertensive medications were more effective than exercise but there was insufficient evidence to suggest that first-line medications significantly reduced blood pressure to a greater extent than did the exercise interventions. Of the first-line treatments, angiotensin receptor blockers and calcium channel blockers had the highest treatment ranking, while exercise had the second lowest treatment ranking, followed by control conditions.

Conclusion

The current evidence base with a bias towards medication research may partly explain the circumspection around the efficacy of exercise in guidelines and practice. Clinicians may justifiably consider exercise for low risk hypertension patients who confirm a preference for such an approach.

Short-Term Changes in Cardiorespiratory Fitness in Response to Exercise Training and the Association with Long-Term Cardiorespiratory Fitness Decline: The STRRIDE Reunion Study

Background

Substantial heterogeneity exists in the cardiorespiratory fitness (CRF) change in response to exercise training, and its long‐term prognostic implication is not well understood. We evaluated the association between the short‐term supervised training‐related changes in CRF and CRF levels 10 years later.

Methods and Results

STRRIDE (Studies of a Targeted Risk Reduction Intervention Through Defined Exercise) trial participants who were originally randomized to exercise training for 8 months and participated in the 10‐year follow‐up visit were included. CRF levels were measured at baseline, after training (8 months), and at 10‐year follow‐up as peak oxygen uptake (vo₂, mL/kg per min) using the maximal treadmill test. Participants were stratified into low, moderate, and high CRF response groups according to the training regimen–specific tertiles of CRF change. The study included 80 participants (age: 52 years; 35% female). At 10‐year follow‐up, the high‐response CRF group had the least decline in CRF compared with the moderate‐ and low‐response CRF groups (−0.35 versus −2.20 and −4.25 mL/kg per minute, respectively; P=0.02). This result was largely related to the differential age‐related changes in peak oxygen pulse across the 3 groups (0.58, −0.23, and −0.86 mL/beat, respectively; P=0.03) with no difference in the peak heart rate change. In adjusted linear regression analysis, high response was significantly associated with greater CRF at follow‐up independent of other baseline characteristics (high versus low [reference] CRF response: standard β=0.25; P=0.004).

Conclusions

Greater CRF improvement in response to short‐term training is associated with higher CRF levels 10 years later. Lack of CRF improvements in response to short‐term training may identify individuals at risk for exaggerated CRF decline with aging.

Isotemporal substitution modeling on sedentary behaviors and physical activity with depressive symptoms among older adults in the U.S.: The national health and nutrition examination survey, 2007-2016

BACKGROUND

Late-life depression is a great burden of public health. Previous studies reported that physical activity is associated with reduced depressive symptoms among older adults, while the competing nature of physical activity and sedentary behaviors has been largely neglected in studies. We aimed to examine the associations of replacing sedentary behaviors with walking/bicycling or moderate-to-vigorous physical activity (MVPA) with depressive symptoms in older adults.

METHODS

A cross-sectional analysis was conducted among 8374 older adults (60 years or older) included in the National Health and Nutrition Examination Survey (NHANES), 2007-2016. The Global Physical Activity Questionnaire was used to measure self-reported time for sedentary behaviors, walking/bicycling, and MVPA. The 9-item Patient Health Questionnaire was used to measure depressive symptoms (including overall, somatic, and cognitive). Z-scores were created for depressive symptoms. Isotemporal substitution models using multivariable linear regression were applied to examine the associations of sedentary behaviors, walking/bicycling, and MVPA with z-scores of depressive symptoms.

RESULTS

Replacing 30 min/day sedentary behaviors with 30 min/day of MVPA (beta (β) = -0.10, 95% confidence interval (CI): -0.14, -0.06) or 30 min/day of walking/bicycling (β = -0.04, 95% CI: -0.06, -0.02) was associated with lower z-score for depressive symptoms. Replacing 30 min/day of walking/bicycling for 30 min/day of MVPA was associated with lower z-score for depressive symptoms (β = -0.06, 95% CI: -0.10, -0.02).

LIMITATIONS

A cross-sectional study design precludes causal inferences.

CONCLUSION

Replacing sedentary behaviors with walking/bicycling or MVPA is associated with lower depressive symptoms among older adults. Future research is expected to investigate the effectiveness of physical activity on prevention and treatment of late-life depression.

Exergaming and Virtual Reality for Health: Implications for Cardiac Rehabilitation

Cardiac Rehabilitation (CR) programs, focused on improving the health trajectory of patients with cardiovascular disease, strive to increase physical activity (PA) and cardiorespiratory fitness. However, historically low compliance with recommended PA has prompted exploration of alternatives to traditional courses of exercise therapy. One alternative, exergaming, or the requirement of physical exercise inherent to a video game's activities, has shown to have a promising impact in improving patient self-efficacy for exercise training using digital hardware (eg, the Wii or the Xbox Kinect). Furthermore, novel technologies in virtual reality can provide an engaging, immersive environment for exergaming techniques, maximizing goal-oriented training and building self-efficacy for patients during CR. Many groundbreaking institutions are already calculating energy expenditure of commercially successful virtual reality games and finding promise in the cardiometabolic responses to a number of virtual reality games. Research is still limited in establishing the efficacy of these games, but virtual reality and exergaming are quickly proving to be appropriate and equivalent alternatives to traditional exercise programs. Though studies have examined the impact of prescriptive exergaming on PA, they have yet to examine the potential for genuine integration of game-based motivational techniques and immersive environments into clinical interaction. The purpose of this review is to describe the current body of evidence and the impact and future potential of virtual reality and exergaming. Further, we will introduce the concept of a "Clinical Arcade" as a new approach to integration of these techniques in CR care.

Obesity, risk of diabetes and role of physical activity, exercise training and cardiorespiratory fitness

The epidemic of obesity contributes to the burden of type 2 diabetes mellitus (T2DM) in the United States and worldwide. Importantly, obesity is not only preventable but can be treated, particularly with lifestyle modifications to forestall T2DM in those with excess adiposity. The mechanisms linking obesity to T2DM are numerous and involve adipose tissue remodeling as a result of unhealthy behaviors, including unhealthy diet, reduced physical activity (PA) and exercise training (ET), and increased sedentary behaviors. Taken together, these factors markedly reduce cardiorespiratory fitness (CRF), one of the strongest predictors for cardiovascular outcomes and all-cause mortality in the general population, but also in those with T2DM. In this review we describe the mechanisms leading to adipose tissue remodeling resulting in obesity, as well as the mechanisms linking excess adiposity to insulin resistance and, in turn, T2DM. We then present the therapeutic strategies that can be implemented in obesity to prevent T2DM, with a brief discussion on weight loss, and greater emphasis on PA and ET. We finally present the evidence to support the beneficial effects of such strategies in patients with established T2DM and discuss the importance of achieving improvements in CRF in this population to potentially improve clinical outcomes.

Exercise-Induced Cardiac Troponin I Increase and Incident Mortality and Cardiovascular Events

BACKGROUND

Blood concentrations of cardiac troponin above the 99^th percentile are a key criterion for the diagnosis of acute myocardial injury and infarction. Troponin concentrations, even below the 99^th percentile, predict adverse outcomes in patients and the general population. Elevated troponin concentrations are commonly observed after endurance exercise, but the clinical significance of this increase is unknown. We examined the association between postexercise troponin I concentrations and clinical outcomes in long-distance walkers.

METHODS

We measured cardiac troponin I concentrations in 725 participants (61 [54-69] yrs) before and immediately after 30 to 55 km of walking. We tested for an association between postexercise troponin I concentrations above the 99^th percentile (>0.040 µg/L) and a composite end point of all-cause mortality and major adverse cardiovascular events (myocardial infarction, stroke, heart failure, revascularization, or sudden cardiac arrest). Continuous variables were reported as mean ± standard deviation when normally distributed or median [interquartile range] when not normally distributed.

RESULTS

Participants walked 8.3 [7.3-9.3] hours at 68±10% of their maximum heart rate. Baseline troponin I concentrations were >0.040 µg/L in 9 participants (1%). Troponin I concentrations increased after walking (P<.001), with 63 participants (9%) demonstrating a postexercise troponin concentration >0.040 µg/L. During 43 [23-77] months of follow-up, 62 participants (9%) experienced an end point; 29 died and 33 had major adverse cardiovascular events. Compared with 7% with postexercise troponin I ≤0.040 µg/L (log-rank P<.001), 27% of participants with postexercise troponin I concentrations >0.040 µg/L experienced an end point. The hazard ratio was 2.48 (95% CI, 1.29-4.78) after adjusting for age, sex, cardiovascular risk factors (hypertension, hypercholesterolemia or diabetes mellitus), cardiovascular diseases (myocardial infarction, stroke, or heart failure), and baseline troponin I concentrations.

CONCLUSIONS

Exercise-induced troponin I elevations above the 99^th percentile after 30 to 55 km of walking independently predicted higher mortality and cardiovascular events in a cohort of older long-distance walkers. Exercise-induced increases in troponin may not be a benign physiological response to exercise, but an early marker of future mortality and cardiovascular events.

Exercise chronotropic incompetence phenotypes the level of cardiovascular risk and exercise gas exchange impairment in the general population. An analysis of the Euro-EX prevention trial

BACKGROUND

Chronotropic insufficiency (CI) is defined as the inability of the heart to increase its rate commensurate with increased demand. Exercise CI is an established predictor of major adverse cardiovascular events in patients with cardiovascular diseases.

AIM

The aim of this study was to evaluate how exercise CI phenotypes different levels of cardiovascular risk and how it may better perform in defining cardiovascular risk when analysed in the context of cardiopulmonary exercise test (CPET)-derived measures and standard echocardiography in a healthy population with variable cardiovascular risk profile.

METHODS

Apparently healthy individuals (N = 702, 53.8% females) with at least one major cardiovascular risk factor (MCVRF; hypertension, diabetes, tabagism, dyslipidaemia, body mass index > 25), enrolled in the Euro-EX prevention trial, underwent CPET. CI was defined as the inability to reach 80% of the chronotropic index, that is, the ratio of peak heart rate - rest heart rate/peak heart rate - age predicted maximal heart rate (AMPHR: 220 - age), they were divided into four groups according to the heart rate reserve (<80%>) and respiratory gas exchange ratio (RER; < 1.05>) as a marker of achieved maximal performance. Subjects with a RER < 1.05 (n = 103) were excluded and the final population (n = 599) was divided into CI group (n = 472) and no-CI group (n = 177).

RESULTS

Compared with no-CI, CI subjects were more frequently females with a history of hypertension in a high rate. CI subjects also exhibited a significantly lower peak oxygen uptake (VO₂) and circulatory power and an echocardiographic pattern indicative of higher left atrial volume index and left ventricular mass index. An inverse stepwise relationship between heart rate reserve and number of MCVRFs was observed (one MCVRF: 0.71 ± 0.23; two MCVRFs: 0.68 ± 0.24, three MCVRFs: 0.64 ± 0.20; four MCVRFs: 0.64 ± 0.23; five MCVRFs: 0.57 ± 18; p < 0.01). In multivariate analysis the only variable found predicting CI was peak VO₂ (p < 0.05; odds ratio 0.91; confidence interval 0.85-0.97).

CONCLUSIONS

In a population of apparently healthy subjects, exercise CI is common and phenotypes the progressive level of cardiovascular risk by a tight relationship with MCVRFs. CI patients exhibit some peculiar abnormal exercise gas exchange patterns (lower peak VO₂ and exercise oscillatory ventilation) and echo-derived measures (higher left atrium size and left ventricle mass) that may well anticipate evolution toward heart failure.

Obesity paradox in cardiovascular disease: where do we stand?

Obesity is associated with an increased risk of developing cardiovascular disease (CVD), particularly heart failure (HF) and coronary heart disease (CHD). The mechanisms through which obesity increases CVD risk involve changes in body composition that can affect hemodynamics and alters heart structure. Pro-inflammatory cytokines produced by the adipose tissue itself which can induce cardiac dysfunction and can promote the formation of atherosclerotic plaques. When obesity and HF or CHD coexist, individuals with class I obesity present a more favorable prognosis compared to individuals who are normal or underweight. This phenomenon has been termed the “obesity paradox.” Obesity is defined as an excess fat mass (FM), but individuals with obesity typically also present with an increased amount of lean mass (LM). The increase in LM may explain part of the obesity paradox as it is associated with improved cardiorespiratory fitness (CRF), a major determinant of clinical outcomes in the general population, but particularly in those with CVD, including HF. While increased LM is a stronger prognosticator in HF compared to FM, in patients with CHD excess FM can exert protective effects particularly when not associated with increased systemic inflammation. In the present review, we discuss the mechanisms through which obesity may increase the risk for CVD, and how it may exert protective effects in the setting of established CVD, with a focus on body composition. We also highlight the importance of measuring or estimating CRF, including body composition-adjusted measures of CRF (ie, lean peak oxygen consumption) for an improved risk status stratification in patients with CVD and finally, we discuss the potential non-pharmacologic therapeutics, such as exercise training and dietary interventions, aimed at improving CRF and perhaps clinical outcomes.

Urocortin 3 Levels Are Impaired in Overweight Humans With and Without Type 2 Diabetes and Modulated by Exercise

Urocortin3 (UCN3) regulates metabolic functions and is involved in cellular stress response. Although UCN3 is expressed in human adipose tissue, the association of UCN3 with obesity and diabetes remains unclear. This study investigated the effects of Type 2 diabetes (T2D) and increased body weight on the circulatory and subcutaneous adipose tissue (SAT) levels of UCN3 and assessed UCN3 modulation by a regular physical exercise. Normal-weight (n = 37) and overweight adults with and without T2D (n = 98 and n = 107, respectively) were enrolled in the study. A subset of the overweight subjects (n = 39 for each group) underwent a supervised 3-month exercise program combining both moderate intensity aerobic exercise and resistance training with treadmill. UCN3 levels in SAT were measured by immunofluorescence and RT-PCR. Circulatory UCN3 in plasma was assessed by ELISA and was correlated with various clinical and metabolic markers. Our data revealed that plasma UCN3 levels decreased in overweight subjects without T2D compared with normal-weight controls [median; 11.99 (0.78-86.07) and 6.27 (0.64-77.04), respectively; p < 0.001], whereas plasma UCN3 levels increased with concomitant T2D [median; 9.03 (0.77-104.92) p < 0.001]. UCN3 plasma levels were independently associated with glycemic index; fasting plasma glucose and hemoglobin A1c (r = 0.16 and r = 0.20, p < 0.05, respectively) and were significantly different between both overweight, with and without T2D, and normal-weight individuals (OR = 2.11 [1.84-4.11, 95% CI] and OR = 2.12 [1.59-3.10, 95% CI], p < 0.01, respectively). Conversely, the UCN3 patterns observed in SAT were opposite to those in circulation; UCN3 levels were significantly increased with body weight and decreased with T2D. After a 3-month supervised exercise protocol, UCN3 expression showed a significant reduction in SAT of both overweight groups (2.3 and 1.6-fold change; p < 0.01, respectively). In conclusion, UCN levels are differentially dysregulated in obesity in a tissue-dependent manner and can be mitigated by regular moderate physical exercise.