Medicine & Science in Sports & Exercise:
Roundtable Consensus Statement
Physical activity in the prevention and treatment of hypertension in the obese
FAGARD, ROBERT H.
Hypertension and Cardiovascular Rehabilitation Unit, Department of Molecular and Cardiovascular Research, Faculty of Medicine, University of Leuven, Leuven, BELGIUM
Address for correspondence: R. Fagard, M.D., Ph.D., Prof. of Medicine, U.Z. Gasthuisberg-Hypertensie, Herestraat 49, B-3000 Leuven, Belgium. E-mail: robert.fagard@ uz.kuleuven.ac.be.
Roundtable held February 4–7, 1999, Indianapolis, IN.
FAGARD, R. H. Physical activity in the prevention and treatment of hypertension in the obese. Med. Sci. Sports Exerc., Vol. 31, No. 11, Suppl., pp. S624–S630, 1999.
Purpose: The purpose of this paper was to assess the value of physical exercise in the prevention and treatment of hypertension with particular attention to possible interactions with relative weight.
Methods: We describe epidemiological studies and report meta-analyses of randomized intervention trials, i.e., randomized controlled trials on dynamic physical training and randomized comparative trials of exercise and diet.
Results: Epidemiological studies show an inverse relationship between physical activity or fitness and the incidence of hypertension, which was either independent of body size or more pronounced in the overweight. The weighted net reduction of blood pressure in response to dynamic physical training averages 3.4/2.4 mm Hg (P < 0.001), which appears to be unrelated to the initial body mass index ( BMI) and to its training-induced changes. Exercise is less effective than diet in lowering blood pressure (P < 0.02), and adding exercise to diet does not appear to further reduce blood pressure. Future studies should observe scientific criteria more strictly, address the truly obese (BMI ≥ 30 kg·m−2) and attempt to resolve the blood pressure lowering mechanisms.
Conclusion: Physical activity contributes to the control of blood pressure in overweight as well as in lean subjects.
Salt restriction, moderation of alcohol consumption, weight reduction, and increased physical activity are generally accepted lifestyle measures for the management of hypertension (25,60). Meta-analyses concluded that adequate dynamic physical training contributes to the control of blood pressure (15,21), but it has not been investigated whether the effect would be more pronounced in overweight and obese than in lean subjects. The present review therefore addresses the following questions: 1) Is body mass index (BMI) a significant determinant of the preventive effect of physical activity or fitness on the development of hypertension? 2) Is the effect of dynamic physical training on blood pressure different in obese and nonobese subjects? 3) Are training-induced blood pressure changes related to changes in weight? 4) How does the influence of physical training compare with that of dietary intervention? The first question will be addressed by description of the available material, the others by use of meta-analytical techniques (14).
Selection of Papers
Articles published before August 1998 and relevant to the aims of this review were identified by a computer-assisted literature search and by checking the reference lists of papers on the topic. When meta-analytical techniques were applied, several criteria were used for acceptability of studies: random allocation to intervention groups and control groups or control phases in case of cross-over design; full publication in a peer-reviewed journal; absence of confounding by some other intervention during the intervention of interest. To assess the influence of dynamic physical training on blood pressure, only randomized controlled trials of at least 4 wk duration concerning normotensive or hypertensive subjects, or both, in whom cardiovascular diseases were reasonably well excluded, were considered. When the effects of exercise were compared with those of dietary intervention or with the combination of diet and exercise, random allocation to the intervention groups was required; however, a control group without intervention was not a prerequisite for inclusion. Finally, studies were accepted only when the actual blood pressures for the intervention and the control groups or phases, or the pressure changes during the intervention and control periods, were available.
Database management and statistical analyses were performed with the SAS software (The SAS Institute Inc., Cary, NC). Meta-analyses consisted of analyses of pooled data with study groups as the units of analysis, with weighting for the number of participants in each group. The net effects of physical training were assessed by weighted pooled analyses of the changes in the intervention groups adjusted for control data. The effects of exercise versus diet or versus diet and exercise combined were assessed by weighted pooled analyses on the differences between the changes in the exercise groups and the changes in the intervention groups with which the effect of exercise was compared. Results are reported as weighted means and 95% confidence limits (95% CL). Finally, weighted metaregression analysis was applied to assess whether variations in the results were related to variations in study group characteristics (14).
Physical Activity, Fitness, and Future Blood Pressure
Several studies addressed the relationships between physical activity or fitness and future blood pressure or the incidence of hypertension. Gillum et al. (18) followed 106 subjects from youth to middle age during 32 yr. Physical fitness was derived from pulse rate during a single-stage treadmill exercise test. Individuals who were judged fit had lower systolic blood pressure at follow-up, independent of weight and BMI and of their changes during the follow-up period (r = 0.26;P < 0.01). Blair et al. (3) related physical fitness, assessed by maximal treadmill testing in healthy normotensive men (N = 4,820) and women (N = 1,219), aged 20 to 65 yr, to the incidence of hypertension. After the baseline examination the subjects participated in a follow-up mail survey; the follow-up interval ranged from 1 to 12 yr, with a median of 4 yr. Those with excellent and superior fitness (28% of the participants) comprised the reference high physical fitness category, whereas the remaining four physical fitness categories (very poor to good) comprised the comparison group (72%). After adjustment for age, sex, baseline BMI, blood pressure, and follow-up interval, persons with low levels of physical fitness had a relative risk of 1.52 for the development of hypertension when compared with the highly fit persons (P = 0.02). Sawada et al. (47) investigated the relationship between physical fitness and incidence of hypertension through a prospective study in 3,305 Japanese men whose blood pressure was normal when they received their first physical examination before the age of 50. The blood pressure of 425 subjects was diagnosed as hypertension in the fifth year. The relative risk of hypertension, after adjustment for age, initial blood pressure, body fat, and other confounders was 1.9 times higher in the least fit compared with the fittest group (P < 0.01).
Paffenbarger et al. (43) assessed the incidence of hypertension in 14,998 Harvard male alumni during a 6- to 10-yr follow-up beginning 16 to 50 yr after college entrance. Presence or absence of a background of collegiate sports did not influence the risk of hypertension in this study population, nor did stair-climbing, walking or light sports play by alumni, based on physical activity information obtained by mailed questionnaires in a postcollege health survey. Higher levels of BMI, weight gain since college, history of parental hypertension, and lack of strenuous exercise independently predicted increased risk of hypertension in alumni. Alumni who did not engage in vigorous sports play in postcollege years (59%) were at 35% greater risk of hypertension than the 41% who did (P < 0.001), and this relationship held at all ages, 35 to 74 yr. In addition, the inverse relationship between contemporary vigorous exercise and hypertension was most evident for alumni overweight-for-height. Alumni with a BMI less than 36 U.S. units (20% over ideal weight-for-height) but nonparticipants in vigorous sports were at only 15% increased risk of hypertension over comparably light participants, while alumni with a BMI greater than 36 U.S. units but nonparticipants were at 58% increased risk over similarly heavy participants. Among men with little gain in BMI since college, there was a 25% greater risk of hypertension among inactives than among actives, while the corresponding figure among those whose gain in BMI was greater than five U.S. units (or > 11.5 kg for a constant height) was 43%.
Evidence Statement: Higher levels of physical activity or fitness are associated with a lower incidence of hypertension; the effect of overweight on this relationship is uncertain. (Evidence Category C)
Physical Training and Blood Pressure Control
We identified 44 randomized controlled trials on the effect of dynamic aerobic or endurance exercise on blood pressure at rest in otherwise healthy normotensive or hypertensive individuals (1,2,4–11,16,17,20,22–24,27–42,44–46,49,50,52–58). Of the 2,674 participants, 65% were men. Nineteen studies comprised only men, four only women, and the others included both sexes (or sex unknown in one). Some studies involved several groups of subjects or applied different training regimens in the same participants, so that a total of 68 training groups/programs are available for analysis. Average age of the groups ranged from 21 to 79 yr (median: 44). Duration of training ranged from 4 to 52 wk (median: 16) with a frequency of one to seven weekly sessions (median: three) of 15–70 min each, including warm-up and cool-down activities (median: 50 min). The exercises involved walking, jogging, running in 69% of the studies, cycling in 50%, swimming in 3%, and other exercises were included in 23% of the training regimens. Average training intensity in the various groups varied between 30 and 85% of maximal exercise performance (median: 65%).
Control data were collected only at the beginning and at the end of the control period in 23 studies; three control groups were subjected to light dynamic or recreational exercises, 10 were seen at least once in the research facilities, and another eight were contacted regularly by the investigators. Resting blood pressure was measured by an automatic device in 5 of the 44 studies; when pressure was measured by use of a random zero device (N = 15) or by conventional (or unspecified) methodology (N = 24), the investigator was blinded to the treatment in only five and three studies, respectively.
Table 1 summarizes the overall results. In the 68 study groups, the changes of blood pressure in response to training, after adjustment for the control observations, ranged from +9 to −20 mm Hg for systolic blood pressure and from +11 to −11 mm Hg for diastolic pressure. The overall net changes averaged −3.4/−2.4 mm Hg (P < 0.001), that is, after adjustment for control observations and after weighting for the number of trained participants that could be analyzed in each study group, whose total number amounted to 1,529. Peak oxygen uptake increased significantly by 11.8% (95% CL: 10.3; 13.4), whereas heart rate, BMI, and percent body fat decreased by, respectively 6.8% (5.5; 8.2), 1.2% (0.8; 1.7), and 4.3% (2.5; 6.1).
Influence of BMI.
Table 2 summarizes the results according to whether average baseline BMI, available in 64 study groups, was below 25 kg·m−2 (lean groups) or ≥ 25 kg·m−2 (overweight and obese groups). Age and peak oxygen uptake were similar in the two groups. Overweight subjects had higher baseline values for heart rate and diastolic blood pressure. Training-induced changes in peak oxygen uptake and heart rate did not differ between the groups. Whereas BMI decreased significantly in the overweight (P < 0.001) but not in the lean subjects (P = 0.12), the weighted net changes of systolic and diastolic blood pressure were significant (P < 0.001) and similar in the two groups.
In addition, weighted metaregression analysis showed that there was no significant relationship between the changes in systolic (r = 0.08;P = 0.51) and diastolic (r = 0.06;P = 0.61) blood pressure, respectively, and baseline BMI (N = 64). Finally, changes in blood pressure were not related to changes in BMI for systolic (r = 0.09;P = 0.51) or for diastolic pressure (r = 0.07;P = 0.59) (N = 61). Figures 1 and 2 illustrate these relationships for systolic blood pressure.
Influence of blood pressure.
Average blood pressure was in the normotensive range, defined as systolic blood pressure lower than 140 mm Hg and diastolic pressure below 90 mm Hg, in 52 study groups. Sixteen groups were classified as hypertensive at baseline. The training-induced weighted net change of blood pressure averaged −7.4 (−10.5;−4.3)/−5.8 (−8.0;−3.5) mm Hg in the hypertensives and −2.6 (−3.7;−1.5)/−1.8 (−2.6;−1.1) mm Hg in the normotensives.
Influence of age.
Weighted metaregression analysis revealed that baseline BMI (P = 0.65), systolic (P = 0.29), and diastolic (P = 0.38) blood pressure did not differ according to age. Whereas BMI (y) decreased more in younger than in older subjects in response to exercise training (Δ BMI = −0.82 + 0.01 × year; r = 0.28;P = 0.03), age was not a significant determinant of the blood pressure response (P = 0.33 for systolic, and P = 0.68 for diastolic pressure).
Evidence Statement: Dynamic aerobic training reduces blood pressure independent of changes in weight; the blood pressure lowering effect depends on the initial blood pressure, but not on BMI or age. Evidence Category A
Physical Training, Diet, and Blood Pressure Control
We identified 10 randomized trials in which the influence of diet was compared with that of exercise alone and/or with the combined effects of diet and exercise in mostly overweight subjects (2,7,16,19,23,26,45,49,51,59). Two of these studies did not include a nonexercise nondiet control group (19,59), so that the results have not been adjusted for control data in the meta-analysis. Study duration ranged from 4 to 52 wk (median = 38). Table 3 summarizes the results for the paired comparison of exercise and diet (11 study groups). Only physical training increased peak oxygen uptake. The reduction in BMI was significantly more pronounced in the diet groups than in the exercise groups. Finally the reduction of blood pressure with diet alone (−5.9/−4.2 mm Hg) was superior to that of exercise alone (−3.6/−2.7 mm Hg).
The results on the comparison of combined exercise and diet intervention with diet alone are shown in Table 4 (N = 11). Only the combined intervention increased peak oxygen uptake. Diet alone was less effective in reducing BMI. Nevertheless, there was no evidence that adding physical training to diet was more effective for blood pressure control than diet alone.
Evidence Statement: Dynamic aerobic training is less effective than diet in lowering blood pressure and exercise does not add to the blood pressure reduction by diet alone. Evidence Category A
Several epidemiological studies suggest that the incidence of hypertension is less in physically fit or active people than in unfit or sedentary subjects (3,18,43,47). This relationship was independent of baseline BMI or body fat (3,18,47). However, Paffenbarger et al. (43) reported that the inverse relationship between exercise and the incidence of hypertension was more evident for overweight than for lean Harvard alumni.
The results from cross-sectional studies on the associations between physical activity, fitness, and blood pressure are not quite consistent (12,13). Whereas several studies did not observe significant independent relationships, others did find that blood pressure was lower in fitter or more active subjects. On the whole, the differences in blood pressure between the most and the least fit or active rarely exceeded 5 mm Hg after controlling for confounding factors such as age and body size (12,13). It remains difficult, however, to ascribe differences in blood pressure within a population to differences in levels of physical activity or fitness because of the possible confounding factors which cannot be accounted for. Therefore, longitudinal intervention studies are more appropriate to assess the effect of physical exercise on blood pressure. The present meta-analysis of 44 randomized controlled trials involving 68 study groups indicates that dynamic aerobic exercise reduces blood pressure at rest by an average of 3.4 mm Hg for systolic and 2.4 mm Hg for diastolic pressure above blood pressure changes in nonexercising control groups or periods. Baseline BMI did not affect the blood pressure response: the change in blood pressure was indeed similar in overweight and lean participants. However, the lowering of blood pressure was more pronounced in hypertensive subgroups than in the normotensives. The exercise programs led to decreases of BMI (61), particularly in the overweight and obese subjects, but these changes did not determine the blood pressure response.
Weight reduction has been shown to lower blood pressure in overweight subjects (48). The overall analysis of randomized trials in which physical training was compared with dietary intervention in mostly overweight subjects indicates that diet was more effective in reducing both BMI and blood pressure. When exercise was added to diet, BMI was reduced to a greater extent than with diet alone, but there was no additional effect on blood pressure.
Physical Training and Obesity
Figure 1 shows that a large number of data are available in overweight subjects (BMI: 25–29.9 kg·−2), but that few randomized controlled trials involved obese patients (BMI ≥ 30 kg·m−2). Therefore, future studies should concentrate on the truly obese, not only to assess the influence on blood pressure but also to define the ideal training program in terms of mode, frequency, time, and intensity.
Scientific Validity of Studies
Although a large number of trials were controlled and applied randomization techniques, other important scientific criteria have not always been observed. The following shortcomings were identified in a variable number of training studies: lack of regular follow-up of the control subjects; no advice to keep diet or lifestyle, or both, constant throughout the study periods; a high number of drop-outs; inadequate statistical analyses and lack of adjustment for confounding variables; failure to blind the person who measured the blood pressure to the treatment or to use stationary or ambulatory automated blood pressure devices; and lack of use of an appropriate cuff size in the obese. Future studies should address these issues. However, it should be realized that it is difficult to blind the participants to the treatment in training studies; the inclusion of low-level exercise as placebo treatment is controversial.
The results on hemodynamic changes in response to dynamic training are conflicting; some authors claim that the lowering of blood pressure is based on a reduction of systemic vascular resistance whereas others observed a decrease of cardiac output. Most studies found a decrease of plasma noradrenaline concentrations suggesting a reduction in autonomic nervous activity. Other possible blood pressure lowering mechanisms have been addressed only rarely in randomized controlled exercise trials. Future studies, particularly in the obese, should not only focus on blood pressure but also on mechanisms involved in blood pressure regulation such as the renin-angiotensin-aldosterone system, prostaglandins, endothelial relaxing factor and endothelin, the sympathetic nervous system, insulin sensitivity and finally, genetic polymorphisms that might influence the blood pressure response to physical training.
The authors gratefully acknowledge the secretarial assistance of N. Ausseloos. R. Fagard is holder of the Prof. A. Amery Chair in Hypertension Research, founded by Merck, Sharp, and Dohme (Belgium).
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AEROBIC POWER; BLOOD PRESSURE; BODY FAT; BMI; DIET; EXERCISE
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