The average PEDro scale score for the 5 RCTs was 6.4 ± 0.5 (median: 6). None of the trials involved blinding of therapists, subjects, or assessors. Two studies satisfied the allocation concealment criterion.23,25 The quality assessment of the included studies is reported in Supplemental Digital Content Table 2, available at: http://links.lww.com/JCRP/A69.
ZUMBA FITNESS PROGRAMS IN HEALTHY WOMEN
Barene and colleagues21,22 conducted 2 RCTs in the same group of female hospital employees. They first investigated the effects of 12 wk of a ZF program and a soccer program (60-min sessions, 2-3 times per week in both groups) compared with a control group on CV variables such as
O2max, total body fat mass (BFM) in kg, and BFM%.21 At the end of the intervention, participants in the ZF group significantly improved
O2max by +5% and decreased BFM (−1.1%) compared with the control group. In the second study, Barene et al22 investigated the CV effects of 40 wk of soccer and ZF interventions program (60-min sessions, 2-3 times per week in both groups). They found that, although both ZF and soccer led to reduction in BFM (by −1.3 kg and −1.2 kg, respectively) and BFM% (by −1.3% and −1.2%, respectively), only the ZF group showed a significant improvement in
O2max (+7%), BMI (−0.77 kg/m2), and body weight (−2.1 kg) compared with the control group. Donath et al23 examined the effects of 8 wk (60-min sessions, 2 times per week) of ZF training on CV endurance, as assessed by the 6-min walk test, and BMI in 30 female college students. At the end of the training period, ZF resulted in statistically significant improvements in the 6-min walk test distance (+21%) and BMI (−1.8%) compared with controls. Delextrat et al24 investigated the effects of ZF on CV fitness and body composition. Forty-four women were randomly assigned to ZF or a control group. Cardiovascular fitness and body composition were assessed before and immediately after 8 wk of ZF performed 3 times per week (60-min sessions), compared with the no intervention group. Individuals in the ZF group showed significant improvements in
O2max (+3.1%) but no significant changes in body composition.
Overall, the absolute ES analyses performed between groups revealed low ES for
O2max, anthropometric and body composition profile after 8 to 12 wk of ZF compared with controls,21,23,24 while moderate to large absolute ESs for
O2max and body composition were detected after 40 wk of ZF training22 (Table 1).
ZUMBA FITNESS PROGRAMS IN WOMEN WITH CV RISK FACTORS
Domene et al25 conducted the only RCT on this topic and assessed the effects of ZF on CV risk factors and inflammatory biomarkers in overweight and sedentary women. Participants were randomly assigned to the ZF group (60-min sessions, 1-2 times per week for 8 wk) or a control group (no exercise intervention). The authors found that
O2max increased significantly by 10.5% in the ZF group. In addition, the ZF group also demonstrated statistically significant decreases in BFM (−3.7%), interleukin-6 (−36.4%), and white blood cell count (−31.3%). Micallef et al26 conducted an uncontrolled study among 36 overweight (BMI ≥25 kg/m2) women to evaluate the effects of a ZF program (60-min sessions, 2 times per week for 8 wk) on body weight and BMI. At the end of the program, statistically significant decreases in body weight and BMI (−2.5%) were reported.
In another single-group study, Araneta and Tanori27 assessed the effects of ZF (60-min sessions, 2 times per week for 12 wk) on changes in the components of the metabolic syndrome among 13 sedentary, overweight, or obese women with at least 2 of the metabolic syndrome diagnostic criteria.32 The authors found that systolic and diastolic blood pressure significantly decreased by 10.4% and 8.5%, respectively. Triglycerides decreased by 11.3%, while mean high-density lipoprotein cholesterol, fasting blood glucose, waist and hip circumferences, waist/hip ratio, and body weight improved without reaching statistical significance. Cugusi et al28 enrolled 27 overweight women and investigated the effects of a 12-wk ZF program on CV variables, hematic profile, and body composition (50-min sessions, 2-3 times per week). Significant decreases in body weight (−3.6%), BMI (−3.7%), circumferences (waist: −4.5% and hip: −5%), and BFM in kg (−6.3%) were found. In addition, a significant decrease in systolic and diastolic BP was observed (−3.9% and −5.8%, respectively).
In their clinical uncontrolled study, Krishnan et al29 evaluated the CV improvements from a ZF program (60-min sessions, 3 times per week for 16 wk) in 28 overweight/obese women with type 2 diabetes.
O2max improved by +7.1% and body weight (−1%), and BFM% (−2.6%) experienced significant reductions.
Finally, Rossmeissl et al30 conducted an uncontrolled study and assessed CV fitness, anthropometric profile, and body composition after 12 wk of ZumBeat dance intervention in a group of 17 post-menopausal and sedentary women with a BMI of ≥30 kg/m2 or a waist circumference of ≥94 cm. After the 12-wk intervention (60-min sessions, 2-3 times per week), no significant changes in CV fitness measured by
O2max, anthropometric profile, and body composition were detected.
Overall, ES analyses conducted within ZF groups revealed low ES both for body weight and BMI.26,28,29 Moderate to large ES for circumferences (waist and hip)28,29 and large ES for BP values were observed after 12 wk of ZF.27,28 In addition, very large relative ESs were found for
O2max and BFM% after 16 wk of a ZF intervention.29 The absolute ES analysis conducted for the RCT by Domene et al25 revealed low ES for
O2max, anthropometric and body composition profile, while large absolute ESs for CV inflammatory biomarkers after 8 wk of ZF compared with controls were reported25 (Table 2).
Zumba fitness currently enjoys its status as one of the most appealing, engaging, and popular forms of physical activity with near total female participation.33,34 Moreover, ZF falls in the broad category of physical activity of moderate to vigorous intensity; therefore, if performed consistently at those intensities, it could be a suitable form of training to achieve optimal levels of fitness in young, in adults, and the elderly1,10–14 and consistent with the American College of Sport Medicine guidelines.1,35,36
We sought to systematically ascertain the indirect CV benefits of ZF programs in women via changes in their CV fitness and risk profile following ZF intervention.
Overall, ZF leads to improvements in CV fitness, anthropometric profile, and body composition of healthy women. The duration of the ZF program appears to be directly related to the magnitude of improvement in CV fitness and risk profiles, as shown by greater ES associated with longer-term protocols (ie, >12 wk). Indeed, it is well established that regular physical training induces beneficial changes in cardiac structure and function, thus contributing to improved cardiac output and oxygen delivery during exercise.37 Accordingly, the long-term improvement in
O2max can be explained by augmented cardiac output combined with increased blood supply to skeletal muscle and improved muscle oxidative capacity, all of which are strongly associated with traditional long-term physical activity programs.38,39 Moderate to large absolute ESs were found to be associated with longer-term protocols (ie, >16 wk), even for the anthropometric profile and BFM%.22,29 These data are of particular interest since negative changes in lipid profile and body composition (especially in visceral fat mass) are considered reliable indicators of increased CV risk, contributing to the number of women meeting a diagnosis of metabolic syndrome.40
Based on the RTC by Domene et al,25 8 wk of ZF training led to larger observed ES in inflammatory biomarkers (interleukin-6 and white blood cell count) compared with changes in
O2max and BFM%. This is consistent with the physiological response to exercise preceding the changes in CV macrovariables such as
O2max and BFM%.41
In regard to the safety of ZF, the lack of any reported CV events during ZF sessions suggests that it is a safe physical activity, although the real impact of this form of exercise is difficult to determine because it depends on individual motivation. The overall adherence of 87.3% was considered as good, since at least 80% of the participants completed a program.42
While ZF may be regarded as a potentially promising activity to achieve such positive effects, the limited quality and quantity of the available evidence preclude definitive conclusions on the effectiveness of ZF-based programs on CV health variables.
Only 4 RCTs involving healthy women met the criteria for the present review, of which 221,22 studied the same population (n = 107) for 12 and 40 wk, respectively. The validity of the findings of the RCT included in this review, which reported improved fitness following ZF, should be interpreted cautiously, and generalizability is difficult due to the low pooled sample size(n = 181).
These data are even less consistent for those studies that attempted to elucidate the effects of ZF training in women with specific CV risk factors.25–30 Six studies were included, comprising 1 RCT25 and 5 uncontrolled trials.26–30 The RCT by Domene et al25 was a high-quality trial (PEDro score 7) but was a pilot study with a limited sample size (20 women). Those results need to be validated by further large-scale RCT. The other studies employed a quasi-experimental design, for which causality cannot be established and between-group results are not available, which is a crucial barrier to determining net changes in performance following varying training protocols.43 Moreover, the cumulative sample size of all 6 trials is 141 subjects, which limits the generalizability of the findings reported by the individual studies.
Although ZF instructors use music and choreographed routines to help promote exercising at a moderate to vigorous intensity, this form of physical activity is strictly dependent on the individual motivation of the participants. Therefore, women with CV risk factors may have not have exercised at the desired intensity for the entire duration of the ZF program and this may have affected the findings of these studies.21–30 Moreover, the various formats by which ZF training was taught24,30 (ie, ZumBeat modality avoiding jumps; ZF at home with DVD) need to be taken into account when comparing the findings of the studies.
Further high-quality research is strongly warranted to confirm findings of the included studies that can be considered preliminary for both healthy women and for those with specific CV risk factors. In particular, it is imperative to accumulate data from larger samples on the effects of ZF in the aforementioned populations through adequately powered randomized controlled clinical trials.
Future studies should also, to the extent possible, standardize the administration of training protocols. In particular, RCTs planned in accordance to the exercise prescription guidelines for women with specific CV risk factors35,36 should clearly define essential elements such as (1) exercise dose including intensity, frequency, duration, and an adequate follow-up period, and the intervention protocols should be supervised programs using standardized ZF with a frequency of at least 3 sessions per week, up to 60-min session duration at moderate to vigorous intensity (50%-80% heart rate reserve) and for a sustained period of time, such as 24 wk35,36; (2) limited exercise alternatives comparing ZF with the most common aerobic physical activities, such as swimming, jogging, or cycling; and (3) qualified instructors who should have appropriate knowledge and skills related to exercise prescription for women with preexisting CV risk factors.
Finally, ideal trials should use a specific set of outcome measures, which is crucial for accumulating consistent data to eventually be pooled and aggregated into meta-analytic estimates. These include hard outcome endpoints such as hospitalizations and even mortality data.
Zumba fitness is a safe, feasible, and easy-to-perform exercise program that suits a wide spectrum of fitness levels. This systematic review of existing small sample size trials using varying training protocols has determined dose-/duration-dependent beneficial effects of ZF on
O2max, anthropometric and body composition profiles in both healthy women and those with preexisting CV risk factors. Further high-quality RCTs with long-term follow-up are needed to validate the results from currently available scientific literature in this field.
The authors thank Dr Pablo A. Domene and Professor Svein Barene for the data supplied upon request. This study was supported by the Fondazione Banco di Sardegna and by grant #2015 from the Italian Society of Cardiology and MSD Italia-Merck Sharp & Dohme Corporation for the implementation of the project Physical Exercise and Therapy: An Integrated Approach for the Reduction of Cardiovascular Risk and Health Promotion at St George's University of London.
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cardiovascular health; exercise; physical activity; women; Zumba fitness
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