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Zumba Fitness and Women's Cardiovascular Health

A SYSTEMATIC REVIEW

Cugusi, Lucia, PhD; Manca, Andrea, PhD; Bergamin, Marco, PhD; Di Blasio, Andrea, PhD; Yeo, Tee Joo, MBBS, MRCP; Crisafulli, Antonio, PhD, MD; Mercuro, Giuseppe, MD in collaboration with the Working Group of Gender Cardiovascular Disease of the Italian Society of Cardiology

Journal of Cardiopulmonary Rehabilitation and Prevention: May 2019 - Volume 39 - Issue 3 - p 153–160
doi: 10.1097/HCR.0000000000000326
Scientific Review
Free
SDC

Purpose: Zumba fitness (ZF) is a well-known exercise program involving dance and fitness. Despite its increasing popularity, no analysis has been conducted on studies focusing on the cardiovascular (CV) profile of women who performed this activity. The aim of this systematic review is to provide insights into the impact of ZF on women's CV health.

Methods: Five clinical databases were searched. To be included, the articles had to include (1) women with or without CV risk factors (CVRF) and (2) CV-related outcomes resulting from a ZF program.

Results: Ten studies (322 women; 181 healthy, 141 with CVRF) were included. In healthy women, low absolute effect sizes for maximal oxygen uptake (

O2max), anthropometric and body composition profile after 8 and 12 wk of ZF were found compared with nonparticipants. Moderate to large absolute effect sizes were recorded for

O2max and body composition following 40 wk of ZF. Findings proved promising but less consistent for ZF studies involving women with CVRF due to the absence of control groups.

Conclusions: Data describe ZF as feasible for healthy women and a promising fitness option for those with CVRF. Because of the low quality of the studies on women with CVRF and the overall small sample size along with discrepancies such as the average length of the studies on healthy women, cautious interpretation of the findings is recommended. Further investigations with a standardized design are needed to verify whether ZF may be considered as an alternative fitness option in primary prevention of CV disease in women.

The purpose of this review was to systematically summarize, analyze, and discuss the cardiovascular (CV) benefits of Zumba fitness in women, in order to outline its potential roles in primary prevention of cardiovascular disease in both healthy subjects and in those presenting with specific CV risk factors.

Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy (Drs Cugusi, Crisafulli, and Mercuro); Department of Biomedical Sciences, University of Sassari, Sassari, Italy (Dr Manca); Sport and Exercise Medicine Division, Department of Medicine, University of Padova, Padova, Italy (Dr Bergamin); Endocrine Section, Department of Medicine and Aging Sciences, “G. d'Annunzio” University of Chieti-Pescara, Chieti, Italy (Dr Di Blasio); and Department of Cardiology, National University Heart Centre, Singapore, Singapore (Dr Yeo).

Correspondence: Lucia Cugusi, PhD, Department of Medical Sciences and Public Health, University of Cagliari, Strada Statale 554, Km 4.500 09042 Monserrato (Cagliari), Sardinia, Italy (lucia.cugusi@unica.it).

The authors declare no conflicts of interest.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.jcrpjournal.com).

Regular and continuous physical activity is associated with several health benefits, including improved emotional and psychological status, overall well-being, and reduced mortality.1–3 Despite these widely established beneficial effects and the proliferation of guidelines recommending exercise to lower one's risk of cardiovascular disease, the prevalence of sedentary lifestyles is continuously increasing, especially in women.2,3

In addition, the incidence of myocardial infarction in women, although lower than that in men, increases dramatically after menopause, partly due to a decrease in endogenous estrogens.4,5 Moreover, most post-menopausal women tend to further reduce their general activity, potentially leading to an increased risk of chronic diseases such as hypertension and obesity.4

To overcome the barrier of a sedentary lifestyle and its associated cardiovascular disease risks in women, it is necessary to identify novel and sustainable forms of physical activity that can appeal to large numbers for a sufficient duration and at an appropriate intensity to induce fitness and health effects, especially for those with cardiovascular (CV) risk factors such as obesity, type 2 diabetes, and hypertension.

To this purpose, unconventional forms of physical activity such as aerobic dances, step aerobics, and cultural dances seem appropriate, as they represent enjoyable and effective exercise options, especially for women.6–9 Looking outside the medical context and into the area of fitness training, 1 of these emerging activities is Zumba fitness (ZF). Zumba fitness is a well-known lifestyle workout that combines Latin rhythms with different movements, entertainment, and fitness. Zumba fitness is universally taught by certified professionals who encourage participants to work at a moderate to vigorous exercise intensity.10 Previous studies on ZF showed that this training strategy (performed at an average of 79% of HRmax and 66% of maximal oxygen uptake [

O2max]) is capable to enhance cardiorespiratory fitness.10,11 In addition, due to its average energy expenditure of 369 kcal for a typical class (length approximately 40 min), ZF meets the American College of Sport Medicine recommendations for exercise prescription in healthy subjects of all ages.1,10–13

The purpose of this review was to systematically summarize, analyze, and interpret the CV benefıts of ZF in women, in order to outline its potential roles in primary prevention of cardiovascular disease in both healthy subjects and women presenting with specific CV risk factors.

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METHODS

PROTOCOL AND LITERATURE SEARCH

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used as a reporting structure for this systematic review.14 Electronic searches of 5 citation databases from inception to March 2017 were conducted and included PubMed/MEDLINE, Scopus, Web of Science, the Cochrane Database (Cochrane Central Register of Controlled Trials), and ClinicalTrials.gov. A comprehensive search strategy for primary studies was developed and performed by 2 of the authors (L.C. and A.M.), using the following key words: “Zumba” or “Zumba®.” Only full-text articles were included and the references of all selected articles were checked for further relevant publications. Data collection and analysis were performed between February and March 2017. Randomized controlled trials (RCTs) and clinical uncontrolled trials were considered. A detailed literature search strategy for each of the databases can be found in Supplemental Digital Content Table 1, available at: http://links.lww.com/JCRP/A68.

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SELECTION PROCESS AND DATA EXTRACTION

The articles included in this review met the following criteria based on the Patient, Intervention, Comparison, Outcome model15: (1) women of all ages with or without specific CV risk factors, namely, hypertension, dyslipidemia, type 2 diabetes, overweight/obesity, metabolic syndrome, smoking, post-menopause, family history of premature coronary artery disease, and a sedentary lifestyle (defined as ≤1 d/wk of moderate to vigorous physical activity for no more than 30 min); and (2) analyses of CV-related outcomes arising from a ZF program (defined as lasting ≥2 wk duration). Titles and abstracts of relevant articles were independently assessed by 2 authors (L.C. and A.M.) and duplicates were removed. A full-text article was evaluated when the title or abstract presented insufficient information to determine inclusion. In case of disagreement, a mutual discussion to reach consensus was carried out and, if necessary, a third author (A.C.) contributed to the final decision.

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DATA COLLECTION AND QUALITY ASSESSMENT

The number and characteristics of the participants (ie, age, presence of CV risk factors, body mass index [BMI]), interventions (duration, frequency and number of weeks of ZF, presence of control group or other exercise group), and CV-related outcomes (ie, CV fitness as assessed using

O2max, anthropometric profile, body composition, and hematic variables) at each time point were extracted and collected independently using a standardized data extraction form.

The risk-of-bias assessment for included RCTs was performed by employing the Physiotherapy Evidence Database (PEDro) scale. The PEDro scale is based on the Delphi list developed by Verhagen et al16 to assess the methodological quality of RCTs in physical therapy. The PEDro total score ranges from 1 to 10 points (a higher score corresponds to a higher methodological study quality).16

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STATISTICAL ANALYSIS

The clinical relevance of the intervention-induced changes was estimated by calculating the Cohen d effect size (ES): small, ≤0.5; moderate, 0.51-0.79; large, ≥0.8,17 according to the formulas by Hedges and Olkin,18 which correct for bias deriving from the employment of pooled standard deviations. For each clinical uncontrolled study, relative ES comparing pre- versus post-ZF intervention was calculated. These relative ESs were then adjusted, as recommended for within-subject studies.19 For the RCTs, absolute ESs were calculated comparing Zumba versus other interventions and/or controls. The ES analysis is considered as a valid method in clinical studies and systematic reviews to estimate the practical significance of the findings and to present the magnitude of the recorded effects in a standardized metric regardless of the scale used to assess the variables.20 All calculations were based on data provided in the full text of the studies. In cases in which data were missing or unavailable from the article, a formal request was sent to the corresponding author.

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RESULTS

STUDY SELECTION

The primary search yielded 164 potential studies. Of those, 4 RCTs involving healthy women and 6 studies (1 RCT and 5 clinical uncontrolled studies) focusing on CV-related outcomes arising from ZF programs for women with specific CV risk factors met all the eligibility criteria and were included in the qualitative synthesis.21–30 After the analysis of the full texts, 1 study was excluded because of an observational-only design.31 A comprehensive flow diagram for the study selection process is presented in the Figure.

Figure

Figure

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QUALITATIVE DATA SYNTHESIS

The selected studies were published between 2014 and 2016 and enrolled a total of 322 women aged 18 to 65 y. Four RCTs involved healthy women (n = 181),21–24 and 6 studies (1 RCT and 5 clinical uncontrolled studies) enrolled subjects with preexisting CV risk factors (n = 141), namely, overweight or obesity,25–30 type 2 diabetes,29 metabolic syndrome,27 sedentary lifestyle,25–30 and post-menopause.30

Of the 5 RCTs, all compared the effects of ZF to control groups (conventional care alone or/and no exercise intervention).21–25 Two RCTs reported data from more than 1 exercise protocol (ZF and soccer); however, the authors did not compare the 2 training groups because of the assumptions in their statistical model that gave them the power to only compare each of the training groups with the control group.21,22

Different frequencies and durations of ZF programs were tested in the trials, ranging from 1 to 3 times per week for 8 to 40 wk. On average, interventions were carried out for 13.6 ± 9.6 wk (95% CI, 7.6-19.6 wk). Each ZF session consisted of warm-up (flexibility and strength exercises), a main phase, and cooldown. Overall, ZF was taught in its standard format,10 except for the study by Rossmeissl et al,30 which used ZumBeat (a modified type of Zumba, aiming to reduce strain for the musculoskeletal system by avoiding high-impact jumping movements), and in the study by Delextrat et al24 in which the ZF program was unsupervised (used DVD at home). None of the studies reported CV events during any of the exercise sessions. The average dropout rate was 12.7%, with a general adherence rate of 87.3%.

Cardiovascular fitness variables, such as maximal or submaximal heart rate and measured

O2max (except for the study by Krishnan et al,29 in which the

O2max was estimated), were analyzed in 8 studies,21–25,28–30 the anthropometric profile in all the included studies, and body composition in 7 trials.21,22,24,25,28–30 Blood pressure was evaluated in 7 studies21,22,25,27–30 and hematic profile in 5 trials.22,25,27–29 Only 1 RCT assessed all of the aforementioned variables along with specific inflammatory biomarkers (interleukin-6 and white blood cell count).25 The main results for each study in terms of significance and clinical relevance (relative ES for clinical uncontrolled studies and absolute ES for RCT) of intervention-induced changes are detailed in Tables 1 and 2.

Table 1

Table 1

Table 2

Table 2

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QUALITY ASSESSMENT

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.

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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).

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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).

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DISCUSSION

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.

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CONCLUSIONS

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.

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ACKNOWLEDGMENTS

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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Keywords:

cardiovascular health; exercise; physical activity; women; Zumba fitness

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