|Year : 2015 | Volume
| Issue : 1 | Page : 38-45
Effectiveness of short-term aerobic exercise program on cardiovascular risk profile in moderate risk adults: A randomized controlled pilot study
Vijay Pratap Singh1, Preeti Thakur1, Bidita Khandelwal2
1 Department of Physiotherapy, Sikkim Manipal Institute of Medical Science, Tadong, Gangtok, Sikkim, India
2 Department of Medicine, Sikkim Manipal Institute of Medical Science, Tadong, Gangtok, Sikkim, India
|Date of Web Publication||14-Jan-2015|
Dr. Vijay Pratap Singh
Department of Physiotherapy, Sikkim Manipal Institute of Medical Science, 5th Mile, Tadong, Gangtok - 737 101, Sikkim
Source of Support: None, Conflict of Interest: None
Background: According to World Health Report 2002, cardiovascular diseases (CVDs) will be the largest cause of death and disability by 2020 in India. In 2020, 2.6 million Indians are predicted to die due to coronary heart disease, which constitutes 54.1% of all CVD deaths. Nearly half of these deaths are likely to occur in young and middle-aged individuals (30-69 years). We undertook this study with objectives to evaluate the cardiovascular risk profile in asymptomatic individuals with moderate risk factors and to understand the effect of the short-term (3 weeks) exercise over cardiovascular risk factors. Materials and Methods: A randomized controlled trial was conducted with a total of 34 subjects comprising of 17 subjects in each group. Subjects underwent biochemical tests like fasting lipid (total cholesterol [TC], triglyceride, high-density lipoproteins [HDLs], low-density lipoproteins [LDLs]) and fasting blood glucose. Other outcome measures were VO 2 max, body mass index and body fat % (BF%). Results: This study suggested that 3 weeks of moderate intensity aerobic training has a beneficial effect in lowering the cardiovascular risk profiles in adults with moderate risk factors. This training reduced TC, improves HDL, reduced LDL and improved aerobic capacity by improving VO 2 max and reducing BF%.
Keywords: Aerobic exercise program, risk profile, VO 2
|How to cite this article:|
Singh VP, Thakur P, Khandelwal B. Effectiveness of short-term aerobic exercise program on cardiovascular risk profile in moderate risk adults: A randomized controlled pilot study. CHRISMED J Health Res 2015;2:38-45
|How to cite this URL:|
Singh VP, Thakur P, Khandelwal B. Effectiveness of short-term aerobic exercise program on cardiovascular risk profile in moderate risk adults: A randomized controlled pilot study. CHRISMED J Health Res [serial online] 2015 [cited 2021 Apr 11];2:38-45. Available from: https://www.cjhr.org/text.asp?2015/2/1/38/149343
| Introduction|| |
According to World Health Report 2002, cardiovascular diseases (CVDs) will be the largest cause of death and disability by 2020 in India. In 2020, 2.6 million Indians are predicted to die due to coronary heart disease (CHD) which constitutes 54.1% of all CVD deaths. Nearly half of these deaths are likely to occur in young and middle-aged individuals (30-69 years). Currently, Indians experience CVD deaths at least a decade earlier than their counterparts in countries with established market economies. The Global Burden of Disease study estimates that 52% of CVD deaths occur below the age of 70 years in India. The contributing factors for the growing burden of CVDs are increasing prevalence of cardiovascular risk factors especially hypertension, dyslipidemia, diabetes, overweight or obesity, physical inactivity and tobacco use. 
The prevalence of coronary artery disease (CAD) is rising rapidly in urban India. Lifestyle changes and aggressive control of risk factors are urgently needed to reverse this trend. In adults, overweight and low levels of aerobic fitness are independently associated with an increased risk of CVD mortality. 
The biology of atherosclerotic disease, its determinants and complications are a continuum of risk in the population. At one end of the spectrum are young individuals without atherosclerotic disease who have not yet been sufficiently exposed to the life-style and environmental factors responsible for this disease and its complications. Then, there are an increasing number of individuals who develop asymptomatic atherosclerosis as a consequence of their exposure to smoking, an unhealthy diet and sedentary life-style, which result in obesity, hypertension, dyslipidemia, diabetes and other risk factors for atherosclerosis and its complications. 
Coronary artery disease is usually due to atherosclerosis of large and medium-sized arteries and dyslipidemia has been found to be one of the most important contributing factors. As it has long been known that lipid abnormalities are major risk factors for premature CAD, studies on the prevalence of these risk factors are urgently needed. Pathological studies have shown that both the presence and extent of atherosclerotic lesions at autopsy after unexpected death of children and young adults correlate positively and significantly with established risk factors, for example increased low density lipoprotein-cholesterol (LDL-C), increased triglycerides [TGs], increased systolic and diastolic blood pressure (BP), increased body mass index [BMI], and presence of cigarette smoking. The existing evidence indicates that the primary prevention of atherosclerotic disease should begin in childhood by having a practical approach to cardiovascular health promotion and identification and management of known risk factors for CVD in children and young adults. 
A study was performed to determine the cardiovascular risk showed that the risk of developing CVD increases with increasing age. The known age dependence of total cholesterol (TC) and LDL-C is less pronounced for those following a healthy lifestyle. This suggests that the age-dependent rise of these parameters is partly preventable. 
Physical activity has been proved to be effective in reducing cardiovascular risk factors in asymptomatic, special and diseased population. Special population corresponds to individuals with family history of diabetes, hypertension, dyslipidemia, etc., Various studies stated that only long term exercise needed to induce a difference in the cardiovascular risk profile,  compliance brings the effectiveness of long-term physical activity which is poorly followed by the community-dwelling adults. 
There is dearth of research which has evaluated short-term effectiveness (3 weeks) of the exercise training over the cardiovascular risk profiles. Long term exercise based programs are proven to have beneficial effects on risk factors, this study intends to find out whether short-term program can have beneficial effects and to what extent. Prevention targeted at patients with established coronary disease and a high-risk strategy targeted at healthy individuals at high risk are an integral part of clinical practice. The clinical approaches and the population approaches for CHD prevention are complimentary, but the population strategy is fundamental to reducing the burden of CVD.  The long term effect of aerobic exercise in reduction of cardiovascular risk has been proved, but noncompliance to long term exercise is a major issue. Therefore, we want to see the effect of short term aerobic exercise which would increase compliance to training, and its effect can be known.
We undertook this study with objectives to evaluate the cardiovascular risk profile in asymptomatic individuals and to understand the effect of the short-term (3 weeks) exercise over cardiovascular risk factors.
| Materials and Methods|| |
Ethical committee clearance was received before conducting the study. Advertisement was put up in the college notice board. Only voluntary candidates were accepted. Sample size determination was based on the previous study where a reduction of LDLs by two was minimal important difference.  Based on this assumption power calculation was done with a power 80%, the alpha error 5%, the required sample size was 20. Subjects were allocated to intervention and control group by Random table method. Total of 34 subjects participated comprising of 17 subjects in each group. There were no dropouts in the study as shown in [Figure 1].
|Figure 1: Random allocation of subjects, drop outs, follow-up and analysis|
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Once the candidate reported to the out-patient department they were properly explained regarding the study and various procedures. Written informed consent was obtained. Following which proper history taking was done by the investigator based on the risk factor stratification criteria defined by American College of Sports Medicine (ACSM) as shown in [Table 3].  Subjects underwent biochemical tests like fasting lipid (TC, TG, high-density lipoproteins [HDL], LDL) and fasting blood glucose investigation at hospital laboratory. BP and BMI were measured by an experienced physiotherapist who was blinded to the study. These entire outcomes were measured on the day of commencing the training. After receiving the blood profile investigation reports and completing the history taking, BMI and BP measurement subjects were categorized into three different level of cardiovascular risk: Low risk, moderate risk and severe risk as shown in [Table 3] as per ACSM guidelines. 
Only subjects with moderate cardiovascular risk were recruited in the study due to feasibility of recruitment of subjects. Apart from the above outcome measures, endurance capacity was assessed through Queens College step test to obtain VO 2 max and body fat % (BF%) was measured by skinfold caliper for all the subjects. Subjects who were involved in any exercise program, on medications like steroid, protein supplements, antilipids, antidepressants were excluded. Subjects were asked to continue their usual diet and not to modify during the period of study however we advised subjects about healthy diet after completion of the study so that diet factor could not affect outcomes.
Exercise prescription for intervention and control group followed principles of prescription as described by ACSM, which needs specification for frequency, intensity, duration and mode of training.  Intervention group received moderate intensity aerobic training protocol, with a frequency of 5 days/week for 3 weeks. Exercise was performed at moderate intensity that was determined on the basis of age-predicted maximal heart rate (APMHR).
Age predicted maximal heart rate = 206.9 - (0.67 × Age in years) and moderate intensity is 64-76% of MHR. Duration was 30 min for each session. It included 5-10 min of warm up, 20 min of training and 5-10 min of cool down. Exercise was performed over a calibrated treadmill.
Control group received low-intensity training protocol with a frequency of 5 days/week for 3 weeks. Intensity was moderate intensity that was determined on the basis of APMHR. Low intensity is defined as 50-63% of APMHR. Duration of each session was 30 min. It included 5-10 min of warm up, 20 min of training and 5-10 min of cool down. Treadmill was used for this group as well.
Assessment of all the outcome measures was done twice during the study. First assessment was done on the 1 st day of the intervention in both the group and second assessment was performed on the completion of 3 rd week of training (i.e. 1 day after the last training session). Baseline measurements are shown in [Table 1].
Outcome measures were lipid profile - TC, TGs, HDL, LDL, glucose tolerance assessed by fasting blood sugar (FBS), systolic BP and diastolic BP, BF% and VO 2 max calculated by Queen's step test. Clinical stress testing is most standard method of predicting VO 2 max but application of submaximal testing like Queen's college step test has its own usage, especially in infrastructure limited setting and field setting. Reliability and validity of Queens' college step test is high (r = 0.68, P = 0.001) and its applicability has been proved in adult males and females. 
The change in pre and posttraining outcome measures for both intervention and control group measure was compared with paired t-test, and Independent t-test was performed for comparison among the groups.
| Results and Discussion|| |
Changes in variables in both groups have been shown in [Table 2]. Cardiovascular disease has become the leading cause of mortality worldwide and CHD is now contributing to large and rising burdens of death and disability in many developing countries.  Recent study stresses the scale and seriousness of the emerging challenge of CHD risk factors in India, with particular emphasis on socially deprived groups as well in urbanized group.  One study shows a low prevalence of multiple cardiovascular risk factors (smoking, hypertension, lipid abnormalities and diabetes) among adolescents in an Indian urban population but the prevalence of multiple risk factors increases at age-group 20-29 years with an exponential increase in age group 30-39 years.  Rapid increase in risk factors in young adulthood identifies the target group for interventions. 
|Table 2: The changes in different parameters pre- and post-training in both groups|
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|Table 3: Risk factors and risk stratifi cation of risk factors as prescribed by ACSM|
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It has been documented that the atherosclerotic process begins during childhood though the clinical manifestation occurs in adulthood.  Therefore, early intervention should be initiated once the cardiovascular risk profile is known so that the CHD process is delayed or prevented. It has been found that exercise plays a vital role in prevention or slowing of CAD process by controlling various cardiovascular risk factor such as hypertension, diabetes, dyslipidemia, obesity.  There are an increasing number of individuals who develop asymptomatic atherosclerosis as a consequence of their exposure to smoking, an unhealthy diet and sedentary life-style, especially younger age group individuals and students which result in above mentioned risk factor for atherosclerosis and its complications. Risk factors have been elucidated on the basis of modifiable and non-modifiable in previous literature.  Undue emphasis in the past has been placed on elevations of single risk factors rather than on overall multifactorial coronary or cardiovascular risk.  The potentially modifiable risk factors for CAD were increased concentrations of LDL-C, decreased concentrations of HDL-cholesterol (HDL-C), hypertension, and hyperglycemia in the general population.  Another study reported prevalence levels of CVD risk factors for the young aged population high. 
Moderate amount of physical activity is significantly associated with a more favourable biochemical profile in terms of lipid circulating levels with respect to both absent and intense categories.  One of the studies demonstrated the effectiveness of moderate aerobic exercise in reducing body weight, BF% and waist circumference whilst maintaining lean body mass in moderately overweight Singaporean females.  Physical activity guidelines indicate that all individuals should participate in 30 min of moderate activity 5 days a week in order to gain health benefits and prevent cardiac events. 
Although younger individuals are at lower absolute CHD risk, they will certainly accumulate more benefit from effective life-style and therapeutic interventions over a life-time. To take account of life-time exposure to risk factors, the European recommendations on coronary prevention advocate estimating absolute CHD risk today and projecting that risk to say age 60 years, assuming no change in risk factor levels. In this way, accumulative exposure to risk over a life-time can be estimated and individuals tracking toward a high-risk category in later life can be identified earlier and appropriately managed. Physical activity to reduce one's risk for CVD is strongly recommended in all age group.  Low HDL-C is an independent risk factor for coronary disease and its prevalence is high and increasing and is the most critical determinant of CHD.  It has been found that aerobic training is very much helpful in increasing HDL-C that is the major exercise effect on blood cholesterol and prevailing evidence supports that this change helps slow the progression of CHD. Moderate amount of physical activity is significantly associated with a more favorable biochemical profile in terms of lipid circulating levels with respect to both absent and intense categories.  Exercise exerts relatively little effect on HDL-C. Endurance exercise training did not increase HDL-C levels in men with isolated low HDL-C, while men with hypertriglyceridemia and low HDL-C benefited from a modest (5%), but significant (P = 0.005) increase in HDL-C.  A further study quantified the relationship between effects on HDL-C and the intensity of exercise. 
Aerobic exercise training corrects the HDL 2 and improves the HDL 3 antioxidant effects in type 2 diabetes mellitus, but not in healthy controls  Exercise has been advocated patients with diabetes since centuries. In recent years, the role of exercise in the prevention of type 2 diabetes has been proven to be effective.  Several epidemiological studies have claimed that regular aerobic physical activity has long been associated with an increase in HDL-C plasma levels and a decrease in BP values, contributing to reduced CHD risk. 
Exercise is a cornerstone therapy for the prevention, treatment and control of hypertension. Endurance training decreases BP through a reduction in systemic vascular resistance, in which the sympathetic nervous system and the rennin-angiotensin system appear to be involved, and favorably affects concomitant cardiovascular risk factors.  Aerobic exercise reduces BP in both hypertensive and normotensive persons. An increase in aerobic physical activity should be considered an important component of lifestyle modification for prevention and treatment of high BP.  Long-term physical exercise improves endothelium-dependent vasorelaxation through an increase in the release of nitric oxide in normotensive as well as hypertensive subjects.  The results of a previous study indicated that there was a close association of VO 2 max with fat mass and systolic BP in boys, and only with systolic BP in girls.  some previous studies have tried to evaluate effect of moderate intensity exercises with similar outcomes and validity of tests were mentioned. ,
The result of FBS in the experimental group and control group after 3 weeks of moderate intensity aerobic training showed an increase in their mean by 2 which were not statistically significant. This shows that short term moderate aerobic exercise does not induce beneficiary effect on lowering FBS in euglycemic young adults. The result of my study is in accordance with the previous study  where the result of Fasting blood glucose concentration and per oral glucose tolerance test did not change in either group. Despite 3 weeks of endurance training, there was no improvement in FBS in either group. A possible reason for not having any change in FBS could be possibly due to no dietary restriction and euglycemia in the subjects.
Total cholesterol showed very significant change in the experimental group as compared to control group is shown in [Table 2]. Previous studies have found that moderately active subjects had lower TC and increased HDL-C.  In this study there was improvement seen in the intervention group who received moderate intensity aerobic training when compared to control group who received low-intensity endurance training. The mean differences observed in the intervention group were 5.9 ± 0.5 whereas in control group it was 0.6 ± 0.9. Exercise training is known to decrease cholesterol concentrations and has been shown to increase the intravenous fat clearance. One potential mechanism by which exercise enhances lipid metabolism is alteration of plasma lipase activity and hepatic lipase. The activity of Lipase activity is a key determinant in the rate of catabolism of TG-rich lipoproteins. It has been hypothesized that in order to induce positive change in TG, body weight has to be maintained throughout the training program. These findings are similar to this study where BMI had reduced, and HDL increased after moderate intensity training.  In contrast, there was a study which did not show any reduction in TG level even after 4 weeks of training at different level of physical activity.  In this study there was significant improvement in the HDL level with an increase of 3.0 ± 0.8 after 3 weeks of moderate intensity endurance training whereas in control group the change was not significant after 3 weeks of low-intensity endurance training. In accordance with the present study, one of the previous studies has also reported increased HDL levels, decreased fasting TG concentrations and increased intravenous fat clearance with 6 months of walking exercise with moderate intensity. There are, however, several possible reasons why HDL improved indicating a positive effect of short-term aerobic training. Firstly improvement could be due to a reduction in BMI, which has shown a high correlation with increase HDL and secondly due to a reduction in TGs. In another study, HDL did not change significantly at the different levels of activity as compared to sedentary phase during 4 weeks of training. 
In the present study LDL level reduced in the experimental group that was significant while LDL level increased in the control group which was not statistically significant. This result is in contrast to the previous study, where LDL-C decreased both in the exercise and in the control subjects after 8 weeks of endurance training.  This may be interpreted as for having a reduction in LDL by endurance training, short-term aerobic training of 3 weeks is not sufficient and the training period should be longer. Reasons for an increase in LDL in control group may be due to low-intensity nature of exercise which is not sufficient to bring any positive change. 
The present study found no significant change in systolic and diastolic BP in both the experimental group as well as in control group. The reason for no improvement could be because of the normotensive subjects recruited for this study. A previous study reported that 3 weeks of exercise with dietary modification showed a pronounced reduction in both diastolic and systolic BP in both hypertensive and non-hypertensive individual.  The present study is in contrast to the previous study where both supine systolic and diastolic BPs were lowered by regular exercise, falling by 10/7 mm Hg during the 3 times a week and by 12/7 mm Hg during the 7 times/week schedule with 4 weeks of training.  Another study showed improvement in BP following endurance training where they studied the effect of endurance exercise on BP and other cardiovascular risk factors and found that training lowers BP and that the net BP response is more pronounced in hypertensives than in nonhypertensives. BP reduction is based on a decrease in systemic vascular resistance, in which the sympathetic nervous system and the renin-angiotensin system appear to be involved; and training is associated with favorable effects on other cardiovascular risk factors. 
The mean value of BMI in the experimental group reduced by 1 from baseline, whereas it got increased by 1 in control group. Both groups did not recruit obese category, despite that training showed a beneficial improvement in the BMI in the intervention group which was statistically significant. There was statistically significant reduction in BMI with the difference of the mean of 1.4 after moderate aerobic training without any dietary modification as compared to control group where it showed significant increase with the difference of mean of 1.6. This study is in correlation with the previous study where 14 weeks of high intensity aerobic training produced a significant effect when compared to low intensity training. , This suggests that 3 weeks of moderate training has a beneficial effect.
In the present study, there was a significant improvement in VO 2 max of the intervention group following moderate intensity aerobic training, whereas control group did not produce significant change in VO 2 max after low-intensity aerobic training for 3 weeks.
Body fat % in the present study did not show any improvement after 3 weeks of aerobic training in the intervention group but control group showed an increase in BF% that was statistically significant. A previous study suggested that the reduction in BF% can be brought with low-intensity training that requires training for at least 5 days/week for minimum 12 weeks.  The mechanism behind reduction of BF% at higher intensity (70% of VO 2 max ) has been explained by reduction in subcutaneous adiposity, increased fat mass loss, increased lipolytic activity, reduced postexercise caloric compensation and improved cardiorespiratory condition in basal metabolic rate and oxidation of fatty acids.  In addition, a number of studies have shown that resting energy expenditure is increased by 5-15% for 24-48 h after aerobic exercise of at least 70% of VO 2 max , but does not increase following aerobic exercise at lower intensity.
| Conclusion|| |
This study suggests that 3 weeks of moderate intensity aerobic training has a beneficial effect in lowering the cardiovascular risk profiles in adults with moderate risk factors. This training reduces TC, improves HDL, reduces LDL and improves aerobic capacity by improving VO 2 max and reducing BF%. These positive findings at moderate intensity may enhance the compliance to the exercise training. It also suggests that 3 weeks of duration is not sufficient to induce the effect in improving cardiovascular risk factors like FBS, TC, LDL and BP.
Limitation of this study is a small sample size but this is a pilot study. Males were less in number as compared to females because of which the result cannot be generalized to the entire population. The subjects were not asked to maintain uniform diet during the study period which could be one of the confounding factors. Similar study can be conducted with dietary modification and find the effect of diet modification with short term moderate intensity aerobic training on cardiovascular risk factors. Future studies should be taken with larger sample size and with uniform diet code to avoid effect of variable diet on lipid profile.
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[Table 1], [Table 2], [Table 3]