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Physical exercise

How to prescribe exercise for optimal cardiovascular risk factor control

Whereas exercise is key in the management of patients with cardiovascular disease (CVD) risk [1-3], it is important to optimally prescribe exercise to the patients with different CVD risk factors. A different selection of exercise training modalities does lead to different changes in CVD risk. The aim of this webpage is to provide a state-of-the-art exercise prescription (exercise training intensity, frequency, volume and type, session and programme duration) in patients with different CVD risk factors: obesity, diabetes, dyslipidaemia and hypertension.



Exercise training recommendations [4-11], further refined by the EAPC EXPERT working group [12] for:

Obesity

The greatest reductions in body weight occur in subjects with a higher BMI and when exercise training is combined with dietary intervention. It is recommended to increase the weekly endurance exercise volume >250 minutes (or >1,500 kcal) and to aim for a permanently increased physical activity level. A minimum exercise program duration of 6 months is recommended, followed by a permanently increased daily physical activity level. To maximize the total number of calories burned during exercise training (which is the key factor to successfully reduce the fat mass), moderate-intense (40-60% heart rate reserve (HRR)) endurance exercises involving large muscle groups (e.g. walking, stepping, rowing, cross-training) are recommended, 3 up to 5 days/week. Resistance exercise training is not recommended for fat mass loss, although the addition of resistance exercise training leads to increased resting caloric expenditure, improved blood HDL cholesterol concentrations, and increased muscle strength and lean tissue mass (60-70% of 1 repetition maximum (RM), 12-15 repetitions for 3 series each exercise targeting large muscle groups).

Arterial hypertension

Primarily reductions in systolic blood pressure (BP) may be expected, and especially in hypertensive patients. It is recommended to perform endurance exercise training at moderate intensity (40-60% HRR) for at least 30 minutes per day, 5 days/week (high frequency exercising is key to successful BP reduction). Vigorous exercise training intensities (60-80% HRR) may be considered in patients with a low CVD risk, and may sometimes be more effective. Dynamic resistance exercise training at moderate intensity (50-70% 1RM, 8-10 exercises for large muscle groups, with gradual build up to 2-3 sets per exercise), can be added twice weekly (on non-consecutive days) as dynamic resistance exercise training may lower BP by itself. However, the combination of endurance and resistance exercise training does not lower BP more than endurance exercise training alone. Isometric handgrip exercise training at low intensity (<40% of one maximal volitional contraction), performed as several intermittent bouts of handgrip contractions lasting 2 minutes each for a total of 12-15 minutes per session may assist in decreasing BP.

Dyslipidaemia

Different changes in blood lipid profiles occur in patients with obesity, diabetes or cardiovascular disease. The impact of the intake of blood lipid-lowering drugs (such as statins), but also dietary intervention, is greater on blood lipid profile as opposed to exercise training alone, and thus may overrule the impact of different exercise training modalities. The greatest improvements in blood lipid profile may be anticipated in patients with the worst blood lipid profile. Continuous exercise training with moderate-or high intensity (40-60% HRR) may be preferred in which the caloric expenditure >900 kcal/week (the key target) should be achieved to maximise changes in the blood lipid profile (especially blood HDL cholesterol concentration). Therefore, extend the exercise sessions (>40 minutes/session) as well as the total training programme duration (>40 weeks) and select exercise modes with the highest caloric expenditure/time unit (see section on exercise training in obesity). The addition of resistance training exercises may positively affect the blood HDL cholesterol concentrations: 8-10 repetitions of each series, 70-85% of 1RM, for 3 series/exercise, which should be progressively reached and adapted.

Type 2 diabetes (T2DM)

Greater reductions in blood HbA1c concentrations are anticipated in T2DM patients with higher baseline blood HbA1c concentrations.  T2DM patients are advised to become or remain physically active by walking >30 minutes on at least 5 days/week, ideally every day and every week. In addition, T2DM patients should follow a supervised exercise training intervention ≥150 minutes per week of moderate-intense (40-60% HRR) endurance exercise and/or 90 minutes per week of vigorous-intense endurance exercise (60-80% HRR), ideally 3–4 hours/week. T2DM patients should try to exercise at least 5 days per week (key factor to success) and energy expenditure should be between 1000–2000 kcal per week, for at least six months, preferably followed by a sustained increase in physical activity thereafter. Resistance exercise training (another key factor to success) should be performed at least 2-3 times per week: major muscle groups should be targeted, 2 sets per muscle group with 8-12 repetitions at 70-80% 1RM, or 25-30 repetitions at 40-55% 1RM, respectively. Electro muscle stimulation (EMS) twice weekly for 20 minutes can improve blood HbA1c concentration in T2DM patients and is particularly relevant for patients with limited mobilisation or rehabilitation capacity.

Type 1 diabetes (T1DM)

Although recommended by treatment guidelines, exercise training may increase the risk of (late onset) hypoglycaemia and bears the risk of deteriorating diabetes control due to complex interaction with the regulation of glucose transport into the working muscles, nutrition and insulin therapy. Therefore, exercise training for T1DM should be an integral part of the treatment. Endurance exercise training leads to improvements in chronic glycaemic control. Adding a single bout of high-intense exercise (near maximal efforts or sprint interval training up to 10 seconds/bout) to moderate-intense continuous exercises training (40-60% HRR) may stabilize the fall in glucose concentrations during and after exercise training. Resistance exercise can cause similar hormonal and metabolic responses to those of anaerobic exercise such as HIE, especially when only 1 or 2 sets are performed. Patients with T1DM are encouraged to perform at least 150 minutes of moderate-intense (40-60% HRR) endurance exercise training per week, and, in the absence of contraindications such as moderate or severe proliferative retinopathy, resistance exercise training at least twice per week is recommended (3 sets, 10 repetitions/set, 60-70 %1RM). Chronic glycaemic control may improve in patients with T1DM when exercise training is performed for more than 3 months, training up to 3 times a week, and the patients receive dietary or insulin administration advice from a healthcare professional.

References


[1]. Lin X, Zhang X, Guo J, et al. Effects of Exercise Training on Cardiorespiratory Fitness and Biomarkers of Cardiometabolic Health: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. J Am Heart Assoc. 2015 Jun 26;4(7).

[2]. Murtagh EM, Nichols L, Mohammed MA, Holder R, Nevill AM, Murphy MH. The effect of walking on risk factors for cardiovascular disease: an updated systematic review and meta-analysis of randomised control trials. Prev Med. 2015 Mar;72:34-43.

[3]. Pattyn N, Cornelissen VA, Eshghi SR, Vanhees L. The effect of exercise on the cardiovascular risk factors constituting the metabolic syndrome: a meta-analysis of controlled trials. Sports Med. 2013 Feb;43(2):121-33.

[4] . Piepoli MF, Hoes AW, Agewall S, et al. 2016 European Guidelines on cardiovascular disease prevention in clinical practice. Eur J Prev Cardiol 2016; 23: NP1-96.

[5] . Eckel RH, Jakicic JM, Ard JD, et al; American College of Cardiology/American Heart Association Task Force on Practice Guidelines. 2013 AHA/ACC guideline on lifestyle management to reduce cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014 Jul 1;63(25 Pt B):2960-84.

[6]. Umpierre D, Ribeiro PA, Schaan BD, Ribeiro JP. Volume of supervised exercise training impacts glycaemic control in patients with type 2 diabetes: a systematic review with meta-regression analysis. Diabetologia. 2013 Feb;56(2):242-51.

[7]. Cornelissen VA, Smart NA. Exercise training for blood pressure: a systematic review and meta-analysis. J Am Heart Assoc. 2013 Feb 1;2(1):e004473.

[8]. Schwingshackl L, Dias S, Strasser B, Hoffmann G. Impact of different training modalities on anthropometric and metabolic characteristics in overweight/obese subjects: a systematic review and network meta-analysis. PLoS One. 2013 Dec 17;8(12):e82853.

[9]. Kelley GA, Kelley KS, Roberts S, Haskell W. Comparison of aerobic exercise, diet or both on lipids and lipoproteins in adults: a meta-analysis of randomized controlled trials. Clin Nutr. 2012 Apr;31(2):156-67.

[10]. Tonoli C, Heyman E, Roelands B, Buyse L, Cheung SS, Berthoin S, Meeusen R. Effects of different types of acute and chronic (training) exercise on glycaemic control in type 1 diabetes mellitus: a meta-analysis. Sports Med. 2012 Dec 1;42(12):1059-80

[11]. Vanhees L, Geladas N, Hansen D, et al. Importance of characteristics and modalities of physical activity and exercise in the management of cardiovascular health in individuals with cardiovascular risk factors. Recommendations from the European Association for Cardiovascular Prevention and Rehabilitation (Part II). Eur J Prev Cardiol 2012; 19: 1005-33.

[12]. Hansen D, Dendale P, Coninx K, et al. The EAPC Exercise Prescription in Everyday practice & Rehabilitative Training (EXPERT) tool: a digital training and decision support system for optimized exercise prescription in cardiovascular disease. Concept, definitions and construction methodology. Eur J Prev Cardiol 2017; in press.

The content of this article reflects the personal opinion of the author/s and is not necessarily the official position of the European Society of Cardiology.

The ESC Prevention of Cardiovascular Disease programme is supported by AMGEN, AstraZeneca, Ferrer, and Sanofi and Regeneron in the form of educational grants.

Related link

Report on unmet prevention needs: Physical activity
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