Impact of Changes in Cardiorespiratory Fitness on Hypertension, Dyslipidemia and Survival: An Overview of the Epidemiological Evidence

Exploring the role of blood pressure in the black-white disparity in cardiovascular disease mortality: a causal mediation analysis

BACKGROUND

Cardiovascular diseases (CVDs) are the leading cause of death in the USA, and high blood pressure is a major risk factor for CVD. Despite the overall declining rates of CVD mortality in the USA in recent years, marked disparities between racial and ethnic groups persist, with black adults having a higher mortality rate than white adults. We investigated the extent to which blood pressure mediated the black-white disparity in CVD mortality.

METHODS

Data came from the Multi-Ethnic Study of Atherosclerosis, a diverse longitudinal cohort. We included 1325 black and 2256 white community-based adults aged 45-80 years free of clinical CVD at baseline and followed for 14 years. We used causal mediation analysis to estimate the effect of race on CVD mortality that was mediated through blood pressure.

RESULTS

Black participants had a higher hazard of dying from CVD compared with white participants (adjusted hazard ratio (HR): 1.28 (95% CI 0.88, 1.88)), though estimates were imprecise. Systolic blood pressure mediated 27% (HR: 1.02, 95% CI 1.00, 1.06) and diastolic blood pressure mediated 55% (HR: 1.07, 95% CI 1.01, 1.10) of the racial disparities in CVD mortality between white and black participants. Mediation effects were present in men but not in women.

CONCLUSIONS

We found that black-white differences in blood pressure partially explain the observed black-white disparity in CVD mortality, particularly among men. Our findings suggest that public health interventions targeting high blood pressure prevention and management could be important strategies for reducing racial disparities in CVD mortality.

Association between change in cardiorespiratory fitness and prostate cancer incidence and mortality in 57 652 Swedish men

OBJECTIVES

To examine the associations between changes in cardiorespiratory fitness (CRF) in adulthood and prostate cancer incidence and mortality.

METHODS

In this prospective study, men who completed an occupational health profile assessment including at least two valid submaximal CRF tests, performed on a cycle ergometer, were included in the study. Data on prostate cancer incidence and mortality were derived from national registers. HRs and CIs were calculated using Cox proportional hazard regression with inverse probability treatment weights of time-varying covariates.

RESULTS

During a mean follow-up time of 6.7 years (SD 4.9), 592 (1%) of the 57 652 men were diagnosed with prostate cancer, and 46 (0.08%) died with prostate cancer as the primary cause of death. An increase in absolute CRF (as % of L/min) was associated with a reduced risk of prostate cancer incidence (HR 0.98, 95% CI 0.96 to 0.99) but not mortality, in the fully adjusted model. When participants were grouped as having increased (+3%), stable (±3%) or decreased (-3%) CRF, those with increased fitness also had a reduced risk of prostate cancer incidence compared with those with decreased fitness (HR 0.65, 95% CI 0.49 to 0.86), in the fully adjusted model.

CONCLUSION

In this study of employed Swedish men, change in CRF was inversely associated with risk of prostate cancer incidence, but not mortality. Change in CRF appears to be important for reducing the risk of prostate cancer.

The relationship between cardiorespiratory fitness and blood pressure among airline pilots: a mediation analysis of body composition

OBJECTIVE

Blood pressure (BP), cardiorespiratory fitness (CRF), and body composition are independently associated with health outcomes, yet the relationship between these variables has not been explored among airline pilots. The aim of this study was to evaluate the relationship between CRF and BP, and further examine whether the relationship is mediated by body composition.

METHODS

A cross-sectional study was conducted among 356 airline pilots in New Zealand. We measured height, body mass, BP, waist circumference, skinfolds, and CRF (via a WattBike cycle ergometer submaximal VO 2max test). Partial correlation coefficients were estimated to examine the relationships between all variables while controlling for age and sex. Haye's PROCESS macro and the Sobel test were utilized for the mediation analysis.

RESULTS

All body composition variables (body mass index, waist circumference and body fat percentage) were positively correlated with all BP variables (systolic pressure, diastolic pressure and mean arterial pressure) ( P  < 0.001). CRF was negatively correlated with all body composition and BP variables ( P  < 0.001). The Sobel test and indirect effect were significant ( P  < 0.001), confirming that all body composition variables partially mediate the relationship between CRF and all blood pressure variables.

CONCLUSION

Lower CRF is associated with higher blood pressure, and body composition partially mediates the relationship between these health risk factors. These findings highlight the importance of physical fitness and healthy body composition in the management of blood pressure among this occupational group.

Healthy fitness zone prevalence and age-specific fitness profile of young people in seven European countries in 2022: The EUFITMOS project

BACKGROUND

Physical fitness is a health marker in youth and is associated with current and future health.

OBJECTIVE

Present the healthy fitness zone (HFZ) prevalence and age-specific fitness profile of young people from seven European countries.

METHODS

This study used data from the European Fitness Monitoring System project. The sample comprised 4965 (51.4% boys) youths aged 9 to 18 years. Fitness data were collected by physical education teachers using field-based tests. Raw data from the fitness tests were used to calculate the prevalence and 95% confidence intervals (CI) of participants in the HFZ.

RESULTS

The overall prevalence of boys and girls in the HFZ for all tests was 16.6% (95% CI = 14.7, 18.1) and 14.9% (95% CI = 13.2, 16.6), respectively. Boys have a mainly positive HFZ profiles, except for the 9-year-olds in the sit and reach (z-score difference = -1.20) and the 20 m run for boys 13-18-year-olds (z-score difference range: -0.09 to -0.01). Girls have worse HFZ profiles than boys, being out of the HFZ in several tests. Furthermore, a decreasing trend in z-score difference from the HFZ with age was observed in VO2 peak for boys and girls and sit and reach for girls. Notwithstanding, several country-related, sex and age differences were observed.

CONCLUSIONS

Boys presented mostly healthy age-specific fitness profiles in several fitness tests and ages. These differences should be considered when promoting youth's health through physical activity and fitness, as different fitness levels may require different approaches to implementing health-enhancing physical activity policies.

Obesity, Cardiorespiratory Fitness, and Cardiovascular Disease

PURPOSE OF REVIEW

Obesity, generally defined by body mass index (BMI), is an established risk factor for the development of cardiovascular disease (CVD), while cardiorespiratory fitness (CRF) decreases risk. In chronic CVD, an obesity survival paradox in which higher BMI is associated with improved prognosis has been reported. This paper will examine the effect of obesity on CVD risk, explore obesity as a risk factor in patients with established CVD, and investigate the relationship between CRF, obesity, and CVD.

RECENT FINDINGS

Through metabolic and hemodynamic changes, obesity increases the risk for CVD and contributes to the development of other cardiovascular risk factors such as diabetes, dyslipidemia, and hypertension. Obesity is associated with metabolic, hormonal, and inflammatory changes that leads to atherosclerosis increasing the risk for coronary artery disease, and myocardial remodeling increasing the risk for heart failure. However, it has also been observed that overweight/obese patients with established CVD have a better prognosis when compared to non-obese individuals termed the obesity paradox. CRF is a vital component of health associated with improved cardiovascular outcomes and furthermore has been shown to markedly attenuate or nullify the relationship between obesity and CVD risk/prognosis. Increasing CRF mitigates CVD risk factors and improves overall prognosis in CVD regardless of obesity status.

Association Between Cardiorespiratory Fitness and Cancer Incidence and Cancer-Specific Mortality of Colon, Lung, and Prostate Cancer Among Swedish Men

Importance

Cardiorespiratory fitness (CRF) levels appear to be an important risk factor for cancer incidence and death.

Objectives

To examine CRF and prostate, colon, and lung cancer incidence and mortality in Swedish men, and to assess whether age moderated any associations between CRF and cancer.

Design, Setting, and Participants

A prospective cohort study was conducted in a population of men who completed an occupational health profile assessment between October 1982 and December 2019 in Sweden. Data analysis was performed from June 22, 2022, to May 11, 2023.

Exposure

Cardiorespiratory fitness was assessed as maximal oxygen consumption, estimated using a submaximal cycle ergometer test.

Main Outcomes and Measures

Data on prostate, colon, and lung cancer incidence and mortality were derived from national registers. Hazard ratios (HRs) and 95% CIs were calculated using Cox proportional hazards regression.

Results

Data on 177 709 men (age range, 18-75 years; mean [SD] age, 42 [11] years; mean [SD] body mass index, 26 [3.8]) were analyzed. During a mean (SD) follow-up time of 9.6 (5.5) years, a total of 499 incident cases of colon, 283 of lung, and 1918 of prostate cancer occurred, as well as 152 deaths due to colon cancer, 207 due to lung cancer, and 141 deaths due to prostate cancer. Higher levels of CRF (maximal oxygen consumption as milliliters per minute per kilogram) were associated with a significantly lower risk of colon (HR, 0.98, 95% CI, 0.96-0.98) and lung cancer (HR, 0.98; 95% CI, 0.96-0.99) incidence, and a higher risk of prostate cancer incidence (HR, 1.01; 95% CI, 1.00-1.01). Higher CRF was associated with a lower risk of death due to colon (HR, 0.98; 95% CI, 0.96-1.00), lung (HR, 0.97; 95% CI, 0.95-0.99), and prostate (HR, 0.95; 95% CI, 0.93-0.97) cancer. After stratification into 4 groups and in fully adjusted models, the associations remained for moderate (>35-45 mL/min/kg), 0.72 (0.53-0.96) and high (>45 mL/min/kg), 0.63 (0.41-0.98) levels of CRF, compared with very low (<25 mL/min/kg) CRF for colon cancer incidence. For prostate cancer mortality, associations remained for low (HR, 0.67; 95% CI, 0.45-1.00), moderate (HR, 0.57; 95% CI, 0.34-0.97), and high (HR, 0.29; 95% CI, 0.10-0.86) CRF. For lung cancer mortality, only high CRF (HR, 0.41; 95% CI, 0.17-0.99) was significant. Age modified the associations for lung (HR, 0.99; 95% CI, 0.99-0.99) and prostate (HR, 1.00; 95% CI, 1.00-1.00; P < .001) cancer incidence, and for death due to lung cancer (HR, 0.99; 95% CI, 0.99-0.99; P = .04).

Conclusions and Relevance

In this cohort of Swedish men, moderate and high CRF were associated with a lower risk of colon cancer. Low, moderate, and high CRF were associated with lower risk of death due to prostate cancer, while only high CRF was associated with lower risk of death due to lung cancer. If evidence for causality is established, interventions to improve CRF in individuals with low CRF should be prioritized.

Influence of exercise type and duration on cardiorespiratory fitness and muscular strength in post-menopausal women: a systematic review and meta-analysis

Background and aim

Both cardiorespiratory fitness (CRF) and muscular strength are reported to decrease with age and menopause, which considered to be risk for cardiovascular diseases (CVDs). Previous relevant meta-analyses are inconclusive on the beneficial effects of exercise, particularly in post-menopausal women. In this systematic review and meta-analysis, we investigated the effects of exercise modalities on CRF and muscular strength in post-menopausal women, and identified the effective exercise type and duration.

Methods

A comprehensive search was conducted on PubMed, Web of Science, CINAHL, and Medline to identify the randomized controlled trials, which evaluated exercise effect on CRF, lower- and upper-body muscular strength, and/or handgrip strength in post-menopausal women and compared the results with control. Standardized mean differences (SMD), weighted mean differences (WMD), and 95% confidence intervals (95% CIs) were calculated using random effects models.

Results

A total of 129 studies comprising 7,141 post-menopausal women with mean age and BMI ranging from ∼53 to 90 years and 22 to 35 kg/m², respectively, were included in the meta-analysis. Overall, exercise training effectively increased CRF (SMD: 1.15; 95% CI: 0.87, 1.42; p = 0.001), lower-body muscular strength (SMD: 1.06; 95% CI: 0.90, 1.22; p = 0.001), upper-body muscular strength (SMD: 1.11; 95% CI: 0.91, 1.31; p = 0.001), and handgrip strength (WMD: 1.78 kg; 95% CI: 1.24, 2.32; p = 0.001) in post-menopausal women. These increments were found to be irrespective of ages and intervention durations. Regarding exercise type, aerobic, resistance, and combined training significantly increased CRF and lower-body muscular strength, while resistance and combined training effectively increased handgrip strength. However, only resistance training increased the upper-body muscular strength in women.

Conclusion

Our findings suggest that exercise training is effective in increasing CRF and muscular strength in post-menopausal women, which might be cardioprotective. Both aerobic and resistance training alone or in combination increased CRF and lower-body muscular strength, but only resistance training increased upper-body strength in women.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=283425, identifier: CRD42021283425.

Secular trends of cardiorespiratory fitness in children and adolescents over a 35-year period: Chronicle of a predicted foretold

Background

In the context of concerns regarding the cardiorespiratory fitness (CRF) of youth populations, the aims of this study were: (1) to update reference values for the VO₂max for school-aged Canadians and (2) to document secular trends in CRF after a 35-year interval.

Methods

Between September 2014 and April 2017, the CRF of 3725 students (53.2% boys; 6.0 to 17.9 yrs) was determined using the 20-m shuttle run test. The sample was collected in 36 different schools from six cities of Québec (Canada).

Results

Median values of VO₂max decreased with age in both sexes (p ≤ 0.05). By the age of 10, more than 20% of boys showed VO₂max values below the recommended value (42 ml·kg^-1·min^-1). At the age of 17, that proportion reached 56.8%. A similar proportion of 12 yrs girls (20%) were under the recommended minimal value (37 ml·kg^-1·min^-1) and that value reached 69.9% at the age of 17. Compared to 1982, the VO₂max at age 17 has declined by 18% for boys and 12% for girls. The situation is worse in terms of functional capacity (number of stages completed) with an overall decrease of more than 30%.

Conclusion

This study demonstrates that, compared to data obtained using the same methodology 35 years ago, the CRF and functional capacity of children and adolescents has declined to levels that should raise concerns from a public health perspective. Thus, the development of strategies to promote a physically active lifestyle in youth is more relevant than ever.

Validity and reproducibility of a method to estimate cardiorespiratory fitness in college adults

Introduction: Cardiorespiratory fitness is a predictor of cardiovascular and all-cause mortality. Its assessment in different groups has clinical and public health usefulness. Objective: To evaluate the validity and reproducibility of a no-exercise method [National Aeronautics and Space Administration (NASA) method] to estimate the maximum oxygen consumption (VO2máx) in college adults. Materials and methods: This study included 94 healthy individuals of both sexes (18-55 years). The gold standard was ergospirometry. The validity and reproducibility were evaluated with the intraclass correlation coefficient (ICC) and the Bland-Altman method. Results: Among the participants, we found a mean age of 30.54 ± 9.33 years and a VO2máx of 41.29 ± 9.54 ml O2.kg-1.min-1; 48.9 % were women. A mean difference of VO2máx between ergospirometry and that estimated by the NASA method of 3.41 ± 5.64 ml O2.kg-1.min-1 was found. The concordance between the two methods was good, with an ICC of 0.858 (CI95% 0.672-0.926). The percentage of error was 29.70 %. The reproducibility of the two estimates by the NASA method was excellent, with an ICC of 0.986 (CI95% 0.927-0.995). Conclusions: The NASA method is valid and reproducible to estimate VO2máx in college adults. In addition, it is safe and easy to apply. Estimating cardiorespiratory fitness is recommended to improve screening in cardiometabolic risk programs and to implement timely interventions.

Clinical associations between exercise and lipoproteins

PURPOSE OF REVIEW

One of the major concerns in global health is the deteriorating control of dyslipidemia (DLD), which is a very strong modifiable risk factor for untoward cardiovascular disease (CVD) outcomes. It serves as a foundation for atherosclerotic lesions that can be destabilized by co-inflammatory processes leading to distal clot migration and other related CVD events. There are many misconceptions regarding the management of DLD. Many health sectors advocate for weight loss without a clear-cut target to achieve better CVD outcomes. There is growing evidence that exercise training compliance regardless of weight change is a more reliable indicator of favorable outcomes. This review is intended to understand the relationship between exercise training, lipoprotein readings, and with CVD and all-cause morbidity and mortality.

RECENT FINDINGS

Aerobic exercise training (aET) and resistance exercise training (rET) increase cardiorespiratory fitness (CRF) and muscular strength (MusS), respectively. Regardless of weight loss, aET and rET are both known to independently reduce mortality possibly partly through improvement of lipid profiles. Of the two modes of exercise, rET has propensity for enhanced compliance because of its significant lipid and mortality-attenuating effect even with just brief exercise sessions. However, there are several studies showing that participation in both modes of exercise causes more pronounced improvements in DLD and CVD-related mortality compared with either mode of exercise training alone. In addition, Lipoprotein-a [Lp(a)] has been increasingly acknowledged to be atherogenic because of its LDL core. The close proximity of Lp(a) with macrophages triggers the development of atheromas, plaque formation, and growth. This causes a cascade of inflammatory processes that increase the development of ischemic CVD and calcific aortic valve stenosis. Although exercise training is known to reduce plasma LDL-C levels, it has no direct effect on Lp(a) levels as the latter lipoprotein is not influenced by motion nor exercise. Reviews of multiple studies lead us to infer that exercise training may potentially have an indirect impact on Lp(a) attenuation because of the ability of exercise training to inhibit Proprotein Convertase Subtisilin/Kexin type-9 (PCSK-9), as some studies using pharmacologic therapy with PCSK-9 inhibitors were able to show a concomitant decrease in Lp(a) levels.

SUMMARY

It is clear that normal-to-overweight populations who are highly active have better CVD outcomes and lipid profiles than their sedentary counterparts, and those who were underweight and unfit fared much worse. This allows us to take a more precise approach in the management of DLD rather than plainly focusing on gross weight in patients. Exercise training certainly has beneficial impact on longevity owing to its advantageous effect on lipoprotein levels and particle size. As such, reputable health societies, such as the ESC, ACC, and AHA have prescribed the ideal exercise training regimen, which have noticeable similarities. Increasing the use of wearable devices may help improve our ability to prescribe, quantify, and precisely track physical activity in our continuing efforts to combat increasing morbidity related to unhealthy lifestyles and inactivity.

The associations between exercise and lipid biomarkers

Cardiovascular diseases (CVD) remain the leading cause of death globally, and further efforts are being undertaken to understand and modify CVD risk factors, such as dyslipidemia (DLD), hypertension, and diabetes. The sedentary lifestyle of most individuals today contributes to the prevalence of these conditions. Uncontrolled dyslipidemia serves as a fertile ground for atherosclerotic plaque formation, while lipoproteins (Lp) act as cofactors for inflammatory processes that cause plaque destabilization leading to subsequent CVD events. As such, many health experts and institutions continue to emphasize the importance of cardiorespiratory fitness (CRF) and muscular strength (MusS) with the intent to reduce atherogenic lipoproteins and proprotein convertase subtilisin kexin type 9 (PCSK-9) expression. Concordantly, the two modes of exercise training (ET), such as aerobic ET (aET) and resistance ET (rET) have both demonstrated to improve CRF and MusS, respectively. Although both modes of ET were shown to independently reduce mortality, participation in both forms resulted in a more pronounced improvement in cholesterol levels and CVD-related mortality. Though reduction of adiposity is not a pre-requisite to achieve better control of DLD through increased CRF and MusS, the beneficial effects of physical activity on the inflammatory processes linked to atherosclerosis are almost always associated with a simultaneous decrease in overall adiposity. It is therefore essential to promote both aET and rET, including weight loss in order to attenuate the risks stemming from atherosclerosis and its proinflammatory components.

Association between Cardiorespiratory Fitness and Hypertensive Disorders of Pregnancy: A Systematic Review and Meta-Analysis

Hypertensive disorders of pregnancy (HDP) are associated with future cardiovascular disease (CVD), which may be mediated by diminished cardiorespiratory fitness (CRF). In this systematic review and meta-analysis, we summarize evidence linking CRF with HDP before, during, and after pregnancy. We searched relevant databases to identify observational or randomized studies that measured CRF (VO2 max or peak, VO2 at anaerobic threshold, or work rate at peak VO2) in women with and without HDP. We pooled results using random effects models. Fourteen studies (n = 2406 women) reporting on CRF before, during, and after pregnancy were included. Before pregnancy, women who developed HDP had lower CRF (e.g., VO2max < 37 vs. ≥37 mL O2/min) than those without HDP (two studies, 811 women). VO2max at 14−18 weeks of pregnancy was marginally lower among women who developed preeclampsia vs. normotensive women (three studies, 275 women; mean difference 0.43 mL/kg/min [95% CI 0.97, 0.10]). Postpartum, there was a trend towards lower VO2peak in women with previous preeclampsia (three studies, 208 women; 0.26 mL/kg/min [−0.54, 0.02]). While exploratory, our findings raise the possibility that CRF can identify women at risk for HDP, and furthermore, that HDP confers a hit to a woman’s cardiorespiratory reserve.

Risk of Hypertension and Use of Antihypertensive Drugs in the Physically Active Population under-70 Years Old—Spanish Health Survey

Introduction: Reducing the prevalence of hypertension is a major priority of the World Health Organization (WHO). Its high prevalence and associated risks generate high economic and social costs. Physical activity (PA) is associated with a decrease in hypertension and in the use of antihypertensive drugs. Objective: To explore the association between PA levels (PAL), prevalence of hypertension and the use of antihypertensive drugs in Spanish population. To calculate risks of hypertension and use of antihypertensive in the inactive versus physically active population. Method: This cross-sectional study used data from 17717 individuals, sampled in the 2017 National Health Survey. Interaction by sex, age groups, body mass index (BMI), hypertension prevalence, antihypertensive drugs use and PAL, using a pairwise z-test, and dependence relationships between variables, were studied using a chi square test. Odds ratios of hypertension and antihypertensive drug use were calculated among the inactive and the physically active populations. Results: The findings showed a significant inverse association between prevalence of hypertension, antihypertensive use, and PAL in both sexes and different age and BMI groups, with lower prevalence of hypertension and antihypertensive use when PAL were higher. The risks of hypertension and antihypertensive use seems to be reduced when related to higher PAL compared to inactive people. Conclusions: High PAL is associated with lower prevalence of hypertension and lower antihypertensive use. Thus, being physically active or very active may reduce the risks of suffering from hypertension and the need to use antihypertensives compared to inactive people or walkers.

The relationship between total energy expenditure and physical activity level in women living in an impoverished Brazilian urban area

OBJECTIVE

This study aimed to describe how strong is the relationship between TEE and PAL in women living in an impoverished Brazilian urban area.

METHODS

Anthropometric, hormonal (insulin, TSH, FT₄ , and FT₃ ), body composition (deuterium), TEE (doubly labeled water) and PAL (metabolic equivalent task [MET]-7-day triaxial accelerometer, ActivPAL®) data were collected from 55 women (mean age: 31y, mean BMI: 27.4 kg/m² ). Adjusted-TEE models were calculated incorporating the residuals of anthropometric, hormonal, and body composition variables in the TEE, to assess the relation between MET and adjusted-TEE, through three different analyzes: linear regression, nonlinear regression and change-point regression.

RESULTS

Most participants (89.1%, n = 49) were classified as low-active. There was no association between crude TEE and MET.h/d (R²  = 0.05; p = 0.09). There was a positive, although weak, linear relationship between adjusted-TEE and MET.h/d (β = 2705.26 kcal; 95% CI: 436.25; 4974.27; adj-R²  = 0.08). A change point of this relationship was identified in the MET.h/d value of 1.53 (SD = 0.02; adj-R² = 0.13). The association between adjusted-TEE and MET.h/d before the change point (β = 5101.46 kcal; 95%CI: 978.84; 9224.08; adj-R²  = 0.11) was stronger than the association in the full linear model, nevertheless, it was still weak. This association stop existing when it is assessed in individuals after the change point (β = -6609.92 kcal; 95%CI: -16773.24; 3553.40; adj-R²  = 0.08).

CONCLUSIONS

These results suggest that the relationship between TEE and PAL is weak and it is not completely linear in women living in an impoverished Brazilian urban area.

Association between cardiorespiratory fitness and risk of all-cause and cause-specific mortality

OBJECTIVE

The association of cardiorespiratory fitness (CRF) with all-cause and cause-specific mortality remains unclear in Chinese population. This study aimed to evaluate the risk of all-cause, cardiovascular disease (CVD), cancer and other-cause mortality in Chinese adults using estimated CRF (eCRF).

PATIENTS AND METHODS

We analysed data for 15,566 participants aged ≥20 years recruited in The Rural Chinese Cohort Study during 2007 to 2008 and followed for mortality during 2013 to 2014. eCRF was calculated with sex-specific longitudinal non-exercise algorithms. Cox proportional-hazards models were used to calculate hazard ratios (HRs) and 95% confidence intervals (CIs) for all-cause and cause-specific mortality risk according to baseline eCRF.

RESULTS

During a median of 6.01 years of follow-up, 859 deaths occurred, including 359 from CVD, 221 from cancer, and 279 from other causes. Each 1 metabolic equivalent increment in eCRF was associated with decreased risk of all-cause mortality (men: HR 0.70, 95% CI [0.66-0.74]; women: 0.59, [0.54-0.64]); CVD mortality (men: 0.70 [0.64-0.77]; women: 0.55, [0.48-0.62]); and other-cause mortality (men: 0.68 [0.62-0.75]; women: 0.57, [0.49-0.66]). The area under receiver operating characteristic curve was significantly higher for eCRF than its modifiable components (waist circumference, body mass index and resting heart rate) in predicting all-cause and cause-specific mortality incidence (all p < .001).

CONCLUSION

eCRF was inversely associated with all-cause, CVD and other-cause mortality.

Cardiorespiratory fitness and mortality from all causes, cardiovascular disease and cancer: dose-response meta-analysis of cohort studies

OBJECTIVE

Current evidence of the associations between cardiorespiratory fitness (CRF) and mortality is limited. We performed a meta-analysis to assess the dose-response association of CRF with mortality from all causes, cardiovascular disease (CVD) and cancer in healthy population.

METHODS

PubMed, EMBASE and Web of Science were searched up to 26 December 2019 for reports of cohort studies giving risk estimates for all-cause, CVD and cancer mortality by level of CRF. Cohort studies were included if CRF was assessed by an exercise stress test and reported as at least three levels or per incremental increase, and the association of CRF with all-cause, CVD and cancer mortality was evaluated. Generalised least-squares regression models were used to assess the quantitative relation of CRF with all-cause, CVD and cancer mortality.

RESULTS

34 cohort studies were eligible for the meta-analysis. The pooled relative risks (RRs) for all-cause, CVD and cancer mortality per one-metabolic equivalent increase in CRF were 0.88 (95% CI 0.83 to 0.93), 0.87 (95% CI0.83 to 0.91) and 0.93 (95% CI 0.91 to 0.96), respectively. As compared with lowest CRF, with intermediate CRF, the summary RRs for all-cause, CVD and cancer mortality were 0.67 (95% CI 0.61 to 0.74), 0.60 (95% CI 0.51 to 0.69) and 0.76 (95% CI 0.69 to 0.84), respectively, and with highest CRF were 0.47 (95% CI 0.39 to 0.56), 0.49 (95% CI 0.42 to 0.56) and 0.57 (95% CI 0.46 to 0.70), respectively.

CONCLUSION

Our analysis showed inverse dose-response associations of CRF with all-cause, CVD and cancer mortality, which provides evidence for public health recommendations for preventing all-cause, CVD and cancer mortality.

PROSPERO REGISTRATION NUMBER

CRD42020208883.

The genetic case for cardiorespiratory fitness as a clinical vital sign and the routine prescription of physical activity in healthcare

BACKGROUND

Cardiorespiratory fitness (CRF) and physical activity (PA) are well-established predictors of morbidity and all-cause mortality. However, CRF is not routinely measured and PA not routinely prescribed as part of standard healthcare. The American Heart Association (AHA) recently presented a scientific case for the inclusion of CRF as a clinical vital sign based on epidemiological and clinical observation. Here, we leverage genetic data in the UK Biobank (UKB) to strengthen the case for CRF as a vital sign and make a case for the prescription of PA.

METHODS

We derived two CRF measures from the heart rate data collected during a submaximal cycle ramp test: CRF-vo2max, an estimate of the participants' maximum volume of oxygen uptake, per kilogram of body weight, per minute; and CRF-slope, an estimate of the rate of increase of heart rate during exercise. Average PA over a 7-day period was derived from a wrist-worn activity tracker. After quality control, 70,783 participants had data on the two derived CRF measures, and 89,683 had PA data. We performed genome-wide association study (GWAS) analyses by sex, and post-GWAS techniques to understand genetic architecture of the traits and prioritise functional genes for follow-up.

RESULTS

We found strong evidence that genetic variants associated with CRF and PA influenced genetic expression in a relatively small set of genes in the heart, artery, lung, skeletal muscle and adipose tissue. These functionally relevant genes were enriched among genes known to be associated with coronary artery disease (CAD), type 2 diabetes (T2D) and Alzheimer's disease (three of the top 10 causes of death in high-income countries) as well as Parkinson's disease, pulmonary fibrosis, and blood pressure, heart rate, and respiratory phenotypes. Genetic variation associated with lower CRF and PA was also correlated with several disease risk factors (including greater body mass index, body fat and multiple obesity phenotypes); a typical T2D profile (including higher insulin resistance, higher fasting glucose, impaired beta-cell function, hyperglycaemia, hypertriglyceridemia); increased risk for CAD and T2D; and a shorter lifespan.

CONCLUSIONS

Genetics supports three decades of evidence for the inclusion of CRF as a clinical vital sign. Given the genetic, clinical and epidemiological evidence linking CRF and PA to increased morbidity and mortality, regular measurement of CRF as a marker of health and routine prescription of PA could be a prudent strategy to support public health.

Association of Estimated Cardiorespiratory Fitness in Midlife With Cardiometabolic Outcomes and Mortality

IMPORTANCE

The associations of estimated cardiorespiratory fitness (eCRF) during midlife with subclinical atherosclerosis, arterial stiffness, incident cardiometabolic disease, and mortality are not well understood.

OBJECTIVE

To examine associations of midlife eCRF with subclinical atherosclerosis, arterial stiffness, incident cardiometabolic disease, and mortality.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study included 2962 participants in the Framingham Study Second Generation (conducted between 1979 and 2001). Data were analyzed from January 2020 to June 2020.

EXPOSURES

eCRF was calculated using sex-specific algorithms (including age, body mass index, waist circumference, physical activity, resting heart rate, and smoking) and was categorized as: (1) tertiles of standardized eCRF at examination cycle 7 (1998 to 2001); (2) tertiles of standardized average eCRF between examination cycles 2 and 7 (1979 to 2001); and (3) eCRF trajectories between examination cycles 2 and 7, with the lowest tertile or trajectory (ie, low eCRF) as referent group.

MAIN OUTCOMES AND MEASURES

Subclinical atherosclerosis (carotid intima-media thickness [CIMT], coronary artery calcium [CAC] score); arterial stiffness (carotid-femoral pulse wave velocity [-1000/CFPWV]); incident hypertension, diabetes, chronic kidney disease (CKD), cardiovascular disease (CVD), and mortality after examination cycle 7.

RESULTS

A total of 2962 participants were included in this cohort study (mean [SD] age, 61.5 [9.2] years; 1562 [52.7%] women). The number of events or participants at risk after examination cycle 7 (at a mean follow-up of 15 years) was 728 of 1506 for hypertension, 214 of 2268 for diabetes, 439 of 2343 for CKD, 500 of 2608 for CVD, and 770 of 2962 for mortality. Compared with the low eCRF reference value, high single examination eCRF was associated with lower CFPWV (β [SE], -11.13 [1.33] ms/m) and CIMT (β [SE], -0.12 [0.05] mm), and lower risk of hypertension (hazard ratio [HR], 0.63; 95% CI, 0.46-0.85), diabetes (HR, 0.38; 95% CI, 0.23-0.62), and CVD (HR, 0.71; 95% CI, 0.53-0.95), although it was not associated with CKD or mortality. Similarly, compared with the low eCRF reference, high eCRF trajectories and mean eCRF were associated with lower CFPWV (β [SE], -11.85 [1.89] ms/m and -10.36 [1.54] ms/m), CIMT (β [SE], -0.19 [0.06] mm and -0.15 [0.05] mm), CAC scores (β [SE], -0.67 [0.25] AU and -0.63 [0.20] AU), and lower risk of hypertension (HR, 0.54; 95% CI, 0.34-0.87 and HR, 0.48; 95% CI, 0.34-0.68), diabetes (HR, 0.27; 95% CI, 0.15-0.48 and HR, 0.31; 95% CI, 0.18-0.54), CKD (HR, 0.63; 95% CI, 0.40-0.97 and HR, 0.64; 95% CI, 0.44-0.94), and CVD (HR, 0.46; 95% CI, 0.31-0.68 and HR, 0.43; 95% CI, 0.30-0.60). Compared with the reference value, a high eCRF trajectory was associated with lower risk of mortality (HR, 0.69; 95% CI, 0.50-0.95).

CONCLUSIONS AND RELEVANCE

In this cohort study, higher midlife eCRF was associated with lower burdens of subclinical atherosclerosis and vascular stiffness, and with a lower risk of hypertension, diabetes, chronic kidney disease, cardiovascular disease, and mortality. These findings suggest that midlife eCRF may serve as a prognostic marker for subclinical atherosclerosis, arterial stiffness, cardiometabolic health, and mortality in later life.

The Effects of Exercise on Lipid Biomarkers

The World Health Organization has declared obesity to be a global epidemic that increases cardiovascular disease (CVD) mortality risk factors, such as hypertension, diabetes, dyslipidemia, and atherosclerosis. The increasing ratio of time spent in sedentary activities to that spent performing physically demanding tasks increases the trends to obesity and susceptibility to these risk factors. Dyslipidemia is the foundation of atherosclerotic buildup and lipoproteins serve as cofactors to the inflammatory processes that destabilize plaques. Increasing cardiorespiratory fitness and muscular strength helps attenuate concentrations of low-density lipoproteins (LDLs), such as LDL cholesterol, and increase levels of high-density lipoprotein cholesterol, as well as reduce proprotein convertase subtilisin kexin type 9 expression. Effects of physical activity on the inflammatory pathways of atherosclerosis, specifically C-reactive protein, are more closely related to reducing the levels of adiposity in tandem with increasing fitness, than with exercise training alone. The purpose of this review is to describe the physiology of dyslipidemia and relate it to CVD and exercise therapies.

Association between Cardiorespiratory Fitness and Circulating Proteins in 50-Year-Old Swedish Men and Women: a Cross-Sectional Study

BACKGROUND AND AIMS

A strong cardiorespiratory fitness is suggested to have beneficial effects on cardiovascular risk; the exact mechanisms underlying the cardioprotective effects of fitness remain uncertain. Our aim was to investigate associations between cardiorespiratory fitness and multiple plasma proteins, in order to obtain insights about physiological pathways associated with the effects of exercise on cardiovascular health.

METHODS

In the Prospective investigation of Obesity, Energy and Metabolism (POEM) study (n=444 adults aged 50 years, 50% women), cardiorespiratory fitness was measured by a maximal exercise test on bicycle ergometer with gas exchange (VO₂peak) normalized for body lean mass (dual-energy X-ray absorptiometry (DXA)). We measured 82 cardiovascular proteins associated with cardiovascular pathology and inflammation in plasma samples with a proximity extension assay.

RESULTS

In sex-adjusted linear regression, VO₂peak was associated with 18 proteins after Bonferroni correction for multiple testing (p<0.0006). Following additional adjustment for fat mass (DXA), fasting glucose (mmol/L), low-density lipoprotein (LDL, mmol/L), smoking status, waist/hip ratio, blood pressure (mmHg), education level, and lpnr (lab sequence number), higher VO₂peak was significantly associated with lower levels of 6 proteins: fatty-acid binding protein-4 (FABP4), interleukin-6 (IL-6), leptin, cystatin-B (CSTB), interleukin-1 receptor antagonist (IL-1RA), and growth differentiation factor 15 (GDF-15), and higher levels of 3 proteins: galanin, kallikrein-6 (KLK6), and heparin-binding EGF-like growth factor (HB-EGF), at nominal p-values (p<0.05).

CONCLUSIONS

We identified multiple novel associations between cardiorespiratory fitness and plasma proteins involved in several atherosclerotic processes and key cellular mechanisms such as inflammation, energy homeostasis, and protease activity, which shed new light on how exercise asserts its beneficial effects on cardiovascular health. Our findings encourage additional studies in order to understand the underlying causal mechanisms for these associations.

Epicardial adipose tissue is associated with cardiorespiratory fitness and hemodynamics among Japanese individuals of various ages and of both sexes

Epicardial adipose tissue may affect hemodynamics and cardiorespiratory fitness as it is a metabolically active visceral adipose tissue and a source of inflammatory bioactive substances that can substantially modulate cardiovascular morphology and function. However, the associations between epicardial adipose tissue and hemodynamics and cardiorespiratory fitness remain unclear. This cross-sectional study aimed to examine the association between epicardial adipose tissue volume and hemodynamics, and cardiorespiratory fitness among Japanese individuals of various ages and of both sexes. Epicardial adipose tissue volume was measured in 120 participants (age, 21–85 years) by cardiac magnetic resonance imaging. To evaluate cardiorespiratory fitness, peak oxygen uptake was measured by cardiopulmonary exercise testing. Peak cardiac output and arteriovenous oxygen difference were calculated by impedance cardiography. The epicardial adipose tissue volume was significantly increased in middle-aged and older women. The epicardial adipose tissue volume was significantly and negatively correlated to peak cardiac output and peak oxygen uptake, regardless of age and sex; furthermore, epicardial adipose tissue showed a strong negative correlation with peak heart rate. Epicardial adipose tissue and peak cardiac output were significantly associated (β = -0.359, 95% confidence interval, -0.119 to -0.049, p < 0.001), even after multivariate adjustment (R² = 0.778). However, in the multiple regression analysis with peak oxygen uptake as a dependent variable, the epicardial adipose tissue volume was not an independent predictor. These data suggest that increased epicardial adipose tissue volume may be correlated with decreased peak oxygen uptake, which might have mediated the abnormal hemodynamics among Japanese people of various ages and of both sexes. Interventions targeting epicardial adipose tissue could potentially improve hemodynamics and cardiorespiratory fitness.

Occupational lifting and risk of hypertension, stratified by use of anti-hypertensives and age - a cross-sectional and prospective cohort study

Background

Heavy occupational lifting is prevalent in the general working population and is sparsely reported to associate with hypertension, especially among older and hypertensive workers. We investigated if heavy occupational lifting is associated with hypertension and blood pressure (BP) in both cross-sectional and prospective study designs in the Copenhagen General Population Study, stratified by age, and use of anti-hypertensives.

Methods

Participation was conducted following the declaration of Helsinki and approved by the ethical committee (H-KF-01-144/01). By multivariable logistic and linear regression models, we investigated the association between heavy occupational lifting and hypertension, in a cross-sectional design (n = 67,363), using anti-hypertensives or BP ≥140/≥90 mmHg as outcome, and in a prospective design (n = 7020) with an above-median change in systolic BP (SBP) from baseline to follow-up and/or a shift from no use to use of anti-hypertensives as outcome, with and without stratification by age and use of anti-hypertensives.

Results

The odds ratio for hypertension was estimated at 0.97 (99% CI: 0.93–1.00) in the cross-sectional analysis, and at 1.08 (99% CI: 0.98–1.19) in the prospective analysis. The difference in SBP among workers with versus without heavy occupational lifting was estimated at − 0.29 mmHg (99% CI -0.82 – 0.25) in the cross-sectional and at 1.02 mmHg (99% CI -0.41 – 2.45) in the prospective analysis. No significant interaction between heavy occupational lifting and age, nor use of anti-hypertensives were shown.

Conclusions

Only the prospective analysis indicated heavy occupational lifting to increase the risk of hypertension. Further research on the association between occupational lifting and hypertension are needed.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10651-w.

An Estimation Model for Cardiorespiratory Fitness in Adults with Rheumatoid Arthritis

PURPOSE

Cardiopulmonary exercise testing of peak oxygen uptake (V˙O2peak) is the gold standard to measure cardiorespiratory fitness (CRF). For resource-intensive evaluation, equations estimating CRF (eCRF) may be used. The purpose was to investigate if an eCRF equation from a healthy population is useful in persons with rheumatoid arthritis (RA), and if necessary, develop new equations for eCRF in this group.

METHODS

V˙O2peak results from 93 persons with RA were compared with eCRF calculated by an established equation for healthy individuals including age, sex, physical activity (PA index), resting HR (RHR), and waist circumference. Because of deviation from the observed V˙O2peak, new equations for eCRF in persons with RA were developed from regression analysis of variables associated with observed V˙O2peak.

RESULTS

The established equation overestimated CRF (R = 0.48, root mean square error [RMSE] = 7.07). The new RA equation more accurately estimated CRF (R = 0.81, RMSE = 4.44) (female = 0, male = 1; never smoked = 0, ever smoked = 1): eCRF = 77.961 + (sex × 28.791) - (age × 0.358) - (age-sex interaction × 0.326) - (body mass index [BMI] × 0.700) - (RHR × 0.125) - (smoking × 1.854) + (PA index × 0.211) - (patient global RA assessment × 0.071). Alternative new RA equation (R = 0.79, RMSE = 4.63): eCRF = 77.851 + (sex × 25.460) - (age × 0.381) - (age-sex interaction × 0.254) - (BMI × 0.743) - (RHR × 0.115) - (smoking × 2.154) + (PA index × 0.209).

CONCLUSIONS

The new RA equations better predicted CRF in individuals with RA, preventing overestimation in low-fit persons. The new equation should be preferred when estimating CRF in individuals with RA. The alternative equation, without patient global assessment, is useful for individuals with RA in population-based studies.

An Exercise Prescription for COVID-19 Pandemic

COVID-19 is an alarming public health concern worldwide. COVID-19 is highly contagious and has no approved treatment or vaccine yet. Therefore, the best strategy is prevention. Studies have shown that a healthy lifestyle, regular exercise, balanced eating, and quality sleep are the key elements for protection from this disease. We are going through a distressful period as a nation and as the human race in general. We need to manage this period in the best way possible in physiological and psychological terms. Physical activity is one of the major steps in managing this period in a healthy way. Individuals should be provided information about exercise so that they can perform correct physical activities within their means. This article presents an exercise prescription that can be followed in the days of the COVID-19 pandemic.

Sedentary Behavior, Exercise, and Cardiovascular Health

Sedentary behavior and physical inactivity are among the leading modifiable risk factors worldwide for cardiovascular disease and all-cause mortality. The promotion of physical activity and exercise training (ET) leading to improved levels of cardiorespiratory fitness is needed in all age groups, race, and ethnicities and both sexes to prevent many chronic diseases, especially cardiovascular disease. In this state-of-the-art review, we discuss the negative impact of sedentary behavior and physical inactivity, as well as the beneficial effects of physical activity /ET and cardiorespiratory fitness for the prevention of chronic noncommunicable diseases, including cardiovascular disease. We review the prognostic utility of cardiorespiratory fitness compared with obesity and the metabolic syndrome, as well as the increase of physical activity /ET for patients with heart failure as a therapeutic strategy, and ET dosing. Greater efforts at preventing sedentary behavior and physical inactivity while promoting physical activity, ET, and cardiorespiratory fitness are needed throughout the healthcare system worldwide and particularly in the United States in which the burden of cardiometabolic diseases remains extremely high.

Effect of 8-weeks intensive lifestyle intervention on LDL and HDL subfractions

OBJECTIVE

Atherogenic dyslipidemia is a cardinal feature of obesity and the metabolic syndrome, which increases the risk of cardiovascular diseases. Many interventional studies, describing the influence of weight loss on cardiometabolic risks, are bariatric surgery studies. The aim of our study was to analyze the effect of intensive lifestyle changes on LDL- and HDL-cholesterol subfractions and cardiometabolic risk factors in obese subjects.

METHODS

A group of 41 patients with obesity (11M/30F; 44.1±12.4 years; BMI 30.2±6.3kg/m²) participated in an 8-week weight loss interventional program (NCT02325804), consisting of caloric intake reduced by 30% and physical activity (150min/week). Insulin sensitivity was evaluated according to the homeostasis model assessment of insulin resistance (HOMA-IR) and physical fitness was measured using bicycle ergometry. Lipid subfractions were measured using the Lipoprint system (Quantimetrix Corp., CA, USA).

RESULTS

After the intervention, body weight was reduced by 5.4±4.5kg, as well as body fat mass and waist circumference. Physical fitness improved, systolic and diastolic blood pressure as well as heart rate decreased after the intervention. Insulin sensitivity improved after the intervention. Total, LDL, HDL cholesterol, as well as triglycerides decreased after the intervention. Regarding the lipoprotein subfractions, LDL2 and small HDL subfractions decreased, while others have not changed.

CONCLUSION

Eight weeks of diet and physical activity intervention led to weight and fat mass loss and induced improvement of insulin sensitivity, as well as atheroprotective changes of lipid profile. However, the weight loss associated changes in cholesterol subfractions as cardiovascular risk biomarkers deserve further studies.

Associations of Aerobic Fitness and Maximal Muscular Strength With Metabolites in Young Men

IMPORTANCE

High physical fitness is associated with a reduction in risk of cardiovascular diseases and death, but the underlying mechanisms are insufficiently understood.

OBJECTIVE

To determine how aerobic fitness and muscular strength are associated with serum metabolome measures.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study included Finnish men receiving military refresher training from May 5, 2015, to November 28, 2015, representing partly overlapping groups of individuals with the lowest vs highest aerobic fitness and the lowest vs highest muscular strength. Data analyses were conducted from January 1, 2018, to May 31, 2019.

MAIN OUTCOMES AND MEASURES

The associations of aerobic fitness (determined with maximum oxygen consumption in milliliters per minute per kilogram, measured with maximal cycle ergometer test) and muscular strength (determined with a maximal strength test for lower extremities in kilograms) with 66 metabolome measures from fasting serum samples (nuclear magnetic resonance-based metabolomics) were analyzed.

RESULTS

Participants included 580 Finnish men (mean [SD] age, 26.1 [6.5] years). Including overlap between groups, there were 196 men in the lowest aerobic fitness group and 197 men in the highest aerobic fitness group as well as 196 men in the lowest muscular strength group and 197 men in the highest muscular strength group. Of 66 studied metabolome measures, 48 differed between high vs low aerobic fitness groups, including small very low-density lipoprotein (standardized median difference, -0.67; 95% CI, -0.83 to -0.49), large high-density lipoprotein (standardized median difference, 0.89; 95% CI, 0.69-1.15), total triglyceride levels (standardized median difference, -0.52; 95% CI, -0.65 to -0.34), isoleucine (standardized median difference, -0.37; 95% CI, -0.55 to -0.16), leucine (standardized median difference, -0.55; 95% CI, -0.72 to -0.34), phenylalanine (standardized median difference, -0.54; 95% CI, -0.71 to -0.32), glycerol (standardized median difference, -0.64; 95% CI, -0.81 to -0.48), and glycoprotein (standardized median difference, -0.78; 95% CI, -0.95 to -0.62) concentration, a high unsaturation degree of fatty acids (standardized median difference, 0.59; 95% CI, 0.42-0.81), and apolipoprotein B to apolipoprotein A1 ratio (standardized median difference, -0.88; 95% CI, -1.08 to -0.67). Adding aerobic fitness into the regression model after age, education, smoking, use of alcohol, and dietary factors accounted for more than an additional 5% of variation for 25 metabolome measures (R2 range, 5.01%-15.90% by measure). With these 2 criteria, maximal muscular strength was not associated with any metabolome measures. Aerobic fitness was associated with high large high-density lipoprotein particle concentration (R2, 14.97%; 95% CI, 10.65%-20.85%), low apolipoprotein B to apolipoprotein A1 ratio (R2, 14.49%; 95% CI, 10.58%-19.51%), and low glycoprotein concentration (R2, 15.90%; 95% CI, 11.22%-21.51%). Aerobic fitness was also associated with low very low-density lipoprotein, triglyceride, isoleucine, leucine, phenylalanine, glycerol, and glycoprotein concentrations and with a high unsaturation degree of fatty acids. Adjusting for recent physical activity influenced the results minimally. Adjusting for body fat percentage showed that some of the associations were mechanistically associated with body fat percentage.

CONCLUSIONS AND RELEVANCE

This study provides data on the association of high aerobic fitness with underlying oxidative lipid metabolism associated with a reduction in cardiometabolic risk. High maximal muscular strength is not similarly associated with these benefits.

Changes in midlife fitness, body mass index, and smoking influence cancer incidence and mortality: A prospective cohort study in men

Cancer prevention efforts include modification of unhealthy lifestyle, such as smoking cessation and resisting gain in body weight. Although physical activity is inversely related to risk of several cancers, it is poorly studied whether changes in physical activity or fitness influence future cancer risk. Thus, we aimed to investigate whether changes in midlife cardiorespiratory fitness (CRF), body mass index (BMI), and smoking habits influence cancer incidence and mortality. The study cohort includes 1689 initially healthy men, aged 40-59 years. Measurements of CRF, BMI and information on smoking habits were collected in two repeated waves, 7 years apart. Cox regression models estimated associations as hazard rates (HR) with 95% confidence intervals (CI), between midlife changes in the modifiable lifestyle factors and cancer incidence and mortality. The men were followed prospectively for more than 30 years. Compared to CRF loss (>5%), improved CRF (>5%) was associated with lower cancer incidence (HR 0.81, 95% CI 0.67-0.98) and mortality (HR 0.70, 95% CI 0.54-0.92), and maintaining the CRF stable yielded lower cancer incidence (HR 0.76, 95% CI 0.61-0.95). No association was seen for BMI gain, but maintaining the BMI stable was related to lower cancer incidence (HR 0.77, 95% CI 0.60-0.98), compared to BMI loss. Continue smoking was associated with higher cancer incidence and mortality, compared to men who stopped smoking. In particular, this study adds new knowledge about the potential preventive role of CRF in cancer development and emphasizes lifestyle modification as a highly important effort in cancer prevention.

Prevalence and Control of Dyslipidemia in Patients Referred for High Blood Pressure: The Disregarded "Double-Trouble" Lipid Profile in Overweight/Obese

Introduction

We evaluated the prevalence and control of dyslipidemia in a wide sample of patients referred to our ESH “Hypertension Excellence Centre” for high blood pressure (BP). Furthermore, we evaluated the role of adiposity on the serum lipid profile.

Methods

Observational study on 1219 consecutive outpatients with valid ambulatory BP monitoring (ABPM) referred for high BP. Patients with body mass index (BMI) ≥ 25 kg/m² were defined as overweight/obese (OW/OB). Dyslipidemia and the control rates of low-density lipoprotein cholesterol (LDLc) were defined according to the 2016 ESC/EAS Guidelines.

Results

Mean age: 56.5 ± 13.7 years. Male prevalence: 55.6%. OW/OB patients were 70.2%. The prevalence of dyslipidemia was 91.1%. Lipid-lowering drugs were taken by 23.1% of patients. Patients with controlled LDLc comprised 28.5%, while BP was controlled in 41.6% of patients. Only 12.4% of patients had both 24-h BP and LDLc controlled at the same time. The higher the cardiovascular (CV) risk was, the lower was the rate of LDLc control (p < 0.001). Patients in secondary prevention had worse LDLc control than patients in primary prevention (OR 3.5 for uncontrolled LDLc, p < 0.001). OW/OB showed a more atherogenic lipid profile, characterized by lower high-density lipoprotein cholesterol (HDLc) (p < 0.001), higher non-HDLc (p = 0.006), higher triglycerides (p < 0.001), higher non-HDLc/HDLc (p < 0.001) and higher (non-HDLc + non-LDLc) (p < 0.001).

Conclusion

Dyslipidemia is still too often neglected in hypertensives, especially in patients at higher CV risk. OW/OB hypertensives have a “double-trouble” atherogenic lipid pattern likely driven by adiposity. We encourage a comprehensive evaluation of the lipid profile in all hypertensives, especially if they are OW/OB, to correctly assess their CV risk and improve their management.

Funding

Article processing charges funded by Servier SpA.

Relation of Isolated Low High-Density Lipoprotein Cholesterol to Mortality and Cardiorespiratory Fitness (from the Henry Ford Exercise Testing Project [FIT Project])

Isolated low high-density lipoprotein cholesterol (HDL-C) is associated with lower fitness and increased mortality. Whether the association between isolated low HDL-C and mortality differs by fitness is uncertain. Patients in the Henry Ford ExercIse Testing Project (FIT Project) completed a physician-referred treadmill stress test and those prescribed lipid-lowering medications or with known cardiovascular disease were excluded. Isolated low HDL-C was defined as HDL-C <40 mg/dl for men and <50 mg/dl for women with low-density lipoprotein cholesterol (LDL-C) and triglycerides <100 mg/dl (n = 688). An optimal lipid panel was defined as HDL-C ≥40 mg/dl for men and ≥50 mg/dl for women with LDL-C and triglycerides <100 mg/dl (n = 2,923). Mortality was ascertained through Social Security Death Index linkage. Patients with isolated low HDL-C had a mean age of 48.9 ± 12.9 years and 62.9% were women. Over a mean follow-up of 10.3 ± 5 years, 12.8% of patients with isolated low HDL-C and 8.7% with optimal lipids died. Compared to individuals with optimal lipids, those with isolated low HDL-C who achieved <6 METs had a lower survival (p = 0.02), whereas there was no mortality difference for those who achieved 6 to 10 METs (p = 0.13) or ≥10 METs (p = 0.66). In adjusted Cox models, the mortality hazard for those with isolated low HDL-C compared with optimal lipids was 1.73 (95% confidence interval [CI] 1.18 to 2.54), 1.90 (95% CI 1.19 to 3.04), and 0.97 (95% CI 0.53 to 1.78) for the METS categories of <6, 6 to 10, and ≥10. In conclusion, individuals with isolated low HDL-C fitness significantly improved risk stratification and only those with lower fitness had an increased totality mortality risk.

Cardiorespiratory fitness in patients with rheumatoid arthritis is associated with the patient global assessment but not with objective measurements of disease activity

Objective

Patients with rheumatoid arthritis (RA) suffer from more cardiovascular disease (CVD), and develop cardiovascular risk factors at an earlier age than the general population. Cardiorespiratory fitness (CRF) is an important predictor of cardiovascular health. There are few data regarding CRF of RA patients, measured as peak oxygen uptake (VO_2peak) by the gold standard method; cardiopulmonary exercise testing. We compared CRF in RA patients to those from a healthy population, and investigated if risk factors for CVD and RA-specific variables including subjective and objective disease activity measures were associated with CRF in RA patients.

Methods

VO_2peak tests of RA patients (n=93) were compared to those of an age-matched and gender-matched healthy population (n=4631) from the Nord-Trøndelag Health Study. Predictors of VO_2peak were found using Lasso (least absolute shrinkage and selection operator) regression, followed by standardised multiple linear regression.

Results

Women with RA ≥40 years and men with RA aged 40-49 years or 60-69 years had up to 20% lower CRF than the healthy population in the same age groups. By relative importance, body mass index (standardised coefficient=-0.25, p<0.001), physical activity level (coefficient=0.21, p<0.001), patient global assessment (PGA; coefficient=-0.14, p=0.006), systolic blood pressure (coefficient=-0.12, p=0.016), resting heart rate (coefficient=-0.11, p=0.032) and smoking (coefficient=-0.10, p=0.046) were significant predictors of CRF (R²=0.82, gender-adjusted and age-adjusted).

Conclusion

CRF in RA patients was lower than in a healthy population. CRF was associated with common risk factors for CVD and the PGA score. Focusing on fitness in RA patients may improve cardiovascular health.

Cardiorespiratory fitness, body mass index and heart failure incidence

AIMS

Obesity is associated with increased risk of heart failure (HF). This risk may be modulated by improved cardiorespiratory fitness (CRF) as CRF is associated with favourable health outcomes. Thus, we assessed the interaction between body mass index (BMI), CRF and HF.

METHODS AND RESULTS

Cardiorespiratory fitness and BMI were assessed in 20 254 US male veterans (mean age 58.0 ± 11.3 years), who completed a maximal exercise treadmill test between 1987 and 2017. All had no evidence of ischaemia or HF prior to the exercise test. They were classified based on age-stratified quartiles of peak metabolic equivalents (METs) achieved as: least-fit (4.5 ± 1.3), low-fit (6.7 ± 1.3), moderate-fit (8.1 ± 1.1), and high-fit (11.2 ± 2.4); and according to BMI as normal weight (18.5-24.9 kg/m² ), overweight (25-29.9 kg/m² ), and obese (≥ 30.0 kg/m² ). During a median follow-up of 13.4 years, there were 2979 HF events (10.8 events/1000 person-years). HF risk was significantly higher in the obese category [hazard ratio (HR) 1.22, 95% confidence interval (CI) 1.10-1.36; P < 0.001], but was no longer significant after further adjustment for METs. When compared to the least-fit, HF risk declined progressively with increased CRF within all BMI categories. The risk was 63% (HR 0.37, 95% CI 0.30-0.47; P < 0.001), 66% (HR 0.37, 95% CI 0.28-0.40; P < 0.001), and 73% (HR 0.27, 95% CI 0.22-0.34; P < 0.001) lower for high-fit individuals within normal weight, overweight and obese categories, respectively.

CONCLUSIONS

Increased CRF was associated with progressively lower HF risk regardless of BMI, suggesting that the elevated HF risk associated with obesity may be modulated by improved CRF.

The Association between the Change in Directly Measured Cardiorespiratory Fitness across Time and Mortality Risk

BACKGROUND

The relationship between cardiorespiratory fitness (CRF) and mortality risk has typically been assessed using a single measurement, though some evidence suggests the change in CRF over time influences risk. This evidence is predominantly based on studies using estimated CRF (CRF_e). The strength of this relationship using change in directly measured CRF over time in apparently healthy men and women is not well understood.

PURPOSE

To examine the association of change in CRF over time, measured using cardiopulmonary exercise testing (CPX), with all-cause and disease-specific mortality and to compare baseline and subsequent CRF measurements as predictors of all-cause mortality.

METHODS

Participants included 833 apparently healthy men and women (42.9 ± 10.8 years) who underwent two maximal CPXs, the second CPX being ≥1 year following the baseline assessment (mean 8.6 years, range 1.0 to 40.3 years). Participants were followed for up to 17.7 (SD 11.8) years for all-cause-, cardiovascular disease- (CVD), and cancer mortality. Cox-proportional hazard models were performed to determine the association between the change in CRF, computed as visit 1 (CPX1) peak oxygen consumption (VO_2peak [mL·kg^-1·min^-1]) - visit 2 (CPX2) VO_2peak, and mortality outcomes. A Wald-Chi square test of equality was used to compare the strength of CPX1 to CPX2 VO_2peak in predicting mortality.

RESULTS

During follow-up, 172 participants died. Overall, the change in CPX-CRF was inversely related to all-cause, CVD, and cancer mortality (p < 0.05). Each 1 mL·kg^-1·min^-1 increase was associated with a ~11, 15, and 16% (all p < 0.001) reduction in all-cause, CVD, and cancer mortality, respectively. The inverse relationship between CRF and all-cause mortality was significant (p < 0.05) when men and women were examined independently, after adjusting for years since first CPX, baseline VO_2peak, and age. Further, the Wald Chi-square test of equality found CPX2 VO_2peak to be a significantly stronger predictor of all-cause mortality than CPX1 VO_2peak (p < 0.05).

CONCLUSION

The change in CRF over time was inversely related to mortality outcomes, and mortality was better predicted by CRF measured at subsequent test than CPX1 CRF. These findings emphasize the importance of adopting lifestyle behaviors that promote CRF, as well as support the need for routine assessment of CRF in clinical practice to better assess risk.

An Update on the Role of Cardiorespiratory Fitness, Structured Exercise and Lifestyle Physical Activity in Preventing Cardiovascular Disease and Health Risk

The cardiovascular disease (CVD) pandemic has placed considerable strain on healthcare systems, quality of life, and physical function, while remaining the leading cause of death globally. Decades of scientific investigations have fortified the protective effects of cardiorespiratory fitness (CRF), exercise training, and physical activity (PA) against the development of CVD. This review will summarize recent efforts that have made significant strides in; 1) the application of novel analytic techniques to increase the predictive utility of CRF; 2) understanding the protective effects of long-term compliance to PA recommendations through large cohort studies with multiple points of assessment; 3) and understanding the potential harms associated with extreme volumes of PA.

The Effects of Exercise and Physical Activity on Weight Loss and Maintenance

Obesity represents a major health problem in the United States and is associated with increased prevalence of cardiovascular (CV) disease risk factors. Physical activity (PA) and exercise training (ET) are associated with reduced CV risk, improved cardiometabolic risk factors, and facilitated weight loss through creating a negative energy balance. Clinicians need to counsel overweight and obese patients on how much PA/ET is needed to promote weight loss and weight loss maintenance. This will help establish realistic expectations and maximize improvements in CV risk factors. Although the minimum guidelines for aerobic PA (150 min of moderate or 75 min of vigorous physical activity per week) can improve CV health, these levels are generally inadequate for clinically significant weight loss or weight maintenance without caloric restriction. The purpose of this review is to evaluate the role of ET to promote clinically significant weight loss and promote weight maintenance. In particular, we will evaluate the likelihood of weight loss from ET programs composed of aerobic training only, resistance training only and programs that combine diet and ET. We will also explore the role of PA in promoting short-term and long-term weight maintenance.

Insulin Therapy Increases Cardiovascular Risk in Type 2 Diabetes

Insulin therapy increased cardiovascular (CV) risk and mortality among type 2 diabetes (T2D) patients in several recently reported clinical outcomes trials. To assess whether this association is causative or coincidental, PubMed searches were used to query the effects of insulin therapy for T2D on CV health and longevity from large-scale outcomes trials, meta-analyses, and patient registry studies, as well as basic research on insulin's direct and pleiotropic actions. Although several old studies provided conflicting results, the majority of large observational studies show strong dose-dependent associations for injected insulin with increased CV risk and worsened mortality. Insulin clearly causes weight gain, recurrent hypoglycemia, and, other potential adverse effects, including iatrogenic hyperinsulinemia. This over-insulinization with use of injected insulin predisposes to inflammation, atherosclerosis, hypertension, dyslipidemia, heart failure (HF), and arrhythmias. These associations support the findings of large-scale evaluations that strongly suggest that insulin therapy has a poorer short- and long-term safety profile than that found to many other anti-T2D therapies. The potential adverse effects of insulin therapy should be weighed against proven CV benefits noted for select other therapies for T2D as reported in recent large randomized controlled trials.