Evaluating a Nationwide Recreational Football Intervention: Recruitment, Attendance, Adherence, Exercise Intensity, and Health Effects

Evaluation of a football fitness implementation initiative for an older adult population in a small-scale island society

Background

The proportion of older people increases globally, which calls for sustainable interventions promoting healthy aging. Therefore, we aimed to evaluate the potential of Football Fitness as a sustainable model to promote quality of life, mental health, and physical function for older adult.

Methods

The study was conducted in collaboration with a municipality, a football club, and a university, and was designed as a randomized controlled trial. A total of 66 people (34 women, 32 men) older than 60 years were randomly assigned (60/40) to a Football Fitness (FOT) (n = 38, 20 women, 18 men) and a control group (CON) (n = 28, 14 women, 14 men). FOT participated in Football Fitness for 12 weeks. Quality of life (QoL) and mental wellbeing were determined pre-and post-intervention. Physical loading and Flow experience were measured in one representative training session. Blood pressure (BP), Yo-Yo Intermittent endurance test level 1 (Yo-Yo IE1), sprint performance, postural balance, and body composition were also performed pre-and post-intervention.

Results

An improvement in mental wellbeing was observed for both groups from pre- to post-intervention (p values <0.001) with no between-group differences. Regarding QoL, the environment domain improved in FOT compared to CON (p = 0.02). Mean Flow (M = 5.69; SD = 1.07) and perceived importance (M = 4.20; SD = 1.42) and average experienced difficulty was M = 5.23 (SD = 2.67), perceived skill (M = 5.23; SD = 2.56), and perceived balance (M = 5.64; SD = 1.56). These levels of flow can be characterized as being high. A between-group effect (p = 0.02) existed for systolic BP, which decreased (p < 0.01) by -5% [-8; -1%] in CON and remained unchanged in FOT. Both groups improved the Yo-Yo IE1 to a similar extent, with 28% [11; 44%] (p = 0.001) in FOT and 27% [9; 46%] in CON (p = 0.005). Postural balance improved (p = 0.004) by 38% [13; 63%] in FOT only, resulting in a superior (p = 0.01) balance score in FOT compared to CON post-intervention (p = 0.004).

Conclusion

Football Fitness improved the environmental quality of life domain and postural balance in older adults. Additionally, it appears to be a feasible group activity for older adults that promotes high flow and physical loading during training.

"11 for Health" in the Faroe Islands: Popularity in schoolchildren aged 10-12 and the effect on well-being and health knowledge

BACKGROUND

We aimed to investigate the popularity of the "11 for Health program for Europe" for 10-12-year-old Faroese children and the effects on well-being and health knowledge.

METHODS

We applied a cluster-randomized controlled trial, including a total of 19 school clusters, randomized into intervention schools (IG, n = 12) and control schools (CG, n = 7). A total of 261 children (137 boys and 124 girls) participated. IG completed the 11-week program, consisting of 2 × 45 min weekly sessions with football drills, small-sided games, and health education. CG continued their regular education. Pre- and post-intervention, the participants completed a shortened version of the multidimensional well-being questionnaire KIDSCREEN-27 and a 34-item multiple-choice health knowledge questionnaire.

RESULTS

Between-group differences (p < 0.05) were observed in change scores for physical well-being and overall peers and social support in favor of IG compared with CG, as well as for physical well-being in IG girls compared with CG girls. Between-group differences in change score for overall health knowledge (11.8%, p < 0.001, ES: 0.82) were observed in favor of IG, as well as for playing football (8.9%, p = 0.039, ES: 0.24), be active (8.1%, p = 0.017, ES: 0.32), control your weight (18.5%, p < 0.001, ES: 0.52), wash your hands (19.5%, p < 0.001, ES: 0.59), eat a balanced diet (19.3%, p < 0.001, ES: 0.64), get fit (12.1%, p = 0.007, ES: 0.34), and think positive (5.5%, p = 0.039, ES: 0.22). The program was reported as enjoyable with equal moderate-to-high scores for girls (3.68 ± 1.23; ±SD) and boys (3.84 ± 1.17) on a 1-5 Likert Scale.

CONCLUSION

The "11 for Health program for Europe" improved physical well-being, peers, and social support and broad-spectrum health knowledge in 10-12-year-old Faroese schoolchildren and was rated popular.

The relationship between the pan-immune-inflammation value and long-term prognoses in patients with hypertension: National Health and Nutrition Examination Study, 1999-2018

Background

Direct antihypertensive therapy in hypertensive patients with a high CVD risk can reduce the incidence of cardiovascular death but increase adverse cardiovascular events, so additional ways to identify hypertensive patients at high risk may be needed. Studies have shown that immunity and inflammation affect the prognoses of patients with hypertension and that the pan-immune-inflammation value (PIV) is an index to assess immunity and inflammation, but few studies have applied the PIV index to patients with hypertension.

Objective

To explore the relationship between the PIV and long-term all-cause and cardiovascular mortality in patients with hypertension.

Method

Data from the National Health and Nutrition Examination Survey (NHANES) 1999-2018 with a mortality follow-up through December 31, 2019, were analyzed. A total of 26,781 participants were evaluated. The patients were grouped based on PIV levels as follows: T1 group (n = 8,938), T2 group (n = 8,893), and T3 group (n = 8,950). The relationship between the PIV and long-term all-cause and cardiovascular death was assessed by survival curves and Cox regression analysis based on the NHANES recommended weights.

Result

The PIV was significantly associated with long-term all-cause and cardiovascular mortality in patients with hypertension. After full adjustment, patients with higher PIV have a higher risk of all-cause [Group 3: HR: 1.37, 95% CI: 1.20-1.55, p < 0.001] and cardiovascular [Group 3: HR: 1.62, 95% CI: 1.22-2.15, p < 0.001] mortality.

Conclusion

Elevated PIV was associated with increased all-cause mortality and cardiovascular mortality in hypertensive patients.

Metabolic Changes After a 24-Week Soccer-Based Adaptation of the Diabetes Prevention Program in Hispanic Males: A One-Arm Pilot Clinical Trial

Aims: One third of the U.S. adult population is estimated to have obesity-associated prediabetes. Hispanics have a 50% higher type 2 diabetes death rate compared to non-Hispanic whites, yet low participation in lifestyle change programs, making this subgroup an important target for prevention. Our objective was to determine the feasibility and the effects of an intervention implementing the Center for Disease Control and Prevention National Diabetes Prevention Program (NDPP) plus recreational soccer (RS) in Hispanic men.

Methods: Overweight and obese Hispanic men, aged 30–57 years with prediabetes at screening were recruited (n = 41). Trained soccer coaches led 30-min facilitated discussion of the NDPP modules after each RS session, with two sessions per week for 12 weeks and once per week for the following 12 weeks. The 1-h RS sessions followed the Football Fitness curriculum. Assessments included body mass index, waist circumference, bioelectrical impedance analysis (InBody 270), blood pressure, glycated hemoglobin (HbA1c), and validated physical fitness tests. Multilevel mixed models assessed the outcomes as a function of time and cohort and incorporated an unstructured covariance structure to examine the changes from baseline to 24 weeks. All analyses were conducted as intent-to-treat using SAS v 9.4.

Results: Hispanic males (n = 41; mean age 41.7 [0.1] years) were obese at baseline (mean BMI 32.7, standard error of mean [0.7], mean weight 93.9 [2.2] kg). Attendance rate was 65% overall at 12 weeks but differed between cohorts. Five mild injuries occurred over the trial. After 24 weeks of the NDPP+RS intervention, there were significant decreases in systolic and diastolic blood pressure (%change −4.7[SE 2.4]; 95% CI [−11.5, −1.7] and −6.1 [1.7] mmHg; [−9.6, −2.6], respectively), HbA1c (−0.2 [0.1]; [−0.3, −0.1]), Despite significant reductions in weight (−3.8 [0.7]; [−5.2, −2.5]), waist circumference (−6.6 [0.7] cm; [−8.0, −5.1]), body fat % (−1.9 [0.5]; [−2.8, −1.0]), lean body mass was preserved (−0.9 [0.3]; [−1.6, −0.2]).

Conclusion: A 24-week soccer-based adaptation of the Diabetes Prevention Program is safe and feasible among middle-aged Latino men.

Improved metabolic fitness, but no cardiovascular health effects, of a low-frequency short-term combined exercise programme in 50-70-year-olds with low fitness: A randomized controlled trial

We evaluated the cardiometabolic effects of a 15-week combined exercise programme, implemented in sports clubs, for 50-70-year-olds with low aerobic fitness. In a randomized controlled trial, 45 participants (26 women) with low fitness were randomly assigned (2:1-ratio) to a training group (TG, n = 30) or inactive control group (CG, n = 15). TG had 15 weeks with one weekly 90-min supervised group-based session in a recreational sports club with combined aerobic exercise and strength training and were encouraged to perform home-based training 30 min/wk. Evaluations of relative VO_2max (mLO₂/min/kg), blood pressure, resting heart rate (HR), echocardiography, peripheral arterial tonometry, body composition, lipid profile and HbA1c were performed at 0 and 15 wks. Average HR during supervised training was 113 ± 13 bpm (68.6 ± 7.0%HR_max), with 4.3 ± 6.6% spent >90%HR_max. At 15-wk follow-up, intention-to-treat analyses revealed no between-group difference for VO_2max/kg (0.4 mLO₂/min/kg, 95%CI -0.8-1.5, P = 0.519; -3 mL/min, 95%CI -123-118, P = 0.966) or other cardiovascular outcomes (all P > 0.05). Compared to CG, total fat mass (-1.9 kg; 95%CI -3.2 to -0.5, P = 0.005), total fat percentage (-1.3%, 95%CI -2.2 to -0.3, P = 0.01) and total/HDL cholesterol ratio (P = 0.032) decreased in TG. Regular adherence to supervised training was high (81%), but 0% for home-based exercise. In conclusion, the group-based supervised training was associated with high adherence and moderate exercise intensity, whereas insufficiently supported home-based training was not feasible. Together, 15 wks of combined exercise training did not improve aerobic fitness or affected cardiovascular function in 50-70-yr-olds with low aerobic fitness, whereas some positive effects were observed in metabolic parameters.HighlightsCombined exercise training implemented in a sports club elicited moderate aerobic intensity in 50-70-year-old untrained individuals.Supervised group-based training had high adherence whereas unsupported home-based training had very low adherence.15 weeks of low-frequency combined moderate intensity exercise training improved lipid profile and fat mass, but had no effect on cardiovascular fitness.

Physical fitness and activity changes after a 24-week soccer-based adaptation of the U.S diabetes prevention program intervention in Hispanic men

PURPOSE

One third of the U.S. adult population is estimated to have prediabetes. Hispanics have a 50% higher type 2 diabetes (T2DM) death rate compared to non-Hispanic whites, yet low participation in lifestyle change programs, making this subgroup an important target for prevention efforts. The purpose of this study was to determine the effects of an exercise intervention implementing the Center for Disease Control and Prevention National Diabetes Prevention Program (NDPP) plus recreational soccer (RS) in Hispanic men.

METHODS

Overweight and obese Hispanic men, aged 30-57 years with prediabetes at screening were recruited from the community. Trained soccer coaches led 30-min facilitated discussion of the NDPP modules after each RS session, with two weekly sessions delivered over 12 wks, then once a wk until 24 wks. The 1-h RS sessions followed the Football Fitness curriculum structure. Standardized study assessments included objectively measured physical activity via fitness tracker, physical fitness via validated field tests, global positional system soccer specific metrics and behavior change questionnaires. Mixed models assessed the outcomes as a function of time and cohort and incorporated an unstructured covariance structure to examine the difference between baseline, 12 and 24 wks. All analyses were conducted as intent-to-treat and generated using SAS v 9.4.

RESULTS

Hispanic males (n = 41; mean age 41.9 [6.2 SD] years) were obese at baseline (mean BMI 32.7, standard error [0.7]). After 24 wks of the NDPP+RS intervention, there were significant beneficial changes in vertical jump (2.8 [1.3] cm; p = 0.048), agility and lower extremity muscular power (figure 8-run) at 12 wks (-4.7% change; p = 0.001) and 24 wks (-7.2% change; p < 0.0001), predicted VO2 max (12 wks: 1.9%; p = 0.007; 24 wks 1.0%; p = 0.036), modified push-ups increased 22% (p < 0.0001) at 12 wks and 31% (p < 0.0001) at 24 wks, dynamic sit-ups increased 10% (p = 0.005) at 12 wks and 15% (p < 0.0001) at 24 wks.

CONCLUSION

Among middle-aged Latino men, broad-ranging significant improvements in physical fitness were observed after 24 wks participating in lifestyle education plus RS in a single arm feasibility trial.

Effects of a 16-week recreational team handball intervention on aerobic performance and cardiometabolic fitness markers in postmenopausal women: A randomized controlled trial

BACKGROUND

Postmenopausal women have an elevated risk of developing cardiovascular diseases, which can be counteracted by conventional exercise regimes or recreational football. Less is known about the impact of exercise programmes based on other team sports. Thus, we examined the effects of recreational team handball on aerobic performance, cardiorespiratory fitness and cardiometabolic health in untrained postmenopausal women.

METHODS

Sixty-seven participants (age 68 ± 6 years, stature 157 ± 6 cm, body mass 67 ± 10 kg, fat mass 37 ± 7%, VO_2peak 25.2 ± 3.6 mL/min/kg, Yo-Yo intermittent endurance level 1 test performance (YYIE1) 230 ± 103 m) with no previous experience of team handball were randomly allocated to either a team handball (THG, n = 41) or a control (CG, n = 26) group. THG performed 2-3 60-min training sessions per week for 16 weeks. YYIE1 performance and cardiometabolic markers were evaluated at baseline and post-intervention.

RESULTS

Average attendance during recreational team handball training was 1.9 ± 0.4 sessions per week, with mean heart rates of 76 ± 6%HR_max and 18 ± 9 min (44 ± 20% of total time) played at HR > 80%HR_max. A between-group effect was observed for YYIE1 performance, with a more pronounced improvement in aerobic exercise performance in THG compared to CG (70 ± 62 vs 15 ± 44%; p < 0.001). Within-group improvements (p < 0.05) were observed for THG with regard to VO_2peak (7 ± 10%), incremental treadmill test time to exhaustion (TTE) (11 ± 14%), total cholesterol (-3 ± 9%) and low-density lipoprotein cholesterol (-2 ± 14%), with no significant changes in CG except an increase (p < 0.05) in TTE. Post-intervention values were higher for THG vs CG for YYIE1 performance (88%; 406 ± 216 vs 216 ± 75 m) and VO_2peak (10%; 27.5 ± 3.8 vs 24.9 ± 3.6 mL/min/kg).

CONCLUSIONS

Recreational team handball can be used to obtain moderate-to-vigorous aerobic intensities, and just 2 weekly 60-min team handball training sessions for 16 weeks can result in improvements in aerobic performance and in markers of cardiorespiratory fitness in postmenopausal women with no previous experience of the sport.

Gender-dependent evaluation of football as medicine for prediabetes

PURPOSE

Training intensity and health effects of football were investigated gender specifically in individuals with prediabetes.

METHODS

Participants with prediabetes (age 60 ± 6 years) were randomised into a football and dietary advice group (FD-men n = 13 and FD-women n = 14) or a dietary advice only group (D-men n = 12 and D-women n = 11). FD performed football training (twice/week for 16 weeks), while both groups received dietary advice. Body composition, bone variables, blood pressure, blood lipid profile and peak oxygen uptake (VO2peak) were determined pre- and post-intervention.

RESULTS

Mean heart rate during football training was 79 ± 2 and 80 ± 3% HRmax for FD-men and FD-women, respectively, with peak heart rate values of 96 ± 1 and 97 ± 2% HRmax, with no gender differences. VO2peak increased more (P < 0.05) in FD-men and FD-women than in D-men and D-women. However, relative delta change in VO2peak was 21 ± 14% in FD-women, which was greater (P < 0.05) than in FD-men (11 ± 12%). Reduction in SBP and DBP, respectively, was similar in FD-men (- 10.8 ± 13.0 and - 7.3 ± 11.8 mmHg) and FD-women (- 11.3 ± 11.0 and - 7.1 ± 6.2 mmHg), with within-gender differences for men. Total plasma cholesterol and LDL cholesterol decreased (P < 0.05) by - 0.7 ± 1.1 and - 0.5 ± 0.9 mmol L-1, respectively, in FD-women and - 0.2 ± 0.4 and - 0.2 ± 0.3 mmol L-1 in FD-men, with no significant gender differences (P = 0.08). Body fat content was lowered (P < 0.05) by 3 and 4%-points in FD-men and FD-women, respectively.

CONCLUSION

Gender-mixed football training combined with dietary advice causes broad-spectrum health effects for men and women with prediabetes, with minor gender-specific differences. Thus, the intensity and training-induced effects of football training are also high for elderly women with prediabetes.

Effects of a 6-Week Faroese Chain Dance Programme on Postural Balance, Physical Function, and Health Profile in Elderly Subjects: A Pilot Study

The present pilot study investigates the impact of a Faroese chain dance intervention on health profile, mobility, and postural balance in elderly subjects. Healthy elderly subjects (n=27; age 75 ± 5 yrs) were randomised into an intervention group (IG) and a control group (CG). IG performed twice-weekly sessions of Faroese chain dance over 6 weeks. Dancing sessions lasted 30 min in the initial 3 weeks and 45 min in the final 3 weeks. Health profile was determined before and after intervention by measuring blood pressure, resting heart rate, muscle mass, and body fat content. Postural balance was evaluated using the Berg Balance Scale (BBS) and Fullerton Advanced Balance Scale (FAB) tests, while mobility was assessed using the Short Physical Performance Battery (SPPB), the Timed Up & Go (TUG) test, the 6-min walk test, and the 30-s sit-to-stand test. Systolic and diastolic blood pressure were lowered (9 ± 6 and 6 ± 3 mmHg, respectively) in IG, with a tendency (P=0.07) for a greater change score than in CG. Mean arterial pressure declined (P<0.05) by 7 ± 3 mmHg in IG, which tended (P=0.09) to be greater than in CG. IG improved (P<0.05) on BBS and FAB scores by 3.6 ± 2.1% and 15.8 ± 8.3%, with the change score for FAB being greater (P<0.05) than in CG (0.3 ± 1.6). Moreover, the postintervention SPPB score was improved (P<0.05) more in IG (13.9 ± 7.4%) compared to CG, while performance in the 30-s sit-to-stand, 6-min walk, and TUG tests improved (4–15%; P<0.05) in IG only. Body fat content was reduced (P<0.05) from 36.3 ± 2.8% to 34.8 ± 2.8% in IG, with no between-group differences and no change in CG (34.1 ± 2.8% to 33.7 ± 3.1%). In conclusion, a 6-week Faroese chain dance programme lowers blood pressure and improves postural balance and physical function in elderly.

Effects of a Short-Term Recreational Team Handball-Based Programme on Physical Fitness and Cardiovascular and Metabolic Health of 33-55-Year-Old Men: A Pilot Study

Recreational team handball is an intermittent high-intensity exercise mode with physiological demands in the range of those found to enhance health and physical fitness of sedentary adults. We examined the effects of a short-term team handball-based training programme on physical fitness and metabolic and cardiovascular health of sedentary 33-55-year-old former male team handball players. Twenty-four participants were divided into team handball (THG; n=15) and control groups (CG; n=9) and evaluated at baseline and postintervention. During 12 weeks, THG performed 2-3 60-min recreational team handball matches weekly (average: 2.2 ± 0.7), and CG maintained an inactive lifestyle. Average heart rate (HR) during matches was 80 ± 7%HRmax, with peak values of 91 ± 6%HRmax. A time-by-group interaction was shown in aerobic performance (p=0.016), postural balance (p=0.019), maximum oxygen uptake (VO2max) (p=0.023), resting HR (p<0.001), high-density lipoprotein (HDL) cholesterol (p=0.048), and fasting blood glucose (p=0.052) in favor of THG. THG improved aerobic performance (80%, p<0.001), VO2max (14%, p<0.001), and postural balance (27%, p=0.018). Decreases in resting HR (16%, p<0.001) and fasting blood glucose (7%, p=0.015) and increases in HDL cholesterol (11%, p=0.002) were found in THG. Recreational team handball practice shows positive physical fitness and health-related adaptations, with high attendance, which may contribute to the reduction of the risk of developing lifestyle diseases.

The Yo-Yo Intermittent Tests: A Systematic Review and Structured Compendium of Test Results

Background: Although Yo-Yo intermittent tests are frequently used in a variety of sports and research studies to determine physical fitness, no structured reference exists for comparison and rating of test results. This systematic review of the most common Yo-Yo tests aimed to provide reference values for test results by statistical aggregation of published data.

Methods: A systematic literature search for articles published until August 2017 was performed in MEDLINE, Web of Science, SPORTDiscus and Google Scholar. Original reports on healthy females and males ≥16 years were eligible for the analysis. Sub-maximal test versions and the Yo-Yo Intermittent Recovery Level 1 Children's test (YYIR1C) were not included.

Results: 248 studies with 9,440 participants were included in the structured analysis. The Yo-Yo test types most frequently used were the Yo-Yo Intermittent Recovery Level 1 (YYIR1, 57.7%), the Yo-Yo Intermittent Recovery Level 2 (YYIR2, 28.0%), the Yo-Yo Intermittent Endurance Level 2 (YYIE2, 11.4%), and the Yo-Yo Intermittent Endurance Level 1 (YYIE1, 2.9%) test. For each separate test, reference values (global means and percentiles) for sports at different levels and both genders were calculated.

Conclusions: Our analysis provides evidence that Yo-Yo intermittent tests reference values differ with respect to the type and level of sport performed.The presented results may be used by practitioners, trainers and athletes to rate Yo-Yo intermittent test performance levels and monitor training effects.

Effects of recreational football on women's fitness and health: adaptations and mechanisms

The review describes the fitness and health effects of recreational football in women aged 18-65 years. The review documents that 2 × 1 h of recreational football training for 12-16 weeks causes marked improvements in maximal oxygen uptake (5-15%) and myocardial function in women. Moreover, mean arterial blood pressure was shown to decrease by 2-5 mmHg in normotensive women and 6-8 mmHg in hypertensive women. This review also show that short-term (< 4 months) and medium-term (4-16 months) recreational football training has major beneficial impact on metabolic health profile in women, with fat losses of 1-3 kg and improvements in blood lipid profile. Lastly, 2 × 1 h per week of recreational football training for women elevates lower extremity bone mineralisation by 1-5% and whole-body bone mineralization by 1-2% within 4-12-month interventions. These training adaptations are related to the high heart rates, high number of fast runs, and multiple changes of direction and speed occurring during recreational football training for untrained women. In conclusion, regular small-sided football training for women is an intense and versatile type of training that combines elements of high-intensity interval training (HIIT), endurance training and strength training, thereby providing optimal stimuli for cardiovascular, metabolic and musculoskeletal fitness. Recreational football, therefore, seems to be an effective tool for prevention and treatment of lifestyle diseases in young and middle-aged women, including hypertension, type 2 diabetes and osteopenia. Future research should elucidate effects of football training for elderly women, and as treatment and rehabilitation of breast cancer patients and other women patient groups.

Broad-spectrum health improvements with one year of soccer training in inactive mildly hypertensive middle-aged women

The study tested the hypothesis that long-term soccer training has positive impact on cardiovascular profile, body composition, bone health, and physical capacity in inactive, pre-menopausal women with mild hypertension. The study applied a randomized controlled design in which physically inactive middle-aged women were separated into a soccer training group (n=19; SOC) and a control group (n=12; CON). SOC performed 128±29 (±SD) one-h small-sided soccer training sessions over one year. Blood pressure, body composition, blood lipid profile, and fitness level were determined pre- and post-intervention. Over one year, mean arterial pressure decreased more in SOC than in CON (-5±7 vs +4±5 mmHg; P<.05). Total-body fat mass decreased more (P<.05) in SOC than in CON (-2.5±2.5 vs +0.6±3.2 kg; P<.05), while the change scores for lean body mass were not significantly different in SOC (2.6±2.7 kg) compared to CON (1.1±1.9 kg, P=.09). Over one year, change scores in whole-body bone mineral density (0.004±0.032 vs -0.019±0.026 g·cm² ) as well as bone mineral content (30±70 vs -39±113 g) were positive in SOC compared to CON (P<.05). Post-intervention plasma triglycerides decreased more (-0.1±0.7 vs +0.2±0.2 mmol·L^-1 ) and HDL cholesterol increased more (0.2±0.7 vs -0.2±0.2 mmol·L^-1 ) in SOC than in CON (P<.05). Yo-Yo intermittent endurance level 1 (122±105 vs 2±21%) and 20-m sprint performance (6±6 vs -1±2%) increased more (P<.05) in SOC than in CON. In conclusion, long-term soccer training resulted in broad-spectrum improvements in the health profile of untrained, pre-menopausal women with mild hypertension, including cardiovascular, metabolic, and musculo-skeletal benefits.