Physical activity, cardiorespiratory fitness, and exercise training in primary and secondary coronary prevention

The acute effect of exercise on the endothelial glycocalyx in healthy adults: A systematic review and meta-analysis

BACKGROUND

In recent years, it has been demonstrated that when the endothelial glycocalyx, composed of proteoglycans, glycosaminoglycans and glycoproteins, is altered or modified, this property is lost, playing a fundamental role in cardiovascular pathologies. Cardiovascular risk factors can destroy the endothelial glycocalyx layer. Exercise has a positive effect on cardiovascular risk factors, but little is known about its direct effect on the integrity of the endothelial layer.

METHODS

The Cochrane Library, PubMed, Web of Science and Scopus databases were searched from their inception to June 30, 2022. The DerSimonian and Laird method was used to compute pooled effect size estimates and their respective 95% confidence intervals for the acute effect of exercise (within 24 h) on the endothelial glycocalyx and its components in healthy adults.

RESULTS

Ten studies were included in the meta-analysis, with a total of 252 healthy subjects. The types of exercise included were resistance training, interval training, resistance training and maximal incremental exercise, with a duration range of 30-60 min. Glycocalyx assessment times included ranged from 0 to 90 min post-exercise. Our findings showed that endothelial glycocalyx increases after acute effect of exercise in healthy population (.56, 95% CI: .38, .74). The acute effect of exercise on endothelial glycocalyx components were .47 (95% CIs: .27, .67) for glycosaminoglycans, .67 (95% CIs: .08, 1.26) for proteoglycans and .61 (95% CIs: .35, .86) for glycoproteins.

CONCLUSIONS

In a healthy population, various types of exercise showed an acute improvement of the endothelial glycocalyx and its individual components.

Long-Term Mortality Risk According to Cardiorespiratory Fitness in Patients Undergoing Coronary Artery Bypass Graft Surgery

The aim of this study was to evaluate the association between cardiorespiratory fitness (CRF) and long-term survival in United States (US) Veterans undergoing CABG. We identified 14,550 US Veterans who underwent CABG at least six months after completing a symptom-limited exercise treadmill test (ETT) with no evidence of cardiovascular disease. During a mean follow-up period of 10.0 ± 5.4 years, 6502 (43.0%) died. To assess the association between CRF and risk of mortality, we formed the following five fitness categories based on peak workload achieved (metabolic equivalents or METs) prior to CABG: Least-Fit (4.3 ± 1.0 METs (n = 4722)), Low-Fit (6.8 ± 0.9 METs (n = 3788)), Moderate-Fit (8.3 ± 1.1 METs (n = 2608)), Fit (10.2 ± 0.8 METs (n = 2613)), and High-Fit (13.0 ± 1.5 METs (n = 819)). Cox proportional hazard models were used to calculate risk across CRF categories. The models were adjusted for age, body mass index, race, cardiovascular disease, percutaneous coronary intervention prior to ETT, cardiovascular medications, and cardiovascular disease risk factors. P-values < 0.05 using two-sided tests were considered statistically significant. The association between cardiorespiratory fitness and mortality was inverse and graded. For every 1-MET increase in exercise capacity, the mortality risk was 11% lower (HR = 0.89; CI: 0.88-0.90; p < 0.001). When compared to the Least-Fit category (referent), mortality risk was 22% lower in Low-Fit individuals (HR = 0.78; CI: 0.73-0.82; p < 0.001), 31% lower in Moderate-Fit individuals (HR = 0.69; CI: 0.64-0.74; p < 0.001), 52% lower in Fit individuals (HR = 0.48; CI: 0.44-0.52; p < 0.001), and 66% lower in High-Fit individuals (HR = 0.34; CI: 0.29-0.40; p < 0.001). Cardiorespiratory fitness is inversely and independently associated with long-term mortality after CABG in Veterans referred for exercise testing.

Relationship between objectively measured physical activity and subclinical cardiovascular disease: a systematic review

Introduction

The association of physical activity (PA) with subclinical cardiovascular disease (CVD) is unclear. Clarifying this relationship may inform cardiovascular prevention strategies.

Methods

We performed a systematic review (CRD42021226089) using Medline, Embase, CINAHL and Cochrane (1 January 2000 to 1 September 2023). Studies published with adult populations exploring the relationship between objectively measured PA and subclinical CVD were included. Subclinical CVD was assessed using: ankle-brachial index (ABI); arterial stiffness; carotid artery disease; coronary artery atherosclerosis; endothelial function; and measures of cardiac structure and function. The Risk Of Bias In Non-randomised Studies - of Interventions (ROBINS-I) and Cochrane Risk of Bias tools were used for quality review.

Results

Of 68 included studies, most supported an inverse relationship between PA and subclinical CVD. Arterial stiffness was the most common outcome (n=40), and 33 studies suggested that less sedentary behaviour (SB), increased PA and/or higher intensity PA was associated with less arterial stiffness. Ten studies of carotid artery disease (total n=18), six of endothelial function (n=10), two of coronary artery disease (n=3) and all of ABI (n=6) suggested that PA or less SB is associated with less subclinical disease. Five studies assessing cardiac structure/function (n=6) suggested alterations in structure/function with PA.

Conclusions

PA reduces the risk of CVD events, and this systematic review demonstrates that some of the benefits may be mediated by an inverse association between PA and subclinical CVD. Interventions to increase PA are important for CVD prevention, so we provide a comprehensive overview of which surrogate outcome measures may be most useful to assess future CVD prevention interventions.

PROSPERO registration number

CRD42021226089.

The Complementary Effects of Dabigatran Etexilate and Exercise Training on the Development and Stability of the Atherosclerotic Lesions in Diabetic ApoE Knockout Mice

Aim: To determine the complementary effects of dabigatran etexilate (DE), exercise training (ET), and combination (DE + ET) on the development and stability of the atherosclerotic lesions in diabetic apoE knockout (apoE-/-) mice. Methods: In 48 male apoE-/- diabetic mice, streptozotocin (STZ) was induced for 5 consecutive days. Mice received a high-fat diet (HFD) for 8 weeks and then were randomized into four groups (1. Control/CG, 2. DEG: HFD with DE, 3. ETG: ET on treadmill, 4. DE + ETG: combination DE and ET treatment). At the end of the eighth week, all mice were euthanatized and morphometry of the aortic lesions at the level of aortic valve was obtained. Collagen, elastin, MCP-1, TNF-a, matrix metalloproteinases (MMP-2,-3,-9), and TIMP-1 concentrations within plaques at the aortic valve were determined. Results: All active groups had significantly smaller aorta stenosis (DEG:7.9 ± 2.2%, ETG:17.3 ± 5.3%, DE + ETG:7.1 ± 2.7%) compared to CG (23.3 ± 5.5% p < 0.05), reduced the relative intra-plaque content of MCP-1, macrophages, MMP-3, and MMP-9, and considerably increased collagen, elastin, and TIMP-1 (p < 0.05). Group 4 showed the most pronounced results (p < 0.05). Both DEG and DE + ETG significantly reduced MMP-2 and TNF-a concentrations compared to ETG and CG (p < 0.010). Conclusion: DE and ET treatment of diabetic apoE-/- mice resulted in complementary amelioration of atherosclerotic lesions development and stability, mediated by the anti-inflammatory modulation of both DE and ET.

The effect of exercise training level on arterial stiffness after clinically significant weight loss

Arterial stiffness is improved by weight loss. However, no data exist on the impact of aerobic exercise levels on arterial stiffness during weight maintenance. Adults who were  overweight or with obesity (N = 39) participated in a 10-week weight loss program. Participants who achieved ≥7% weight loss were randomized to aerobic training at the minimum physical activity guidelines (PA-REC, 550 MET min/week) or weight maintenance guidelines (WM-REC, 970 MET min/week) for 18 additional weeks. Arterial stiffness (carotid-to-femoral pulse wave velocity [cfPWV], augmentation index normalized for 75 beats/min [AIX75]) and blood pressure [aortic and brachial]) were assessed at baseline, the end of the weight loss phase (week 10), and follow-up (week 28). There was a reduction in cfPWV in participants who met the weight loss goal (-0.34 m/s, p = .02) and approached significance for the entire sample (p = .051). Similarly, there were reductions in AIX75, brachial blood pressure, and aortic blood pressure (p < .05) in the full sample. In the weight maintenance phase, no differences were observed between the PA-REC and the WM-REC groups for change in arterial stiffness or blood pressure (p > .05). However, changes in cfPWV were independently associated with changes in LDL (r2 : 0.45, p = .004) and exercise intensity (r2 : 0.17, p = .033). Aerobic exercise level at the minimum physical activity guidelines or weight maintenance guidelines does not affect the change in PWV or the change in cfPWV after clinically significant weight loss. However, interventions which limit increases in LDL cholesterol and promote high-intensity aerobic exercise may prevent increases in stiffness during weight maintenance.

Clinical challenges facing patient participation in cardiac rehabilitation: cigarette smoking

INTRODUCTION

Cardiac rehabilitation (CR) is highly effective at reducing morbidity and mortality. However, CR is underutilized, and adherence remains challenging. In no group is CR attendance more challenging than among patients who smoke. Despite being more likely to be referred to CR, they are less likely to enroll, and much more likely to drop out. CR programs generally do not optimally engage and treat those who smoke, but this population is critical to engage given the high-risk nature of continued smoking in those with cardiovascular disease.

AREAS COVERED

This review covers four areas relating to CR in those who smoke. First, we review the evidence of the association between smoking and lack of participation in CR. Second, we examine how smoking has historically been identified in this population and propose objective screening measures for all patients. Third, we discuss the optimal treatment of smoking within CR. Fourth, we review select populations within those who smoke (those with lower-socioeconomic status, females) that require additional research and attention.

EXPERT OPINION

Smoking poses a challenge on multiple fronts, being a significant predictor of future morbidity and mortality, as well as being strongly associated with not completing the secondary prevention program (CR) that could benefit those who smoke the most.

Patients with Nonalcoholic Steatohepatitis and Advanced Liver Disease Have the Lowest Cardiorespiratory Fitness

BACKGROUND & AIMS

Cardiorespiratory fitness and liver fibrosis are independently associated with poor outcomes in patients with nonalcoholic steatohepatitis (NASH), however, conflicting reports exist about their relationship. We aimed to better characterize the relationship between cardiorespiratory fitness and liver histology in a cross-sectional study of patients with biopsy-proven NASH.

METHODS

Participants aged 18-75 years completed VO2peak fitness assessment using symptom-limited graded exercise testing. Participants were compared by liver fibrosis stage and NAFLD Activity Score (NAS). Multivariable models were constructed to assess factors related to relative VO2peak, including liver fibrosis and NAS.

RESULTS

Thirty-five participants with mean age 48 ± 12 years and body mass index 33.5 ± 7.6 kg/m2 were enrolled. Seventy-four percent of participants were female and 49% had diabetes. A dose-dependent relationship was found between relative VO2peak and liver fibrosis. Relative VO2peak was significantly lower in participants with advanced fibrosis (F3 disease- 15.7 ± 5.3 vs. ≤ F2 disease- 20.7 ± 5.9 mL/kg/min, p = 0.027). NAS > 5 was also associated with lower relative VO2peak (22.6 ± 5.7 vs. 16.5 ± 5.1 mL/kg/min, p = 0.012) compared to NAS ≤ 5. With multivariable modeling, advanced fibrosis remained independently predictive of relative VO2peak while NAS trended towards significance.

DISCUSSION AND CONCLUSIONS

Advanced liver fibrosis is independently associated with cardiorespiratory fitness in patients with NASH. This may explain the incremental increase in mortality as liver fibrosis stage increases. Further research is needed to determine if exercise training can improve cardiorespiratory fitness across multiple stages of liver fibrosis and directly reduce morbidity and mortality in patients with NASH.

HIIT is most effective than mict on glycemic control of older people with glucose metabolism impairments: A systematic review and metanalysis

INTRODUCTION

Physical exercise can improve glucose metabolism; however, the best type, volume, intensity, and frequency aren't knowledge. High-Intensity Interval Training (HIIT), an emergent exercise type implicated as a short time-efficient exercise to improve metabolic health, needs more investigation regarding the traditional Moderate-Intensity Continuous Training (MICT).

OBJECTIVE

To identify the effects of MICT and HIIT on glycemic control of older people with glucose metabolism impairments.

METHODS

Our research question was based on the PICO model and the systematic review of the literature according to the guidelines of the preferred report items for systematic reviews and PRISMA meta-analyses. An extensive search was conducted in the Web of Science, PubMed, and Scielo databases. Only English language papers were included. The keywords used were "HIIT and metabolism of the elderly", "HIIT and glucose metabolism of the elderly", and "MICT and metabolism of the elderly", which were crossed with the Boolean operators "AND" and "OR" or both according to the guidelines of the PRISMA.

RESULTS

Seventy papers were retrieved in the initial search. After applying all inclusions and exclusion parameters, 63 articles were excluded. In the end, six papers were classified as eligible for this study. All data categorically demonstrates that both HIIT and MICT can improve glucose metabolism with a larger effect size towards the HIIT model after the meta-analysis, pointing to HIIT as the most effective strategy.

CONCLUSION

Both modalities can improve glucose metabolism in the elderly with a clear advantage for HIIT over MICT.

Factors contributing to exercise tolerance in patients with coronary artery disease undergoing percutaneous coronary intervention

BACKGROUND

Exercise tolerance plays a vital role in the process of cardiac rehabilitation in patients undergoing percutaneous coronary intervention (PCI). The study sought to determine the characteristics, risks and correlates of post-PCI exercise tolerance in patients with coronary artery disease (CAD).

METHODS

We analyzed clinical data of 299 CAD patients undergoing elective PCI and completing cardiopulmonary exercise testing (CPET). According to the Weber classification, post-PCI exercise tolerance was evaluated by peak oxygen uptake (VO₂ peak). We assessed the impact of 34 predefined clinical features, cardiac functional parameters, and blood biochemistry data on exercise tolerance by univariate analysis and logistics regression analysis.

RESULTS

Of 299 patients, 74.92% were men and average age was 60.90 ± 10.68 years. VO₂ peak in the entire population was 17.54 ± 3.38 ml/kg/min, and 24.41% (n = 73) were less than 16 ml/kg/min, who were considered to have exercise intolerance. Multivariate logistics regression results showed that sex, diabetes mellitus, number of stents, left atrial diameter (LAD), end-diastolic volume (EDV), and hemoglobin influenced the peak oxygen uptake of CAD patients undergoing elective PCI. (All p < 0.05).

CONCLUSIONS

Nearly one quarter of CAD patients have exercise intolerance in the early post-PCI period. Female, diabetes mellitus, number of stents, LAD, EDV might negatively impacted post-PCI exercise tolerance, which need further warrant by large scale cohort study.

Smart Walk: A Culturally Tailored Smartphone-Delivered Physical Activity Intervention for Cardiometabolic Risk Reduction among African American Women

This article reports the results of Smart Walk: a randomized pilot trial of an 8-month culturally tailored, smartphone-delivered physical activity (PA) intervention for African American women with obesity. Sixty participants (age range = 24−49 years; BMI range = 30−58 kg/m2) were randomized to the Smart Walk intervention (n = 30) or a wellness comparison intervention (n = 30). Results supported the acceptability and feasibility of the intervention, as demonstrated by participant retention (85% at 4 months and 78% at 8 months), Smart Walk app use, and intervention satisfaction (i.e., 100% of PA participants completing the intervention [n = 24] reported they would recommend it to friend). Smart Walk participants also reported greater increases in moderate-to-vigorous PA (4-month between-arm difference in change [b] = 43.3 min/week; p = 0.018; Cohen’s d = 0.69; 8-month b = 56.6 min/week; p = 0.046; d = 0.63) and demonstrated clinically relevant, although not statistically significant (p-values > 0.05), baseline to 4 months improvements in cardiorespiratory fitness (b = 1.67 mL/kg/min; d = 0.40), systolic blood pressure (b = −3.33 mmHg; d = 0.22), diastolic blood pressure (b = −4.28 mmHg; d = 0.37), and pulse wave velocity (b = −0.46 m/s; d = 0.33). Eight-month cardiometabolic outcomes followed similar trends, but had high rates of missing data (45−53%) due to COVID-19 restrictions. Collectively, findings demonstrated favorable outcomes for acceptability and feasibility, while also highlighting key areas for refinement in future research.

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.

Cardiorespiratory Fitness and Depression Symptoms among Adults During the COVID-19 Pandemic: Cooper Center Longitudinal Study

This study examined the relation between cardiorespiratory fitness (fitness) and depression symptoms prior to and during COVID-19 among adults seeking preventive medical care. Participants consisted of 967 patients attending the Cooper Clinic (Dallas, TX) pre-pandemic (March 2018-December 2019) and during the pandemic (March-December 2020). The outcome, depression symptoms, was based on the Center for Epidemiological Studies-Depression (CES-D). Maximal metabolic equivalents task (MET) levels for fitness were determined from the final treadmill speed and grade. Multiple linear regression models were computed by sex. Analysis revealed that mean fitness decreased from 11.4 METs (SD=2.1) prior to the pandemic to 10.9 METs (SD=2.3) during the pandemic (p-value<0.001). The mean CES-D score increased from 2.8 (SD= 3.1) before to pandemic to 3.1 (SD=3.2) during the pandemic (p-value=0.003). Results from multiple linear regression indicate that increased fitness was associated with a statistically significant decrease in depression scores in men (-0.17 per MET; 95%CI -0.33, -0.02) but not women. This modest decrease may have been tempered by high fitness levels and low depression scores at baseline in this well-educated sample.

Cardiac Rehabilitation and Cardiopulmonary Fitness in Children and Young Adults With Congenital Heart Diseases: A Critically Appraised Topic

Public health guidelines and a myriad of studies have proven that exercise is beneficial in the alleviation of various cardio-metabolic diseases. Congenital heart disease (ConHD) is one of the most frequently occurring congenital structural malfunctions in the pediatric population, affecting nine of every 1,000 live births. Only a few studies have established the impact of a structured exercise program on cardiopulmonary fitness in diverse groups of patients with ConHD. It is also alarming to know that a substantial number of these patients and their caregivers often remain very wary of exercise. Anxiety about exercise may increase the risk of developing morbid obesity and other long-term health complications of ConHD. The present review of a critically appraised topic is undertaken to answer the question, “Does structured exercise intervention (cardiac rehabilitation) improve cardiorespiratory fitness in children and young adults with ConHD?” Exercise science and the medical literature were searched for studies that engaged the use of aerobic exercise in patients with different ConHD diagnoses. The search yielded four studies after screening with the inclusion and exclusion criteria, which were further narrowed to three studies after a full-text review. These studies yielded results showing significant increments in peak exercise workload, duration, power output, peak oxygen uptake, or improved tissue oxygenation and muscle strength after an exercise training intervention. It is noteworthy that a group identified as “cyanotic palliated” exhibited the most significant impairment both at baseline and after the exercise intervention. This review provides level 1b medical evidence that a structured exercise program may improve cardiopulmonary fitness in patients with ConHD, which is likely to be beneficial to their overall physical, motor, and psychosocial development. The results of this review may be useful for alleviating the anxiety of patients and their caregivers about participation in structured exercise programs. This review should also motivate future research investigations to develop clinical guidelines for the management of patients with ConHD by adding exercise prescriptions to their daily therapeutic regimens.

Carbon monoxide monitoring to objectively measure smoking status in cardiac rehabilitation

OBJECTIVE

Participation in cardiac rehabilitation (CR) is associated with reduced morbidity and mortality. However, most programs rely on self-report measures when assessing the critical risk factor of smoking. This study examined smoking status using self-report versus objective measurement using expired carbon monoxide (CO) and compared patient characteristics by CO level.

METHOD

Patients were screened for smoking status when entering CR by self-report and by objectively measured CO. Measures of aerobic fitness, educational attainment, depressive symptoms, and self-reported physical function were also collected. The discrepancy between smoking status based on self-report and objective measurement was examined and patient characteristics by CO measurement were compared.

RESULTS

Of the 853 patients screened, 62 self-reported current smoking and 112 had a CO of ≥ 4 ppm. Using a cut-off of ≥ 4 ppm encompassed almost all self-reported smokers (specificity: 98.5%) and identified 61 patients (not reporting current smoking) needing further screening. Further questioning yielded an additional 21 patients with combusted use (tobacco/cannabis), six nonsmoking patients with environmental CO exposure, and 34 where the reason for elevated CO was unknown. CO ≥ 4 ppm patients were younger (62.2 vs. 67.7, p < .01), had higher depression scores (5.6 vs. 3.7, Patient Health Questionairre-9, p < .01), had lower educational attainment (59.0% ≤ high school vs. 31.3%, p < .01), had lower levels of fitness (after controlling for clinical characteristics, p < .01), and completed fewer CR sessions (18 vs. 22, p < .01).

CONCLUSIONS

A substantial number of patients who are actively smoking may be misclassified by relying on patient report alone. CO monitoring provides a simple and objective method of systematically screening patients. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

The effectiveness of eHealth interventions on moderate-to-vigorous intensity physical activity among cardiac rehabilitation participants: a systematic review and meta-analysis (Preprint)

BACKGROUND

Cardiac rehabilitation is a class IA recommendation for patients with cardiovascular diseases. Physical activity is the core component and core competency of a cardiac rehabilitation program. However, many patients with cardiovascular diseases are failing to meet cardiac rehabilitation guidelines that recommend moderate-to-vigorous intensity physical activity.

OBJECTIVE

The major objective of this study was to review the evidence of the effectiveness of eHealth interventions in increasing moderate-to-vigorous intensity physical activity among patients in cardiac rehabilitation. The secondary objective was to examine the effectiveness of eHealth interventions in improving cardiovascular-related outcomes, that is, cardiorespiratory fitness, waist circumference, and systolic blood pressure.

METHODS

A comprehensive search strategy was developed, and a systematic search of 4 electronic databases (PubMed, Web of Science, Embase, and Cochrane Library) was conducted for papers published from the start of the creation of the database until November 27, 2022. Experimental studies reporting on eHealth interventions designed to increase moderate-to-vigorous intensity physical activity among patients in cardiac rehabilitation were included. Multiple unblinded reviewers determined the study eligibility and extracted data. Risk of bias was evaluated using the Cochrane Collaboration Tool for randomized controlled trials and the Cochrane Effective Practice and Organization of Care group methods for nonrandomized controlled trials. A random-effect model was used to provide the summary measures of effect (ie, standardized mean difference and 95% CI). All statistical analyses were performed using Stata 17.

RESULTS

We screened 3636 studies, but only 29 studies were included in the final review, of which 18 were included in the meta-analysis. The meta-analysis demonstrated that eHealth interventions improved moderate-to-vigorous intensity physical activity (standardized mean difference=0.18, 95% CI 0.07-0.28; P=.001) and vigorous-intensity physical activity (standardized mean difference=0.2, 95% CI 0.00-0.39; P=.048) but did not improve moderate-intensity physical activity (standardized mean difference=0.19, 95% CI -0.12 to 0.51; P=.23). No changes were observed in the cardiovascular-related outcomes. Post hoc subgroup analyses identified that wearable-based, web-based, and communication-based eHealth intervention delivery methods were effective.

CONCLUSIONS

eHealth interventions are effective at increasing minutes per week of moderate-to-vigorous intensity physical activity among patients in cardiac rehabilitation. There was no difference in the effectiveness of the major eHealth intervention delivery methods, thereby providing evidence that in the future, health care professionals and researchers can personalize convenient and affordable interventions tailored to patient characteristics and needs to eliminate the inconvenience of visiting center-based cardiac rehabilitation programs during the COVID-19 pandemic and to provide better support for home-based maintenance of cardiac rehabilitation.

TRIAL REGISTRATION

PROSPERO International Prospective Register of Systematic Reviews CRD42021278029; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=278029.

The Value of Cardiopulmonary Exercise Testing in Predicting the Severity of Coronary Artery Disease

Background: There have been a limited number of quantitative studies on the relationship between coronary artery disease (CAD) and cardiorespiratory fitness (CRF), as measured by cardiopulmonary exercise testing (CPET). Thus, we aimed to investigate the association between CRF and the severity of coronary artery disease from the most comprehensive perspective possible, and to affirm the predictive value of CPET in the severity assessment of CAD. Methods: Our study included 280 patients with coronary angiography, who had undergone CPET in Tongji Hospital. The patients’ CRF was measured through their peak oxygen uptake (VO2@peak), their oxygen uptake at the anaerobic threshold (VO2@AT) and through other parameters of CPET on a bicycle ergometer. The severity of the coronary artery disease was assessed in the following three layers: functionally significant lesions (quantitative flow ratio [QFR] ≤ 0.8), the number of stenotic coronary arteries (SCA, stenosis ≥ 50%) and the Gensini score. The correlation analyses were carried out between the CRF and the severity of the coronary artery disease. A ROC curve was plotted, and the AUC was calculated to distinguish the severe CAD and the non-severe CAD patients, as measured by the QFR, the number of SCA, and the Gensini score. Results: The VO2@AT and VO2@peak were inversely associated with the QFR. The VO2@AT, VO2@peak and VO2/kg@peak were associated with the number of SCA. Meanwhile, the VO2@AT, VO2/kg@AT, VO2@peak and VO2/kg@peak were associated with the Gensini score. An ROC analysis proved that a combination of traditional clinical risk factors and the VO2@peak/VO2prediction is valuable in predicting CAD severity. Conclusions: Our study demonstrated a strong and inverse association between CRF and the severity of CAD. A combination of traditional clinical risk factors and CRF is valuable in predicting CAD severity.

Association between Cardiorespiratory Fitness and Metabolic Syndrome in Korean Older Adults

BACKGROUND

Little is known about the relationship between non-exercise-based estimation of cardiorespiratory fitness (eCRF) and metabolic syndrome (MetS) in Korea. The current study examined the prognostic role of eCRF in the risk stratification of MetS in a representative sample of Korean older adults (1822 men and 3069 women).

METHODS

The data used in the current study were extracted from the Korea National Health and Nutrition Examination Surveys IV and V. eCRF was obtained using a previously validated algorithm. MetS was defined according to the National Cholesterol Education Program definition with the acceptance of a Korean-specific waist circumference cutoff point.

RESULTS

Lower eCRF was significantly correlated with abnormalities in several components of MetS, including abdominal obesity, elevated glucose, elevated triglycerides, and decreased high-density lipoprotein cholesterol. Furthermore, there was an inverse linear relationship between MetS prevalence and eCRF levels; higher eCRF was significantly and independently associated with lower prevalence of MetS.

CONCLUSION

The current findings suggest that eCRF can be adopted as a prognostic measure in determining the risk for MetS for elderly persons.

High School Football and Risk for Depression and Suicidality in Adulthood: Findings From a National Longitudinal Study

BACKGROUND

There is growing public concern regarding the potential long-term effects of playing football on brain health, specifically that playing football before and during high school might cause damage to the brain that manifests years or decades later as depression or suicidality. This study examined if playing high school football was associated with increased lifetime risk for depression, suicidality over the past year, or depressed mood in the past week in men aged between their middle 30 s to early 40 s.

METHODS

Publicly available data from the National Longitudinal Study of Adolescent to Adult Health were analyzed. This longitudinal, prospective cohort study sampled nationally representative U.S. youth starting in 1994-1995 (Wave I) and most recently in 2016-2018 (Wave V). A total of 3,147 boys participated in Wave I (median age = 15), of whom 1,805 were re-assessed during Wave V (median age = 38).

RESULTS

Of the 1,762 men included in the study, 307 (17.4%) men reported being diagnosed with depression and 275 (15.6%) reported being diagnosed with an anxiety disorder or panic disorder at some point in their life. When comparing men who played high school football to those who did not, there were no differences in the proportions of the sample who had a lifetime diagnosis of depression, lifetime diagnosis of anxiety/panic disorders, suicidal ideation in the past year, psychological counseling in the past year, or current depressed mood. However, men who received psychological counseling and/or experienced suicidal ideation during adolescence were significantly more likely to report a lifetime history of depression, suicidal ideation in the past year, and current depressed mood.

CONCLUSION

Individuals who reported playing football during adolescence did not have an increased risk of depression or suicidal ideation when they were in their middle 30 s to early 40 s, but mental health problems during adolescence were associated with an increased risk for psychological health difficulties more than 20 years later.

Associations Between Physical Fitness, Objectively Measured Physical Activity and Academic Performance

There is evidence that physical activity (PA) can improve the academic performance. We recruited healthy adolescent girls, aged 11–12 years, and measured their PA with the accelerometer ActiGraph GT3X for the consecutive 5 days. Physical fitness (PF) was measured with eight motoric tests and three anthropometry measures. Academic performance (AP) was assessed for the six academic narrated school subjects. The results revealed that the girls were more physically active during the week days and less active at weekend (557 vs. 516 counts/min). Physical education grade shows the highest overall correlations with the results of the PF test battery (r = 0.53–0.95, p < 0.01). Nevertheless, correlations surprisingly decrease for the combined daily PA (r = 0.45), especially the weekend PA (r = 0.28). Grade point average and PF correlated moderately (r = 0.43-0.64), while they were moderate to high for PA (r = 0.59–0.87). Many questions arose after the completion of the present study and several new topics opened up, such as the question of how parental education affects the duration of PA and AP of the children and the influence of the place of residence AP of the children.

Prothrombotic and Inflammatory Markers in Elderly Patients with Non-Alcoholic Hepatic Liver Disease before and after Weight Loss: A Pilot Study

Background: Non-alcoholic fatty liver disease (NAFLD) is a pathological condition, ranging from fatty liver to chronic steatohepatitis (NASH), liver cirrhosis, and eventually to hepatocellular carcinoma. Recent findings suggest that patients with NAFLD have an increased risk of cardiovascular events and thromboembolism, which is independent of metabolic diseases that are frequently associated with NAFLD, such as diabetes, hyperlipidemia, and obesity. Methods: We evaluated 30 NAFLD patients, before and after weight loss. Plasma levels of C-reactive protein (CRP), fibrinogen, plasminogen activator inhibitor-1 (PAI-1), von Willebrand factor (VWF), homocysteine, coagulation protein S, Thrombin activable fibrinolysis inhibitor (TAFI), and factor VII (FVII) were assessed to evaluate whether they should be responsible of the prothrombotic state of NAFLD after weight loss. Results: At baseline, patients affected by NAFLD had a significantly higher levels of CRP, fibrinogen, PAI-1, VWF antigen, and FVII levels. After weight reduction, we observed a significant drop of inflammatory and prothrombotic markers, as well as glucometabolic, lipid profile. Conclusion: These findings provide evidence for a link between NAFLD/NASH and thromboembolism. The association seems to be linked with primitive thrombotic state and hypercoagulation due to increased levels of coagulation factors and reduced levels of PAI-1. This hypercoagulation state might explain increased levels of thrombosis and splanchnic thrombosis observed in NASH correlated cirrhosis.

A pilot randomised controlled trial of a structured, home-based exercise programme on cardiovascular structure and function in kidney transplant recipients: the ECSERT study design and methods

BACKGROUND

Cardiovascular disease (CVD) is a major cause of morbidity and mortality in kidney transplant recipients (KTRs). CVD risk scores underestimate risk in this population as CVD is driven by clustering of traditional and non-traditional risk factors, which lead to prognostic pathological changes in cardiovascular structure and function. While exercise may mitigate CVD in this population, evidence is limited, and physical activity levels and patient activation towards exercise and self-management are low. This pilot study will assess the feasibility of delivering a structured, home-based exercise intervention in a population of KTRs at increased cardiometabolic risk and evaluate the putative effects on cardiovascular structural and functional changes, cardiorespiratory fitness, quality of life, patient activation, healthcare utilisation and engagement with the prescribed exercise programme.

METHODS AND ANALYSIS

Fifty KTRs will be randomised 1:1 to: (1) the intervention; a 12week, home-based combined resistance and aerobic exercise intervention; or (2) the control; usual care. Intervention participants will have one introductory session for instruction and practice of the recommended exercises prior to receiving an exercise diary, dumbbells, resistance bands and access to instructional videos. The study will evaluate the feasibility of recruitment, randomisation, retention, assessment procedures and the intervention implementation. Outcomes, to be assessed prior to randomisation and postintervention, include: cardiac structure and function with stress perfusion cardiac MRI, cardiorespiratory fitness, physical function, blood biomarkers of cardiometabolic health, quality of life and patient activation. These data will be used to inform the power calculations for future definitive trials.

ETHICS AND DISSEMINATION

The protocol was reviewed and given favourable opinion by the East Midlands-Nottingham 2 Research Ethics Committee (reference: 19/EM/0209; 14 October 2019). Results will be published in peer-reviewed academic journals and will be disseminated to the patient and public community via social media, newsletter articles and presentations at conferences.

TRIAL REGISTRATION NUMBER

NCT04123951.

A Cultural Dance Program Improves Hypertension Control and Cardiovascular Disease Risk in Native Hawaiians: A Randomized Controlled Trial

BACKGROUND

Native Hawaiians have higher hypertension (HTN) and cardiovascular disease (CVD) rates than non-Hispanic whites, calling for culturally responsive interventions to close this gap.

PURPOSE

We tested the effects of a 6-month behavioral intervention, a cultural dance program based on hula (the customary dance of Hawai'i), for improving blood pressure (BP) and CVD risk among Native Hawaiians with uncontrolled HTN.

METHODS

In a randomized controlled trial, we tested the effects of the hula-based intervention among 263 Native Hawaiians with uncontrolled HTN (systolic ≥ 140 or ≥ 130 mmHg if diabetes) and no CVD at enrollment. All participants received a brief culturally tailored heart health education before random assignment to the hula-based intervention (n = 131) or the education-only waitlist control (n = 132). Intervention received hula lessons and group-based activities for 6 months. Control received only 1-week education through 6 months.

RESULTS

Intervention yielded greater reductions in systolic (-15.3 mmHg) and diastolic (-6.4 mmHg) BP than control (-11.8 and -2.6 mmHg, respectively) from baseline to 6 months (p < .05). At 6 months, 43% of intervention participants compared to 21% of controls achieved a HTN stage <130/80 mmHg (p < .001). The 10-year CVD risk reduction was two times greater for the intervention group than the control group based on the Framingham Risk Score calculator. All improvements for intervention participants were maintained at 12 months.

CONCLUSIONS

This trial represents one of the few rigorously conducted examinations of an Indigenous practice leveraged for health promotion, with implications for other ethnic populations.

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.

Edmonton Obesity Staging System: an improvement by cardiopulmonary exercise testing

BACKGROUND/OBJECTIVES

Different approaches are used to classify obesity severity. Beyond classical anthropometric measurements, the Edmonton Obesity Staging System (EOSS) considers medical, physical and psychological parameters. However, this method has some limitations, principally due to the absence of an objective measure for physical impairment. The aim of our study is thus to overcome this limitation suggesting a new functional parameter obtained by cardiopulmonary exercise testing (CPET), i.e., cardiorespiratory fitness (CRF), expressed as weight-adjusted peak oxygen consumption (VO₂peak/kg).

SUBJECTS/METHODS

This observational cross-sectional study conducted on a population of 843 patients affected by obesity finally enrolled 500 subjects. Every patient underwent clinical, anthropometric, biochemical assessment and CPET. First, participants have been classified according to standard EOSS in five stages. Second, patients were reclassified according to the new modified EOSS (EOSS-CRF) based on their age- and gender-appropriate VO₂peak/kg percentiles as reported in the healthy normal-weight population of the FRIEND registry.

RESULTS

VO₂peak/kg was significantly different between standard EOSS classes 1 and 2 and classes 1 and 3 (ANCOVA p model = 0.004), whereas patients in classes 2 and 3 showed similar CRF. The EOSS-CRF classification varied in number of patients in each class compared to EOSS, particularly with a shift from class 2 to class 3. Moreover, CRF showed that physical impairment is less addressed by EOSS when compared to EOSS-CRF.

CONCLUSIONS

The integration of EOSS with CRF allowed us to assign to each patient a severity index that considers not only clinical parameters, but also their functional impairment through a quantitative and prognostically important parameter (VO₂peak/kg). This improvement of the staging system may also provide a better approach to identify individuals at increased risk of mortality leading to targeted therapeutic management and prognostic risk stratification for patients with obesity.

Domains of Physical Activity in Relation to Stiffness Index in the General Population

Background

Regular exercise training represents an important modifier of arterial stiffness (AS). Therefore, sex‐specific relations between domains of physical activity (PA; commuting, domestic, and leisure‐time PA, including active sport and occupational PA) with AS were investigated.

Methods and Results

Stiffness index by digital photoplethysmography was investigated in 12 650 subjects from the GHS (Gutenberg Health Study). Self‐reported PA was evaluated by the “Short Questionnaire to Assess Health‐Enhancing Physical Activity” and reported as activity score peer week, being a combined measure of duration, frequency, and intensity of PA. Multivariable linear regression analysis demonstrated strong beneficial effects of repetitive activities, such as active commuting or leisure‐time PA–related walking on AS in men, but not in women. Lower AS associated with endurance training was also found among men and premenopausal women. In contrast, intense occupational PA was related to stiffer vessels in men (P<0.0001) and women (P=0.0021) in a fully adjusted model. Combination of both, performing endurance training and having stiffness index values below median, resulted in the best survival. In contrast, subjects with elevated stiffness index at baseline without any endurance activities demonstrated the worst survival.

Conclusions

In this population representative sample, a differential impact of domains of self‐reported PA on AS was demonstrated. Our data strengthen the importance of regular endurance PA to induce a reduction of AS, which, in turn, may improve cardiovascular prognosis. We also report deleterious effects of intense occupational PA on stiffness index, a finding that needs further confirmation by larger prospective trials.

Obesity paradox and heart failure

BACKGROUND

There is scientific consensus that obesity increases the risk of cardiovascular diseases (CVD), including heart failure (HF). However, in CVD, many studies observed greater survival in overweight or class 1 obesity individuals. This counterintuitive observation was termed "obesity paradox" (OP).

OBJECTIVE AND METHODS

This article is a narrative overview of the relationship between OP and CVD, particularly HF. The sources used were MEDLINE/PubMed, CINAHL, EMBASE, and Cochrane Library, from 2001 to 31 May 2020, exception for a 1983 work of historical importance. Studies reporting association and prognostic impact of obesity in HF and the impact of body composition on cardiac structure and myocardial function in obesity were also included in this review. In addition, we examined references from the retrieved articles and explored several related websites. Ultimately, we chose 79 relevant documents. Fifty-three were specifically focused on OP and HF.

RESULTS

In this review, we made a summary of the evidence coming from a series of studies investigating OP. Many of these studies do not take into consideration or underestimate some of the more important morpho-functional variables of patients suffering from HF: among these, body composition and visceral adiposity, sarcopenic obesity, muscle fitness (MF), and cardiorespiratory fitness (CRF). A high body mass index (BMI) represents a risk factor for HF, but it also seems to exert a protective effect under certain circumstances. Fat distribution, lean mass, and cardio fitness could play an essential role in determining the observed differences in the HF population.

CONCLUSION

BMI does not distinguish between the metabolically healthy and metabolically unhealthy obesity. The obesity impact on morbidity and premature mortality can be underestimated and, therefore, may lead to incorrect clinical courses.

LEVEL OF EVIDENCE

Level V, Narrative review.

Injury patterns among national-level athletes in Lebanon: a retrospective study

Objectives:This study aims to assess the annual prevalence, associated factors, and characteristics of musculoskeletal disorders among Lebanese national-level athletes.Methods: Lebanese athletes aged 18 and over and who competed in a top-level national championship during an entire athletics season were invited to participate in the study. Data were collected through questionnaire assessing self-reported injury during the past year. Injury, dependent variable of the study, was defined as a musculoskeletal condition that made the athlete partially or completely abstains from training or competition for a 1-week minimum injury period.Results: Among the 250 eligible athletes, 210 (84.0%) (25.5±6.7 years) completed the questionnaire. The 1-year retrospective injury prevalence was 51.9% (95% confidence interval, 45.1%-58.7%). Injured athletes reported 150 injuries: 128 (85.3%) affected the lower extremities, and 111 (74.0%) occurred during training. The most common type was muscle cramps/spasm (n=53; 35.3%); and overuse (n=121; 80.7%) was the predominant cause. Athletes who mainly practiced endurance disciplines (-p-value=0.042), who participated in international athletics championships (-p-value=0.047), and who were taking chronic medications (-p-value=0.049) had more injuries in the past year.Conclusion: These findings may help inform potential injury prevention programs, which should target injuries affecting the lower extremities, and consider the factors associated with injury risk among Lebanese athletes.

Blood Pressure in Children: Association with Anthropometric Indicators, Body Composition, Cardiorespiratory Fitness and Physical Activity

Fundamento:

Evidências apontam variáveis antropométricas e de condicionamento físico como fatores associados à pressão arterial infantil. Analisá-los em apenas um contexto é um meio relevante de identificar o peso que cada um deles pode apresentar no desenvolvimento da hipertensão arterial.

Objetivo:

Identificar as possíveis associações de medidas antropométricas, da composição corporal, da atividade física moderada-vigorosa (AFMV) e da aptidão cardiorrespiratória (ApC) com a pressão arterial em crianças.

Métodos:

Estudo correlacional com abordagem quantitativa. Duzentos e quinze (215) estudantes com idades de 6 a 12 anos de uma escola pública de Porto Alegre, selecionados por critério de conveniência. A pressão arterial foi aferida através de um esfigmomanômetro digital. Para o tratamento dos dados, os valores de pressão arterial sistólica e diastólica foram padronizados (escore Z) e somados. As variáveis testadas como preditoras foram: AFMV; Percentual de gordura (%G); Índice de massa corporal (IMC); Razão cintura/estatura (RCE); Maturação somática; ApC. Após a verificação dos parâmetros de normalidade, as associações brutas e ajustadas (para sexo, idade e maturação somática) foram testadas através de equações de regressão linear. Para as análises, foi considerado p < 0,05.

Resultados:

Três diferentes modelos indicaram os melhores conjuntos de fatores associados à pressão arterial padronizada: O Modelo 1 (R² = 0,21) se constituiu das variáveis RCE (β = 9,702) e AFMV (β = – 0,021); O Modelo 2 (R² = 0,19) foi composto pelas variáveis IMC (β = 0,156) e AFMV (β = – 0,021); O Modelo 3 (R² = 0,18) incluiu as variáveis %G (β = 0,063) e ApC (β = – 0,004).

Conclusões:

A pressão arterial de crianças é predita pelas variáveis corporais %G, IMC e RCE. Além disso, está associada negativamente à AFMV e a ApC.

Cardiorespiratory fitness, muscular strength, and obesity in adolescence and later chronic disability due to cardiovascular disease: a cohort study of 1 million men

Aims

Cardiorespiratory fitness, muscular strength, and obesity in adulthood are risk factors for cardiovascular disease (CVD). However, little is known regarding the associations of these risk factors, already in adolescence, with later disability due to chronic CVD. Hence, we investigated associations of cardiorespiratory fitness, muscular strength, and body mass index (BMI) in adolescence with later chronic disability due to specific causes of CVD disability (i.e. cerebrovascular disease, ischaemic heart disease and heart failure).

Methods and results

This population-based cohort study included 1 078 685 male adolescents (16–19 years) from the Swedish military conscription register from 1972 to 1994. Cardiorespiratory fitness (bicycle ergometer test), muscular strength (knee extension strength), and BMI were measured during the conscription examination. Information about disability pension due to CVD was retrieved from the Social Insurance Agency during a mean follow-up of 28.4 years. Cardiorespiratory fitness was strongly and inversely associated with later risk of chronic CVD disability for all investigated causes. The association was particularly strong for ischaemic heart diseases (hazard ratio 0.11, 95% confidence interval 0.05–0.29 for highest vs. lowest fitness-quintiles). Furthermore, overweight/obesity were associated with CVD disability for all investigated causes. Conversely, associations of muscular strength with CVD disability were generally weak.

Conclusions

This study provides evidence for associations between low levels of cardiorespiratory fitness and obesity with later risk of chronic disability due to CVD. Preventive actions may begin at young ages and include promotion of cardiorespiratory fitness and healthy body weight.

Patients with Diabetes Complicated by Peripheral Artery Disease: the Current State of Knowledge on Physiotherapy Interventions

Diabetes mellitus (DM) is one of the major public health problems that account for morbidity, mortality, and disability worldwide. The presence of DM increases the risk of peripheral artery disease (PAD), as well as accelerates its course, making these patients more susceptible to ischemic events and impaired functional status. Unfortunately, alternative treatments for vascular complications in diabetes are poorly researched. Physiotherapy (kinesitherapy combined with different physical therapy agents) in individuals with DM and coexisting PAD may offer an important complementary therapy alternative. Early therapeutic measures can significantly improve patient outcomes, reduce cardiovascular risk, and improve daily life quality. The article provides an update on the current state of knowledge on physiotherapy interventions in the course of DM in patients with coexisting PAD.

Do Patients Maintain Proper Long-Term Cardiopulmonary Fitness Levels After Cardiac Rehabilitation? A Retrospective Study Using Medical Records

Objective

To examine whether patients who participated in a cardiac rehabilitation (CR) program after hospitalization for acute coronary syndrome maintained cardiorespiratory fitness (CRF) in the community.

Methods

We conducted a retrospective study including 78 patients who underwent percutaneous coronary intervention or coronary artery bypass graft surgery at our hospital’s cardiovascular center and participated in a CR program and a 5-year follow-up evaluation. Patients were divided into a center-based CR (CBCR) group, participating in an electrocardiography-monitored exercise training in a hospital setting, and a home-based CR (HBCR) group, receiving aerobic exercise training and performed self-exercise at home.

Results

No significant differences were found between groups (p>0.05), except the proportion of non-smokers (CBCR 59.5% vs. HBCR 31.7%; p=0.01). In both groups, the maximal oxygen consumption (VO_2max) increased significantly during the first 12 weeks of follow-up and remained at a steady state for the first year, but it decreased after the 1-year follow-up. Particularly, VO_2max at 5 years decreased below the baseline value in the HBCR group. In the low CRF group, the CRF level significantly improved at 12 weeks, peaked at 1 year, and was still significantly different from the baseline value after 5 years. The high CRF group did not show any significant increase over time relative to the baseline value, but most patients in the high CRF group maintained relatively appropriate CRF levels after 5 years.

Conclusion

Continuous support should be provided to patients to maintain optimal CRF levels after completing a CR program.

Left Ventricular Fibrosis in Middle-Age Athletes and Physically Active Adults

INTRODUCTION

Cardiac magnetic resonance (CMR) late gadolinium enhancement (LGE) and T1 mapping techniques enable the quantification of focal and diffuse myocardial LGE, respectively. Studies have shown evidence of fibrosis in middle-age athletes, but not relative to physically active (PA) adults who perform recommended physical activity levels. Therefore, we examined cardiac remodeling and presence of left ventricular (LV) LGE and T1 values in both recreational middle-age endurance athletes (EA) and PA adults.

METHODS

Healthy EA and PA adults (45-65 yr) completed a standardized 3-T CMR protocol with ventricular volumetry, LV LGE, and T1 mapping.

RESULTS

Seventy-two EA and 20 PA participants (mean age, 53 ± 5 vs 56 ± 4 yr; P < 0.01; V˙O2peak = 50 ± 7 vs 37 ± 9 mL·kg·min, P < 0.0001) were examined, with CMR data available in 89/92 participants. Focal LV LGE was observed in 30% of participants (n = 27/89): 33% of EA (n = 23/69; 33%) and 20% of PA (n = 4/20; 20%). LGE was present at the right ventricular hinge point (n = 21/89; 23.5%) or identified as ischemic (n = 2/89; 2%) or nonischemic (n = 4/89; 4%). Focal LV LGE was observed similarly in both EA and PA (P = 0.25). EA had larger LV chamber sizes and T1 native values (1169 ± 35 vs 1190 ± 26, P = 0.02) compared with PA, with similar LV ejection fraction. Global extracellular volume (ECV) was similar in both EA and PA (22.6% ± 3.5% vs 21.5% ± 2.6%, P = 0.26), with no relationship between global ECV and LV mass (r = -0.16, P = 0.19).

CONCLUSIONS

Focal LGE at the right ventricular hinge point was detected at the same frequency in both groups, was unrelated to demographic or clinical indices, and was found without evidence of global ECV expansion in EA, suggesting a physiologic remodeling response. The long-term clinical implications of hinge-point LGE require clarification using prospective, long-term follow-up studies.

The Effect of Aerobic Training and Increasing Nonexercise Physical Activity on Cardiometabolic Risk Factors

PURPOSE

Epidemiological studies suggest that sedentary behavior is an independent risk factor for cardiovascular mortality independent of meeting physical activity guidelines. However, limited evidence of this relationship is available from prospective interventions. The purpose of the present study is to evaluate the combined effect of aerobic training and increasing non-exercise physical activity on body composition and cardiometabolic risk factors.

METHODS

Obese adults (N=45) were randomized to 6-months of aerobic training (AERO), aerobic training and increasing non-exercise physical activity (~3,000 steps above baseline levels) (AERO-PA), or a control group (CON). The AERO and AERO-PA groups performed supervised aerobic training (3-4 times per week). The AERO-PA group wore Fitbit One accelerometers and received behavioral coaching to increase non-exercise physical activity.

RESULTS

There was a larger increase in fitness in the AERO-PA group (0.27 L/min, 0.16 to 0.40) compared to the AERO group (0.09 L/min, CI: -0.04 to 0.22) and the CON (0.01, CI: -0.11 to 0.12) groups. While significant findings were not observed in the entire study sample, when the analysis was restricted to participants compliant to the intervention (N=33), we observed significant reductions in waist circumference, percent weight loss, body fat, 2-hr glucose and 2-hr insulin in comparison to the CON group (p<0.05), but not the AERO group. Further, linear regression models showed that change in steps was associated with 21% and 26% of the variation in percent weight loss and percent fat loss, respectively.

CONCLUSION

Increasing non-exercise physical activity with aerobic training may represent a viable strategy to augment the fitness response in comparison to aerobic training alone and has promise for other health indicators.

Reduced cardiac response to the adrenergic system is a key limiting factor for physical capacity in old age

Ageing is associated with a progressive reduction in physical capacity reducing quality of life. One key physiological limitation of physical capacity that deteriorates in a progressive age-dependent manner is cardiac reserve. Peak cardiac output falls progressively with advancing age such that in extreme old age there is limited ability to enhance cardiac output beyond basal function as is required to support the increased metabolic needs of physical activity. This loss of dynamic range in cardiac output associates with a progressive reduction in the heart's response to adrenergic stimulation. A combination of decreases in the expression and functioning of beta1 adrenergic receptors partially underlies this change. Changes in end effector proteins also have a role to play in this decline. Alterations in the efficiency of excitation-contraction coupling contribute to the reduced chronotropic, inotropic and lusitropic responses of the aged heart. Moderate to vigorous endurance exercise training however has some potential to counter elements of these changes. Further studies are required to fully elucidate the key pivotal mechanisms involved in the age-related loss of response to adrenergic signalling to allow targeted therapeutic strategies to be developed with the aim of preserving physical capacity in advanced old age.

Aerobic capacity and respiratory patterns are better in recreational basketball-engaged university students than age-matched untrained males

Study aim: To asses and compare the aerobic capacity and respiratory parameters in recreational basketball-engaged university students with age-matched untrained young adults.

Material and methods: A total of 30 subjects were selected to took part in the study based on recreational-basketball activity level and were assigned to a basketball (BG: n = 15, age 22.86 ± 1.35 yrs., body height 185.07 ± 5.95 cm, body weight 81.21 ± 6.15 kg) and untrained group (UG: n = 15, age 22.60 ± 1.50 yrs., body height 181.53 ± 6.11 cm, body weight 76.89 ± 7.30 kg). Inspiratory vital capacity (IVC), forced expiration volume (FEV1), FEV1/IVC ratio, maximal oxygen consumption (VO2max), ventilatory threshold (VO2VT) and time to exhaustion, were measured in all subjects. Student T-test for independent Sample and Cohen’s d as the measure of the effect size were calculated.

Results: Recreational basketball-engaged students (EG) reached significantly greater IVC (t = 7.240, p < 0.001, d = 1.854), FEV1 (t = 10.852, p < 0.001, d = 2.834), FEV1/IVC ratio (t = 6.370, p < 0.001, d = 3.920), maximal oxygen consumption (t = 9.039, p < 0.001, d = 3.310), ventilatory threshold (t = 9.859, p < 0.001, d = 3.607) and time to exhaustion (t = 12.361, p < 0.001, d = 4.515) compared to UG.

Conclusions: Long-term exposure to recreational basketball leads to adaptive changes in aerobic and respiratory parameters in male university students.

Prescribed exercise to Reduce Recidivism After Weight Loss-Pilot (PREVAIL-P): Design, methods and rationale

Clinically significant weight loss is associated with health benefits for overweight and obese adults. Participation in adequate amounts of physical activity is critical for weight maintenance. However, the recommended amount of physical activity needed to promote weight maintenance is based primarily on retrospective studies that quantified physical activity levels through questionnaires which tend to overestimate physical activity levels. In addition, the present literature has provided little data on the impact of these physical activity levels on cardiovascular and diabetes risk factors, which may have equal or more clinical importance than weight changes. The Prescribed Exercise to Reduce Recidivism After Weight Loss-Pilot (PREVAIL-P) study will evaluate the effect of aerobic exercise training amount on weight maintenance following clinically significant weight loss in overweight and obese adults (BMI 25-40 kg/m2) age 30-65 years. Participants (N = 39) will complete a 10-week OPTIFAST® weight loss program with supervised aerobic exercise training. Individuals who achieve ≥7% weight loss from baseline will be subsequently randomized to levels of aerobic training consistent with physical activity recommendations (PA-REC) or weight maintenance recommendations (WM-REC) for 18 additional weeks. The primary outcome of the PREVAIL-P study will be change in weight from the completion of OPTIFAST® program to the end of the study. Notable secondary measures include changes in clinically relevant cardiometabolic risk factors between study groups (e.g. blood lipids concentrations, oral glucose tolerance, arterial stiffness). This pilot study will be used to estimate the effect sizes needed for a randomized controlled trial on this topic.

Individual and combined associations between cardiorespiratory fitness and grip strength with common mental disorders: a prospective cohort study in the UK Biobank

BACKGROUND

Depression and anxiety are common mental disorders that increase physical health risks and are leading causes of global disability. Several forms of physical fitness could be modifiable risk factors for common mental disorders in the population. We examined associations between individual and combined markers of cardiorespiratory fitness and grip strength with the incidence of common mental disorders.

METHODS

A 7-year prospective cohort study in 152,978 UK Biobank participants. An exercise test and dynamometer were used to measure cardiorespiratory and grip strength, respectively. We used Patient Health Questionnaire-9 and Generalised Anxiety Disorder-7 scales to estimate the incidence of common mental disorders at follow-up.

RESULTS

Fully adjusted, longitudinal models indicated a dose-response relationship. Low and medium cardiorespiratory fitness was associated with 1.485 (95% CIs, 1.301 to 1.694, p <  0.001) and 1.141 (95% CIs, 1.005 to 1.297, p = 0.041) higher odds of depression or anxiety, compared to high cardiorespiratory fitness. Low and medium grip strength was associated with 1.381 (95% CIs, 1.315 to 1.452, p <  0.001) and 1.116 (95% CIs, 1.063 to 1.172, p <  0.001) higher odds of common mental disorder compared to high grip strength. Individuals in the lowest group for both cardiorespiratory fitness and grip strength had 1.981 (95% CIs, 1.553 to 2.527, p <  0.001) higher odds of depression, 1.599 (95% CIs, 1.148 to 2.118, p = 0.004) higher odds of anxiety, and 1.814 (95% CIs, 1.461 to 2.252, p <  0.001) higher odds of either common mental disorder, compared to high for both types of fitness.

CONCLUSIONS

Objective cardiorespiratory and muscular fitness markers represent modifiable risk factors for common mental disorders. Public health strategies to reduce common mental disorders could include combinations of aerobic and resistance activities.

High-Intensity Interval Training versus Moderate-Intensity Continuous Training on Health Outcomes for Children and Adolescents: A Meta-analysis of Randomized Controlled Trials

Low cardiorespiratory fitness (CRF) is considered as an established risk factor for cardiovascular and metabolic disorders. However, the effectiveness of high-intensity interval training (HIIT) versus moderate-intensity continuous training (MICT) in children and adolescents remained uncertain. Electronic databases of the PubMed, EmBase, and the Cochrane library were searched for randomized controlled trials (RCTs) investigated the role of HIIT versus MICT for children and adolescents throughout December 2019. Sixteen RCTs involving a total of 543 children were selected for final meta-analysis. HIIT versus MICT showed high peak VO2 (weighted mean differences (WMD): 2.68; 95% confidence intervals (CIs): 1.81 to 3.55; $P<0.001$ ), and no evidence of heterogeneity and publication bias was detected. However, there were no significant differences detected between HIIT and MICT on the levels of peak heart rate (HRmax), fat mass, free fat mass, weight, body mass index, waist circumference, systolic blood pressure, diastolic blood pressure, glycemia, insulinemia, total cholesterol, high density lipoprotein, low density lipoprotein, triglycerides, HOMA-IR, HbA1c, and leptinemia. The findings of this study revealed that HIIT versus MICT showed a significant improvement in peak VO2 in children and adolescents. Further large-scale RCTs should be conducted to compare the long-term effects of HIIT versus MICT in children and adolescents.

Balance Tests in Pre-Adolescent Children: Retest Reliability, Construct Validity, and Relative Ability

Balance is an essential prerequisite for the normal physical development of a child. It consists of the ability to maintain the body’s centre of mass over its base of support, which is enabled by automatic postural adjustments, and maintain posture and stability in various conditions and activities. The present study aimed to determine the measurement characteristics (reliability and concurrent validity) and the relative ability of balance tests and different motor tests in healthy 11-year-olds. We also evaluated the impact of vision on balance ability. Our results showed high interrater reliability (from 0.810 to 0.910) and confirmed the construct validity of the included balance tests. Girls performed significantly better than boys in laboratory tandem stance in following balance components: total sway path with eyes open (BSEO) (t = 2.68, p = 0.01, effect size (ES) = 0.81), total body sway with eyes closed of centre of pressure (CoP) displacement in the a-p direction (BSEC) (t = 1.86, p = 0.07, ES = 0.57), mean velocity of CoP displacements (VEO) (t = 2.67, p = 0.01, ES = 0.83), mean amplitude of CoP displacements in the a-p direction (AapEO) (t = 3.38. p = 0.00, ES = 1.01) and in mean amplitude of CoP displacements in the m-l direction (AmlEO) (t = 3.68, p = 0.00, ES = 1.19). With eyes closed, girls performed significantly better (t = 2.28, p = 0.03, ES = 0.70) than boys did in the mean amplitude of COP displacements in the a-p direction (AapEO) and significantly better (t = 2.37, p = 0.03, ES = 0.71) in the mean amplitude of COP displacements in the m-l direction (AmlEC). Insignificant correlations between different balance tests, except for a correlation between the flamingo test and one-leg stance on a low beam (r = 0.558, p < 0.01), show that each test assesses different aspects of balance ability; therefore, balance cannot be assessed with a single test.

Effects of Exercise Therapy for Adults With Coronary Heart Disease: A Systematic Review and Meta-analysis of Randomized Controlled Trials

BACKGROUND

Exercise therapy has been recommended as a core element for the prevention of coronary heart disease (CHD). However, the independent impact of exercise therapy remains unclear.

OBJECTIVE

The aim of this study was to assess the effects of exercise therapy compared with no exercise control in patients with CHD.

METHODS

We searched 8 electronic databases from January 2000 to March 2020. Randomized controlled trials with at least 6 months of follow-up that evaluated the effects of exercise therapy on hospital admissions, health-related quality of life (HRQoL), mortality, and morbidity in adults with CHD were included. Two reviewers independently screened records for eligibility, extracted data, and assessed risks of bias using the Cochrane tool. Meta-analyses were conducted using the random-effects model.

RESULTS

We included 22 randomized controlled trials involving 4465 participants. Compared with no exercise control, exercise therapy reduced all-cause hospital admissions (10 studies; risk ratio, 0.46; 95% confidence interval, 0.25-0.83; I = 64%) and cardiovascular mortality (9 studies; risk ratio, 0.44; 95% confidence interval, 0.22-0.89; I= 0%) across all studies reporting these outcomes at their longest follow-up. Eight of 14 studies that assessed HRQoL observed a significant improvement in at least 1 domain or overall HRQoL with exercise therapy compared with control. There were no significant reductions in cardiovascular hospital admissions, all-cause mortality, incidence of myocardial infarction, or revascularization.

CONCLUSIONS

This review shows the independent benefits of exercise therapy in reducing all-cause hospital admissions and cardiovascular mortality for adults with CHD.

The Role of Nutri(epi)genomics in Achieving the Body's Full Potential in Physical Activity

Physical activity represents a powerful tool to achieve optimal health. The overall activation of several molecular pathways is associated with many beneficial effects, mainly converging towards a reduced systemic inflammation. Not surprisingly, regular activity can contribute to lowering the “epigenetic age”, acting as a modulator of risk toward several diseases and enhancing longevity. Behind this, there are complex molecular mechanisms induced by exercise, which modulate gene expression, also through epigenetic modifications. The exercise-induced epigenetic imprint can be transient or permanent and contributes to the muscle memory, which allows the skeletal muscle adaptation to environmental stimuli previously encountered. Nutrition, through key macro- and micronutrients with antioxidant properties, can play an important role in supporting skeletal muscle trophism and those molecular pathways triggering the beneficial effects of physical activity. Nutrients and antioxidant food components, reversibly altering the epigenetic imprint, have a big impact on the phenotype. This assigns a role of primary importance to nutri(epi)genomics, not only in optimizing physical performance, but also in promoting long term health. The crosstalk between physical activity and nutrition represents a major environmental pressure able to shape human genotypes and phenotypes, thus, choosing the right combination of lifestyle factors ensures health and longevity.

Comparing the Effect of Combining Exercise with Rosuvastatin versus Atorvastatin on Lipid Profile and Functional Capacity: A Retrospective Cohort Study

Background

Statins and exercise are recommended for managing hypercholesterolemia. However, statin types may vary in their interaction with exercise. We compared rosuvastatin versus atorvastatin combination with exercise on lipid profile and functional capacity.

Methods

A retrospective cohort study using data from a 12-week cardiovascular rehabilitation program between 2014 and 2016. Statin use was determined through prescriptions, and the average exercise minutes/week were computed from exercise logs. The outcomes were changes in total cholesterol, low- and high-density lipoproteins (LDL and HDL), triglycerides, and functional capacity (6-minute walk test (6MWT)). Directed acyclic graphs were used to identify potential confounders, accounted for using multiple linear regression modeling.

Results

The cohort included 282 patients from 106 atorvastatin and 176 rosuvastatin users. The average exercise minutes/week was 109.4 ± 66.1 among atorvastatin and 106.7 ± 49.1 among rosuvastatin users. Interaction models suggested that a higher number of exercise minutes/week were more favorable among atorvastatin users on total cholesterol and LDL (0.004, 95% CI: 0.001, 0.008 and 0.004, 95% CI: 0.001, 0.007, respectively) but did not reach significance for HDL and triglycerides. Rosuvastatin use was associated with greater increases in 6MWT; however, we observed no between-group differences in interaction estimates by the type of statin used.

Conclusion

Rosuvastatin use could blunt the beneficial effect of exercise on LDL and total cholesterol compared to atorvastatin. No significant differences were observed in triglycerides, HDL, and functional capacity levels. Additional studies are warranted with randomized treatments and larger samples. Healthcare providers should continue prescribing statins alongside recommending exercise modalities, with a careful follow-up for rosuvastatin users.

Non-exercise based estimation of cardiorespiratory fitness is inversely associated with metabolic syndrome in a representative sample of Korean adults

Background

This study investigated the association between non-exercise based estimation of cardiorespiratory fitness (eCRF) and metabolic syndrome (Mets) in Korean adults aged 18 years and older (13,400 women and 9885 men).

Methods

Data from the 2008 and 2011 Korea National Health and Nutrition Examination Surveys IV and V in South Korea were analyzed. eCRF was assessed with a previously validated procedure. Participants were classified into 5 categories from the lowest quantile to the highest quantile based on individual eCRF distributions.

Results

The findings showed an independent and inverse association between eCRF and Mets in women and men separately. Individuals in the highest eCRF category (quantile 5) had a significantly lower prevalence of Mets (14.5 and 14.8% for women and men, respectively) compared with their counterparts (40.4 and 46.4% for women and men, respectively) in the lowest eCRF category (quantile 1), and the association showed a graded response, with the quantiles 2, 3, and 4 also significantly associated with a lower prevalence of Mets compared with the quantile 1. Furthermore, the prevalence of Mets in the highest quantile compared with the lowest quantile remained statistically significant in both men (p < 0.05) and women (p < 0.05) even after adjustments for age, body mass index, skeletal muscle index, smoking, heavy drinking, vitamin D, caloric intake, and dietary intakes of carbohydrates, fats, and proteins.

Conclusion

The findings support a preventive role for eCRF against Mets in Korean adults.

Effects of Exercise Training in Postoperative Patients With Congenital Heart Disease: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Background

The purpose of this meta‐analysis is to assess the effects of exercise training on quality of life, specific biomarkers, exercise capacity, and vascular function in congenital heart disease (CHD) subjects after surgery.

Methods and Results

We searched the Cochrane Central Register of Controlled Trials, MEDLINE, and EMBASE from the date of the inception of the database through April 2019. Altogether, 1161 records were identified in the literature search. Studies evaluating outcomes before and after exercise training among postoperative patients with congenital heart disease were included. The assessed outcomes were exercise capacity, vascular function, serum NT‐proBNP (N‐terminal pro‐B‐type natriuretic peptide) levels and quality of life. We analyzed heterogeneity by using the I² statistic and evaluated the evidence quality according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) guidelines. Nine randomized controlled trials were included. The evidence indicated that exercise interventions increased the one of the quality of life questionnaire score (mean difference=3.19 [95% CI, 0.23, 6.16]; P=0.03; I²=39%) from the score before the interventions. However, no alterations in exercise capacity, vascular function, NT‐proBNP or quality of life were observed after exercise training. The results of the subgroup analysis showed that NT‐proBNP levels were lower in the group with exercise training than in the group without exercise training over the same duration of follow‐up. The evidence quality was generally assessed to be low.

Conclusions

In conclusion, there is insufficient evidence to suggest that physical exercise improves long‐term follow‐up outcomes of congenital heart disease, although it has some minor effects on quality of life.

Self-care of patients with type 2 diabetes mellitus over the course of illness: implications for tailoring support

Purpose

Type 2 diabetes requires patients to make lifestyle changes and perform daily self-care. To determine at what stages patients may need particular self-management support, we examined (1) whether patients' performance of self-care related to their diabetes duration, and (2) whether illness characteristics (treatment and complications) and diabetes-related distress influenced this relationship.

Methods

Cross-sectional data from 590 type 2 diabetes patients were analysed through linear and logistic regression analysis. Self-care behaviours were assessed by the revised Summary of Diabetes Self-Care Activities (SDSCA) measure. Diabetes duration (model 1), treatment and complications (model 2), and distress, as assessed by the Problem Areas In Diabetes (PAID) scale (model 3), were stepwise included. Sociodemographic characteristics were added to all models to account for confounding.

Results

Patients with a longer history of diabetes were less physically active, but monitored their blood glucose levels more frequently than more recently diagnosed patients. These relationships were mediated by the presence of complications and the use of insulin, with lower levels of physical activity being found among patients with macrovascular complications and higher frequencies of glucose monitoring among patients on insulin. All predictors together explained maximally 5% of the variance in self-care, except for glucose monitoring (37%) and smoking (11%).

Conclusion

Type 2 diabetes patients' self-care activity changes over the course of illness. To provide tailored self-management support, diabetes care providers should take into account patients' phase of illness, including their treatment and complications, as well as their personal characteristics and distress level.

Exercise and Cardiovascular Protection

Accumulating evidence has demonstrated that exercise training not only reduces cardiovascular disease risk but also provides direct endogenous cardiovascular protection. The mechanisms that have been proposed to be responsible for exercise-induced cardioprotection include intrinsic myocardial changes such as increased cytosolic antioxidant capacity and altered mitochondrial phenotype, myokine-mediated metabolic and anti-inflammatory effects in the cardiovascular system, and systemic effects on the cardiovascular system via interorgan cross talk. There remains much to be elucidated in the mechanisms for exercise-afforded cardioprotection. This chapter reviews exercise-induced acute and chronic responses in cardiovascular system, the epidemiological evidence of exercise training and cardiorespiratory fitness in the primary and secondary prevention of cardiovascular diseases, and the current understanding of the mechanisms of exercise-induced cardiovascular protective effects.

Lifestyle Behaviors and Socio-Demographic Factors Associated with Overweight or Obesity Among Saudi Females Attending Fitness Centers

OBJECTIVE

To examine the associations of overweight or obesity with several lifestyle and socio-demographic factors among Saudi women attending fitness centers in Riyadh.

METHODS

Saudi females (n = 460) aged 16 years and older were recruited from 12 randomly selected fitness centers in Riyadh, using a stratified clustered sampling technique. Bodyweight and height were measured. Lifestyle behaviors were assessed using a previously validated instrument, and included physical activity, sedentary behaviors, sleep, and dietary habits.

RESULTS

Over 62% of the participants were either overweight or obese. Mean BMI values for females younger than age 30 years (26.4 ± 5.3) were significantly lower than those 30 years of age or older (29.2±5.6, p >0.001). There was a significant correlation (r = 0.450, p < 0.001) between BMI levels and the participant's reason to engage in exercise for weight loss. Females who were overweight/obese are significantly older, married, have more children, have a lower educational degree, earn less income, have higher numbers of obese in the family, and had attempted to lose weight more frequently than non-overweight/non-obese females. No significant differences were detected between females who were overweight/obese and those who were not overweight/obese in the majority of the lifestyle-related variables, except that females who were not overweight or obese showed lower weekly consumption of milk and dairy products (p =0.029) and higher intakes of fast foods per week (p =0.049).

CONCLUSION

Weight loss attempts, age, number of obese in the family, and females' education level emerged as the most important contributory factors to obesity status, explaining nearly 23% of the common variances. A better understanding of the relationships between obesity and lifestyle behaviors is necessary for effective prevention and management of obesity in Saudi females.