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While sedentary behaviors have been shown to increase cardiovascular and mortality risk,1 movement and exercise have many well-established health benefits, including enhanced mental and emotional well-being, increased physical fitness, and prevention of chronic diseases. As part of a healthy lifestyle, exercise routines and increased movement specifically contribute to improved cardiovascular fitness, reduced systemic inflammation,2,3 and a lower risk of cardiovascular disease (CVD) development.4 Many different types of physical activities, from simple movement to high intensity, are all beneficial for heart health. Consideration of the range of exercise options helps to personalize treatment strategies that address a patient’s medical needs, align with their personal goals, and meet them where they are to help increase sustainability.
Fitness and the Healthy Heart
According to the American Heart Association, moderate and vigorous aerobic activity, muscle strengthening through resistance training, increasing daily movement while decreasing sedentary behavior, and adding intensity to physical activity are among the recommendations for enhancing cardiorespiratory fitness in adults.5 Flexibility and balance training are additional functional medicine exercise strategies, and the benefits of specific exercise routines and activities continue to be studied to determine the impacts of each on prevention and improvement of cardiovascular health.
Aerobic and Resistance Training
Aerobic and resistance training programs may have different routines, but both have shown similar benefits for cardiovascular fitness. Two 2020 randomized controlled trials (RCTs) investigated the heart health impact of aerobic, resistance, and combination training for patients with hypertension and found that all three types of training significantly decreased blood pressure levels.6,7 In addition, after eight weeks of training in aerobic, resistance, or a combination of the two activities, one RCT also found that all routines were similarly effective in improving endothelial function evaluated using flow-mediated dilation.7
Interval and Continuous Training
Two recent meta-analyses compared the effectiveness of high-intensity interval training (HIIT) versus moderate-intensity continuous training (MICT) in patients with hypertension and within cardiac rehabilitation programs.8,9 A 2020 meta-analysis found that both interventions increased the maximal oxygen uptake (VO2max) for hypertensive patients compared to control groups and promoted a reduction in systolic blood pressure, while HIIT decreased diastolic blood pressure to a greater extent.8 Investigators concluded that overall, HIIT may be more beneficial for improvement of cardiorespiratory fitness in hypertensive patients.8 A second meta-analysis of 17 studies (n=953) echoed this conclusion for those patients in cardiac rehabilitation programs.9 HIIT was superior to MICT in improving cardiorespiratory fitness with a reported standardized mean difference (SMD) of 0.34 mL/kg/min in VO2peak measurements; studies with programs lasting seven to twelve weeks resulted in the largest cardiorespiratory improvements for patients with coronary artery disease (SMD of 0.43 mL/kg/min); and HIIT was reported to be as safe as MICT for this population.9
Dancing, Walking, and Running
Dancing, walking, and running are aerobic exercises that benefit heart function by improving cardiovascular fitness.5 For hypertensive patients, research studies have shown dancing’s positive impact through the reduction of systolic and diastolic blood pressure compared to control groups.10 A 2018 RCT compared the effects of 60-minute sessions of dancing (3x/week), walking (3x/week), or stretching (1x/week) for eight weeks on cardiovascular risk for sedentary women over 60 years of age.11 Results indicated:11
- Those who followed either the dancing or walking routines had similar increases in peak oxygen consumption (VO2peak) and improvements in balance and lower body muscle strength while those in the active control group (stretching) did not.
- All routines resulted in improved cholesterol, C-reactive protein and TNF-alpha measurements, flexibility, and daily physical activity levels.
A 2020 systematic review of 17 prospective studies (n>30,000) suggested that adding 1,000 walking steps per day helps to lower the risk of all-cause mortality and CVD morbidity and mortality in adults.12 The review indicated that for each 1,000 daily step count increase at baseline, estimated risk reductions were 6-36% for all-cause mortality and 5-21% for CVD at follow-up.12 Further, while the number of daily steps needed for optimal health is not clear, studies indicate health benefits are present below 10,000 steps per day.12
A 2020 meta-analysis of 14 prospective cohort studies (n=232,149) suggested that running was associated with lower risks of all-cause (27%), cardiovascular (30%), and cancer (23%) mortality compared with no running.13 Researchers further noted that analysis did not reveal any significant dose-response trends for weekly running frequency, duration, pace, or total volume, with even the smallest doses of running (i.e., <1 time a week, <50 min a week, and <6 mph) showing significant all-cause mortality benefits.13
Pilates, Tai Chi, and Yoga
Increasing daily movement, even in low-impact ways, is essential for improving heart health. Similar to dancing, Pilates training addresses flexibility, strength, and balance. Specific to cardiovascular fitness, results from two small 2020 RCTs suggested that Pilates is an effective intervention for the improvement of vascular function and blood pressure in hypertensive patients and in populations at risk for hypertension.14,15 A 2020 meta-analysis of RCTs investigated the effects of tai chi exercises on CVD risk factors and quality of life for patients with essential hypertension.16 Results indicated that for this population, tai chi reduced blood pressure, total cholesterol, triglycerides, LDL-C, and blood glucose while improving quality of life.16
Recent meta-analyses also continue to suggest the cardiovascular benefits of practicing yoga. A 2016 meta-analysis of 37 RCTs found that compared to non-exercise controls, improvements of LDL and HDL cholesterols, body mass index, and systolic blood pressure were shown for those who practiced yoga.17 In 2019, a meta-analysis of 49 controlled trials (n=3,517) found that yoga interventions (practiced 4.8+/-3.4 sessions per week; 59.2+/-25 minutes per session; 13.2+/-7.5 weeks) resulted in moderate reductions in systolic and diastolic blood pressure compared with controls.18 In addition, for hypertensive patients that specifically practiced yoga interventions that included breath work or meditation/mental relaxation three times per week, greater blood pressure reductions were noted.18
Research suggests that coordinating exercise timing with a patient’s chronotype may optimize the health benefits of exercise routines.19 Chronotype is based on a person’s underlying clock and refers to their predisposition toward either early or late sleep/wake cycles, or in between those two extremes. Exercise may also be used as a zeitgeber (timing cue) to reset potentially disrupted molecular circadian clocks.19 A 2018 systematic review suggested that exercise promoted chronobiological homeostasis as a time cue supporting optimal health and performance.20 A 2020 randomized clinical study investigated whether timed exercise interventions impacted internal circadian rhythm through phase shifts, defined as the delay/advancement of wake-up times and bedtimes.21 The study focused on sedentary adults and measured dim light melatonin onset before and after either five days of morning (n=26) or evening (n=26) exercise.21 Results indicated that morning exercise induced phase advance shifts greater than evening exercise. In addition, researchers concluded that “late” chronotypes may have circadian benefit from morning or evening exercise while evening exercise may promote circadian misalignment for “early” chronotypes.21
Understanding a patient’s circadian rhythm is just one component that may help clinicians personalize exercise interventions and other lifestyle treatment strategies to address CVD risk factors and chronic cardiovascular diseases. For the latest research on cardiovascular and metabolic health and personalized, effective, and sustainable treatment strategies, learn more from functional medicine experts at IFM’s Cardiometabolic Advanced Practice Module (APM).
- Zhao R, Bu W, Chen Y, Chen X. The dose-response associations of sedentary time with chronic diseases and the risk for all-cause mortality affected by different health status: a systematic review and meta-analysis. J Nutr Health Aging. 2020;24(1):63-70. doi:10.1007/s12603-019-1298-3
- Thompson G, Davison GW, Crawford J, Hughes CM. Exercise and inflammation in coronary artery disease: a systematic review and meta-analysis of randomised trials. J Sports Sci. 2020;38(7):814-826. doi:10.1080/02640414.2020.1735684
- Alizaei Yousefabadi H, Niyazi A, Alaee S, Fathi M, Mohammad Rahimi GR. Anti-inflammatory effects of exercise on metabolic syndrome patients: a systematic review and meta-analysis. Biol Res Nurs. Published online September 17, 2020. doi:10.1177/1099800420958068
- Cleven L, Krell-Roesch J, Nigg CR, Woll A. The association between physical activity with incident obesity, coronary heart disease, diabetes and hypertension in adults: a systematic review of longitudinal studies published after 2012. BMC Public Health. 2020;20(1):726. doi:10.1186/s12889-020-08715-4
- American Heart Association recommendations for physical activity in adults and kids. American Heart Association. Reviewed April 18, 2018. Accessed January 5, 2021. https://www.heart.org/en/healthy-living/fitness/fitness-basics/aha-recs-for-physical-activity-in-adults
- Pires NF, Coelho-Júnior HJ, Gambassi BB, et al. Combined aerobic and resistance exercises evokes longer reductions on ambulatory blood pressure in resistant hypertension: a randomized crossover trial. Cardiovasc Ther. Published online July 20, 2020. doi:10.1155/2020/8157858
- Pedralli ML, Marschner RA, Kollet DP, et al. Different exercise training modalities produce similar endothelial function improvements in individuals with prehypertension or hypertension: a randomized clinical trial [published correction appears in Sci Rep. 2020;10(1):10564]. Sci Rep. 2020;10(1):7628. doi:10.1038/s41598-020-64365-x.
- Leal JM, Galliano LM, Del Vecchio FB. Effectiveness of high-intensity interval training versus moderate-intensity continuous training in hypertensive patients: a systematic review and meta-analysis. Curr Hypertens Rep. 2020;22(3):26. doi:10.1007/s11906-020-1030-z
- Hannan AL, Hing W, Simas V, et al. High-intensity interval training versus moderate-intensity continuous training within cardiac rehabilitation: a systematic review and meta-analysis. Open Access J Sports Med. 2018;9:1-17. doi:10.2147/OAJSM.S150596
- Conceição LS, Neto MG, do Amaral MA, Martins-Filho PR, Oliveira Carvalho V. Effect of dance therapy on blood pressure and exercise capacity of individuals with hypertension: a systematic review and meta-analysis. Int J Cardiol. 2016;220:553-557. doi:10.1016/j.ijcard.2016.06.182
- Rodrigues-Krause J, Farinha JB, Ramis TR, et al. Effects of dancing compared to walking on cardiovascular risk and functional capacity of older women: a randomized controlled trial. Exp Gerontol. 2018;114:67-77. doi:10.1016/j.exger.2018.10.015
- Hall KS, Hyde ET, Bassett DR, et al. Systematic review of the prospective association of daily step counts with risk of mortality, cardiovascular disease, and dysglycemia. Int J Behav Nutr Phys Act. 2020;17(1):78. doi:10.1186/s12966-020-00978-9
- Pedisic Z, Shrestha N, Kovalchik S, et al. Is running associated with a lower risk of all-cause, cardiovascular and cancer mortality, and is the more the better? A systematic review and meta-analysis. Br J Sports Med. 2020;54(15):898-905. doi:10.1136/bjsports-2018-100493
- Rocha J, Cunha FA, Cordeiro R, Monteiro W, Pescatello LS, Farinatti P. Acute effect of a single session of Pilates on blood pressure and cardiac autonomic control in middle-aged adults with hypertension. J Strength Cond Res. 2020;34(1):114-123. doi:10.1519/JSC.0000000000003060
- Wong A, Figueroa A, Fischer SM, Bagheri R, Park SY. The effects of mat Pilates training on vascular function and body fatness in obese young women with elevated blood pressure. Am J Hypertens. 2020;33(6):563-569. doi:10.1093/ajh/hpaa026
- Liang H, Luo S, Chen X, Lu Y, Liu Z, Wei L. Effects of tai chi exercise on cardiovascular disease risk factors and quality of life in adults with essential hypertension: a meta-analysis. Heart Lung. 2020;49(4):353-363. doi:10.1016/j.hrtlng.2020.02.041
- Chu P, Gotink RA, Yeh GY, Goldie SJ, Hunink MG. The effectiveness of yoga in modifying risk factors for cardiovascular disease and metabolic syndrome: a systematic review and meta-analysis of randomized controlled trials. Eur J Prev Cardiol. 2016;23(3):291-307. doi:10.1177/2047487314562741
- Wu Y, Johnson BT, Acabchuk RL, et al. Yoga as antihypertensive lifestyle therapy: a systematic review and meta-analysis. Mayo Clin Proc. 2019;94(3):432-446. doi:10.1016/j.mayocp.2018.09.023
- Gabriel BM, Zierath JR. Circadian rhythms and exercise – re-setting the clock in metabolic disease. Nat Rev Endocrinol. 2019;15(4):197-206. doi:10.1038/s41574-018-0150-x
- Lewis P, Korf HW, Kuffer L, Groß JV, Erren TC. Exercise time cues (zeitgebers) for human circadian systems can foster health and improve performance: a systematic review. BMJ Open Sport Exerc Med. 2018;4(1):e000443. doi:10.1136/bmjsem-2018-000443
- Thomas JM, Kern PA, Bush HM, et al. Circadian rhythm phase shifts caused by timed exercise vary with chronotype. JCI Insight. 2020;5(3):134270. doi:10.1172/jci.insight.134270