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The Journals of Gerontology Series A: Biological Sciences and Medical Sciences 56:M298-M303 (2001)
© 2001 The Gerontological Society of America

Aerobic Exercise and Resting Blood Pressure in Older Adults

A Meta-analytic Review of Randomized Controlled Trials

George A. Kelleya and Kristi Sharpe Kelleyb

a Department of Kinesiology, Northern Illinois University, DeKalb
b Office For Health Promotion, Northern Illinois University, DeKalb

George A. Kelley, Associate Professor, Graduate Program in Clinical Investigation, Director, Meta-Analytic Research Group, MGH Institute of Health Professions, 101 Merrimac Street, Boston, MA 02114-4719 E-mail: gkelley{at}partners.org.

Decision Editor: John E. Morley, MB, BCh


   Abstract
Top
 Abstract
Methods
 Results
 Discussion
 References
 
Background. It is well established that resting systolic and diastolic blood pressure (SBP and DBP, respectively) increases as one ages. This study used the meta-analytic approach to examine the effects of aerobic exercise for reducing resting SBP and DBP in older adults.

Methods. Study data were compiled through use of the following: (i) computer searches (MEDLINE, Current Contents, and Sport Discus), (ii) cross-referencing from bibliographies of retrieved studies and review articles, and (iii) an expert who reviewed our reference list. Inclusion criteria and sources for this study were (i) randomized trials, (ii) aerobic activity as the only exercise intervention, (iii) a nonexercise control group, (iv) an assessment of changes in resting SBP and/or DBP, (v) within-study ages of subjects >=50 years, (vi) English-language studies published in journals, and (vii) studies published between January 1966 and January 1998. Net changes in resting BP were calculated as the exercise minus control group difference.

Results. Fourteen primary outcomes were derived from seven studies. Decreases of approximately 2% and 1% were found for resting SBP and DBP, with only changes in SBP as statistically significant (SBP, mean ± SD = -2 ± 3 mm Hg, 95% confidence interval [CI] = -4 to -1 mm Hg; DBP, mean ± SD = -1 ± 2 mm Hg, 95% CI = -2 to 0 mm Hg).

Conclusions. This study supports the efficacy of aerobic exercise for reducing resting SBP in older adults. However, a need exists for studies that address the effectiveness of this intervention for reducing resting BP in older adults.

IT is well established that both resting systolic and diastolic blood pressure (SBP and DBP, respectively) increase with age among adults in the United States (1). Recent studies examining the effects of aerobic exercise on resting SBP and DBP in adults have led to disappointing results, with only 7% (SBP) and 14% (DBP) of the outcomes reported as statistically significant (2) (3) (4) (5) (6) (7) (8). One of the possible reasons for the lack of statistically significant results may have to do with the sample size for some of these studies. Meta-analysis is a quantitative approach in which individual study findings are combined to arrive at a more objective conclusion about a body of research (9). It is especially useful when the number of subjects that can be enrolled in any one study, as well as the total number of studies, is small (9). This is the case with the aerobic exercise and BP literature dealing with older adults. We have previously reported statistically significant reductions in resting BP across all age groups (10) (11) (12) (13) (14). However, to date, no one has conducted a detailed and quantitative examination on the effects of aerobic exercise on resting BP specifically in older adults. Given the health problems associated with elevated BP, as well as the increasing number of adults aged 50 years and older, a need exists to use a more quantitative approach to examine the effects of aerobic exercise on resting BP in this population. Thus, the purpose of this study was to use the meta-analytic approach to examine the effects of aerobic exercise on resting SBP and DBP in older adults.


   Methods
Top
 Abstract
 Methods
Results
 Discussion
 References
 
Data Sources
Computerized literature searches were performed using MEDLINE, Current Contents, and Sport Discus. In addition, extensive cross-referencing of original and review articles was performed. An expert on exercise and BP (J. Hagberg, PhD, personal written communication, August 14, 1998) also reviewed our reference list for thoroughness.

Study Selection
Inclusion criteria for this study were as follows: (i) randomized trials, (ii) aerobic activity as the only exercise intervention, (iii) a nonexercise control group, (iv) assessment of changes in resting SBP and/or DBP, (v) within-study ages of subjects >=50 years, (vi) English-language studies published in journals, and (vii) studies published between January 1966 and January 1998. We used the age of 50 years as a criterion because of the increasing number of adults aged 50 years and older, as well as the increase in resting BP that occurs as one ages (1). For studies in which resting BP was assessed but not reported, personal contact was made with the authors in an attempt to retrieve such data. To avoid multiple publication bias (15), all studies were examined by both investigators to ensure that only one study on the same group of subjects was included in the analysis.

Data Extraction
Coding sheets that could hold 246 items were developed and utilized in this investigation. In addition, code books, which described how to code each variable on the coding sheet, were also developed and utilized. The major categories of variables coded included the following: (i) study design characteristics, (ii) physical characteristics of subjects, (iii) training program characteristics, (iv) BP assessment characteristics, and (v) primary and secondary outcomes. All data were independently extracted by the two authors. The authors then met and reviewed each coded item. Discrepancies were resolved by consensus.

Statistical Analysis
Primary and secondary outcomes..-- The primary outcomes in this study were changes in resting SBP and DBP, calculated as the difference (exercise minus control) of the changes (initial minus final) in these mean values. For studies that did not report variances for net changes in BP, these were calculated using standard methods (16). Pooled outcomes were calculated by assigning weights equal to the inverse of the total variance for net changes in BP. Ninety-five percent confidence intervals (CIs) were used to establish statistical significance. If the 95% CI included 0 (0.00), it was concluded that there was no effect of aerobic exercise on BP. Heterogeneity of net changes in resting SBP and DBP was examined using the Q statistic (17). A random-effects model was used for all analyses (18). Publication bias (the tendency for journals and/or authors to publish studies that yield statistically significant and positive results) was examined using Kendall's {tau} rank statistic (19). This was accomplished by examining the association between sample size and changes in resting SBP and DBP. Study quality was assessed using a three-item questionnaire designed to assess bias, specifically, randomization, blinding, and withdrawals and/or dropouts (20). The minimum number of points possible was 0, and the maximum, 5, with the higher score indicative of higher quality. For studies that included multiple outcomes because of more than one group, net changes were initially treated as independent data points. Secondary outcomes (changes in body weight, body mass index [BMI], percentage of body fat, maximum oxygen consumption, and resting heart rate) were analyzed using the same approach as that for changes in resting SBP and DBP.

Subgroup analysis..-- Subgroup analyses were performed on categorical variables using analysis-of-variance–like procedures for meta-analysis (17). Net changes in resting SBP and DBP were examined when data were partitioned according to the country in which the study was conducted (United States vs other), gender, medications that could affect resting BP, and cigarette smoking. Subgroup analyses were also performed according to whether subjects had high-normal (SBP and/or DBP >=130/85 mm Hg) or normal BP (21). Insufficient data were available to examine SBP and DBP outcomes partitioned according to established hypertensive and/or normotensive cutoff points (SBP and/or DBP >=140/90 mm Hg) (21). A random-effects model was used for all analyses (18).

Regression analysis..-- To examine what continuous variables, if any, were predictors of changes in SBP, least squares regression models, calculated with each effect size weighted by the reciprocal of its variance, were used (17). Variables examined included study characteristics (study quality), physical characteristics of subjects (initial BP, age, height, body weight, percentage of body fat, maximum oxygen consumption, and resting heart rate), and training program characteristics (length, frequency, intensity, duration, total minutes, and compliance). We did not perform regression analyses for changes in resting DBP since overall and subgroup analyses did not reveal any statistically significant effects or differences. Unless otherwise noted, all data are reported as mean ± SD. Statistical significance was set at p <= .05.


   Results
Top
 Abstract
 Methods
 Results
Discussion
 References
 
Study Characteristics
Nine studies met our criteria for inclusion (2) (3) (4) (5) (6) (7) (8) (22) (23). However, because we were unable to obtain necessary data from two studies (22) (23), a total of seven studies were included in our final analysis. Thus, our percentage of loss that met our inclusion criteria was approximately 22%. A general description of the studies is shown in Table 1 . Four studies were conducted in the United States (2) (3) (5) (7), and one each in Japan (6), Australia (4), and Canada (8). All of the studies appeared to use an analysis-by-protocol approach in the analysis of their BP data. There were a total of 14 exercise and 8 control groups from which 14 primary outcomes were generated. Study quality ranged from 1 to 4 (mean ± SD = 2 ± 1). The seven studies represented pre- and postassessment of resting BP in 802 subjects (563 exercise and 239 control). The percentage of dropout, defined as the percentage of subjects that did not complete the study, ranged from 0% to 37% in the exercise groups (mean ± SD = 18% ± 15%) and 0% to 20% in the control groups (mean ± SD = 10% ± 7%). Subjects in the studies included primarily white and Japanese adults. Exercise and control groups were similar with respect to age, height, weight, BMI, percentage of body fat, maximum oxygen consumption (ml kg-1 · min-1), and resting heart rate (Table 2 ). For those studies that reported such information, one (2) reported that five subjects in the hypertensive endurance-training group and one in the hypertensive control group were taking antihypertensive medications both before and during the study, with one subject in the endurance-training group decreasing the amount taken during the study. Another study (3) simply reported that some of the subjects were taking antihypertensive medications during the study, and another (5) reported that none of the subjects took any type of antihypertensive medications prior to or during the study. One study (5) reported that some of the subjects consumed alcohol, and another (8) reported that alcohol intake averaged 2.8 ± 7.1 g/d-1 in the 25 subjects (47%) that consumed alcohol. Two studies (3) (8) reported that none of the subjects smoked cigarettes; another (5) reported that approximately 25% of the subjects in the study smoked cigarettes. All of the studies appeared to adhere to the American College of Sports Medicine guidelines for the development and maintenance of cardiorespiratory fitness (24). A summary of the training program characteristics for the studies is shown in Table 3 . The rest periods before and between the assessment of resting BP ranged from 5 to 15 minutes and 1 to 2 minutes, respectively. The number of measures ranged from two to nine. Only one study (2) reported the time of day (morning) that BP was assessed.


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  		Table 1. Major Characteristics of Included Studies

 

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  		Table 2. Initial Physical Characteristics of Subjects

 

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  		Table 3. Training Program Characteristics

 
Primary and Secondary Outcomes
As shown in Table 4 , initial resting SBP ranged from 115 to 156 mm Hg in the exercise groups (mean ± SD = 128 ± 12 mm Hg) and 119 to 153 mm Hg in the control groups (mean ± SD = 133 ± 12 mm Hg). For resting DBP, initial resting BP values ranged from 73 to 86 mm Hg in the exercise groups (mean ± SD = 77 ± 4 mm Hg) and 75 to 85 mm Hg in the control groups (mean ± SD = 79 ± 3 mm Hg). Across all categories, small, but statistically significant, decreases were found for resting SBP ( Fig. 1), but not DBP ( Fig. 2). Changes in resting BP were equivalent to an approximately 2% reduction in resting SBP and a 1% reduction in resting DBP. No publication bias was observed for changes in either resting SBP (p = .09) or DBP (p = .09). With each study deleted from the model once, changes ranged from -2 ± 3 mm Hg (95% CI, -3 to -1 mm Hg) to -5 ± 4 mm Hg (95% CI, -8 to -2 mm Hg) for resting SBP and from 0 ± 2 mm Hg (95% CI,1 to 0 mm Hg) to -2 ± 3 mm Hg (-5 to 0 mm Hg) for resting DBP.


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  		Table 4. Blood Pressure Results

 


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  		Figure 1. Ladder plot for changes in resting systolic blood pressure (SBP). The black circles represent the change outcome for each group; the bars that pass through the circles represent the 95% confidence intervals (CIs) for each change outcome. The triangle symbol represents the mean change outcome for resting SBP; the bars that pass through the triangle represent the 95% confidence interval (CI) of the mean change outcome. Values are mean ± SD = -2 ± 3 (95% CI, -4 to -1).

 


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  		Figure 2. Ladder plot for changes in resting diastolic blood pressure (DBP). Black circles represent the change outcome for each group; the bars represent the 95% confidence intervals (CIs) for each change outcome. The triangle symbol represents the mean change outcome for resting DBP; the bars that pass through the triangle represent the 95% confidence interval (CI) of the mean change outcome. Values are mean ± SD = -1 ± 2 (95% CI, -2 to 0).

 
Secondary outcomes are shown in Table 5 . A statistically significant exercise-induced increase of approximately 10% was observed in maximum oxygen consumption. There were no statistically significant changes for any of the other secondary outcomes.


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  		Table 5. Secondary Outcomes

 
Subgroup and Regression Analyses
No statistically significant differences were found when subgroup analyses were performed for changes in resting SBP. However, simple regression analysis revealed a statistically significant association between changes in resting SBP and initial resting SBP (R = .73, standard error of the estimate = 0.57, p = .003). No other statistically significant associations were found for changes in resting SBP and selected variables, including body weight, BMI, and percentage of body fat.


   Discussion
Top
 Abstract
 Methods
 Results
 Discussion
References
 
The overall results of this study suggest that aerobic exercise slightly reduces resting SBP, but not DBP, in adults aged 50 years and older. One of the possible reasons for the smaller-than-expected decrease in resting SBP and the lack of response in DBP may be related to the low baseline BPs observed. For example, we were unable to conduct any type of subgroup analyses according to traditional hypertensive and/or normotensive cut points. However, since we did find a statistically significant association between initial SBP and changes in SBP, this would suggest that those individuals with higher SBP may have more to gain in terms of absolute reductions in SBP.

Two recent narrative reviews (25) (26) focused their discussion on older hypertensive adults, with both concluding that aerobic exercise reduces resting SBP and DBP in older hypertensive adults. One of the reviews (26) reported a weighted average reduction of 6.8 and 8.8 mm Hg in resting SBP and DBP among hypertensive adults aged 61 years and older. The larger reductions observed in the latter review were limited to older hypertensive adults and included both randomized and nonrandomized trials. However, our review was limited to randomized trials in which the majority of subjects had initial resting SBP and DBPs <140/90 mm Hg. We limited our inclusion of studies to randomized trials to ensure that subjects in both groups were similar at the beginning of the study. Clearly, a need exists for additional randomized trials dealing with the effects of aerobic exercise on resting SBP and DBP in older hypertensive adults.

Although the clinical importance of including studies in which subjects were normotensive could be questioned, it has been reported that the relative risk of stroke and coronary heart disease (CHD) is directly related to the level of both SBP and DBP throughout the normotensive and hypertensive range (27) (28). Furthermore, although the relative risk of developing a stroke or CHD is greater in hypertensive adults, the absolute number of these events is small since hypertensive adults only comprise approximately 24% of the adult population in the United States (1). For example, MacMahon and Rodgers (29) found that the greatest number of strokes occurred in those subjects with a DBP in the upper range of normal (80 to 89 mm Hg). Although we do not want to underestimate the importance of BP control in hypertensive adults, it is important to realize that a reduction of only 2 mm Hg in the whole population's SBP has been estimated to reduce the risk of CHD mortality by 4% and stroke mortality by 6% in middle age (30). Therefore, we believe that the 2-mm Hg decrease in resting SBP found in this study is both statistically significant and clinically important.

One potentially confounding variable in exercise and BP studies is the concomitant changes that often occur in body mass. However, we did not find any statistically significant changes for any of the body mass variables assessed (bodyweight, BMI, percentage of body fat), nor did we find any statistically significant associations between changes in resting SBP and changes in any of the body mass variables. Thus, the changes in resting SBP observed in this study appear to be independent of changes in body mass. However, the small sample size in this study may have affected these results.

The fact that we did not find any interactions between training program characteristics and changes in resting SBP was not surprising given the fact that most of the studies used similar protocols for the exercise intervention. Since most of the studies followed the American College of Sports Medicine guidelines for aerobic exercise, it would appear plausible that adherence to these guidelines is appropriate for reducing resting SBP (24). This includes exercising 3 to 5 d/wk at an intensity of 40% to 85% of maximum oxygen consumption for 20 to 60 minutes per session (24).

It appeared that all of the studies in this meta-analysis used an analysis-by-protocol versus intention-to-treat approach in the analysis of their data. In our opinion, we believe that a trial's results should be analyzed using both approaches. An analysis-by-protocol approach is used to determine whether an intervention is efficacious, that is, whether or not the treatment works in those who receive it. With this approach, subjects who drop out of the exercise trial during the course of the study are not included in the final analysis. In contrast, the intention-to-treat approach is used to determine whether the treatment is effective, that is, whether or not the treatment works in the real world (31). With the intention-to-treat approach, dropouts are included in the final analysis. Thus, although aerobic exercise may be efficacious for reducing resting SBP in older adults, it may not be very effective. This may be especially true given the fact that less than 50% of men and 40% of women aged 45 years and older report regular participation in either moderate or vigorous physical activity (32). However, we cannot reach any final conclusions regarding the effectiveness of aerobic exercise for reducing resting SBP and DBP in older adults until studies addressing this issue are conducted.

In conclusion, the results of this study support the efficacy of aerobic exercise for reducing resting SBP in older adults. However, a need exists for studies that address the effectiveness of this intervention for reducing resting BP in older adults.


   Acknowledgments
 
This study was supported by the National Institutes of Health (Grant R01 HL56893). Both authors are currently with MGH Institute of Health Professions, Boston, MA.

Received October 15, 1999

Accepted April 28, 2000


   References
Top
 Abstract
 Methods
 Results
 Discussion
 References
 

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