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Effects of Traditional and Modified Arm Swing Exercise on Abdominal Obesity, Hemodynamics and Quality of Life in Patients with Metabolic Syndrome.

INTRODUCTION

The worldwide prevalence of obesity is increasing (18), which is directly correlated with the prevalence of metabolic syndrome (MetS) (4). The International Diabetes Federation (IDF) estimates that the prevalence of the world's adult population with metabolic syndrome is around 20 to 25% (9). MetS is a complex disorder that includes abdominal obesity, insulin resistance, dyslipidemia, and hypertension (2). Singly or collectively, the disorders associated with MetS result in numerous adverse effects on many systems of the human body (13). Often, the result is an increase in the risk of many subsequent diseases. Recent study has shown that the patients with MetS who had high blood pressure (BP) and abdominal obesity were associated with lower health-related quality of life (QOL) than patients without MetS (11).

Low-intensity exercise training and/or physical activity has been shown to reduce waist circumference (6,23) in healthy adult and reduce BP in healthy and hypertensive subjects (5,7,10). Only one previous study found the hypotensive effect in MetS male Wistar rats (17). Additionally, the improvement of cardiovascular disease (CVD) risk factors included reduction in waist circumference after weight loss and low intensity exercise program for 6 months (12). The impressiveness of changes in body shape derived from weight loss could improve QOL (25). Furthermore, most studies that have investigated the effect of exercise training on QOL were performed in the western exercise pattern while relatively few studies have determined the effects of eastern exercise pattern on QOL in patients with MetS. Apparently, there are no studies in individuals with MetS that examined the effects of low-intensity exercise training on heart rate (HR) and BP.

Arm swing exercise (ASE) is a traditional Chinese exercise (14). It is an interesting exercise modality because it is feasible for most individuals under home-based exercise non-supervised conditions. It is also a good exercise modality because it minimizes the risk of musculoskeletal injury. In addition, the traditional ASE (TASE) training for 8 wks decreased glycated haemoglobin (HbA1c) and oxidative stress in patients with type 2 diabetes mellitus (T2DM) (14). Moreover, TASE has been shown to improve cognitive performance, aerobic capacity, and oxidative stress in older women with mild cognitive impairment (19). It also improves exercise capacity and oxygen consumption in overweight and normal weight sedentary young adults (21), and improves aerobic capacity, functional mobility, and health related QOL in pre-frail elderly women (20). In addition, arm swing exercise training improves exercise capacity to an extent comparable with that of leg cycling exercise training (22).

However, there has been no study investigating the effects of TASE on abdominal obesity, hemodynamics, and QOL in MetS patients. We created the modified ASE (MASE) to increase effort by increasing muscle contraction and joint movement, including shoulder flexion, fist, abdominal muscle contraction, and knee extension. The increased exercise-induced physiological response may be appropriate for patients with MetS, which is linked to the more complicated components than diabetes mellitus or hypertension alone.

Thus, this study investigated and compared the effects of TASE and MASE on abdominal obesity, hemodynamics, and QOL in patients with MetS. We hypothesized that TASE and MASE training could reduce waist circumference, improve HR, BP, and QOL in MetS patients with more benefits from MASE.

METHODS

Subjects

Adults who met the inclusion criteria (e.g., women aged between 35 to 70 yrs, MetS diagnosed by the guidelines of IDF 2006, and non-regular exercise less than 3 d*[wk.sup.-1]) were recruited from Khon Kaen province, Thailand. The exclusion criteria included patients with known cardiovascular diseases, respiratory diseases, neuromuscular disorders, liver and kidney disorders, orthopedic problems that involved shoulder movement, and chronic infection. If the subjects were medicated for T2DM, hypertension, and dyslipidaemia, pharmacology therapies would continue during the study. All subjects provided informed consent according to the Ethical Committee of Khon Kaen University in accordance with the 1964 Declaration of Helsinki (HE 571357). All subjects consented to participate in the study after receiving both verbal and written explanations.

Experimental Design and Protocol

All subjects participated in the screening measurements before the experiment, which included a medical history, electrocardiography, blood sample for routine blood chemistry and hematology, physical measurement (BP and HR), anthropometric measurement, and body fat distribution. All subjects were a simple random sampling assigned to 1 of 2 groups, either the TASE group or the MASE group. The subjects performed the ASE training 10 min*[d.sup.-1] during the 1st week, 20 min*[d.sup.-1] during the 2nd wk, and 30 min*[d.sup.-1] during the 3rd wk until the end of study duration, 6 d*[wk.sup.-1] for 12 wks. The ASE was checked for accuracy in the laboratory at week 2 and follow up by telephone at week 4, 6, 8, 10, and 12. The health related SF-36 questionnaire was obtained from all subjects pre- and post-intervention at the 1st and 85th day of the study.

Parameters Measurement

Anthropometry and Body Composition

A stadiometer (DETECTO, US) was used to measure the subjects' weight in kilograms and height in meters. Body mass index (BMI) was calculated by kilograms per square meter. Waist circumference (WC) was measured at the midpoint between the lower rib margin and iliac crest at the end of inspiration, while hip circumference (HC) was measured at the trochanter level. Waist to hip ratio (WHR) was computed as WC per HC for each subject. Body composition included fat mass and muscle, which were measured by dual-energy x-ray absorptiometry (LUNAR Prodigy, US) software version 14.10.

Hemodynamics Measurement

The subjects' HR and BP were measured by an automatic sphygmomanometer (UA-767 Plus, UK) with the cuff wraps around the upper right arm while in the sitting position.

Quality of Life (QOL)

QOL was determined at rest by the SF-36 questionnaire, which consists of 2 scales. The mental and physical component scales assess eight health domains: physical functioning, physical role, bodily pain, general health, vitality, social functioning, emotional role, and mental health.

Physical Activity and Dietary Assessments

All subjects were asked to maintain their daily physical activity and dietary habits during the exercise training period. During the 1st and 12th wk during the exercise training period, the subjects were asked to keep a physical activity and a food diary for three days that included two weekdays and one weekend day. The record was used to analyze energy intake (8).

Statistical Analyses

All data were expressed as the means and standard error of mean (means [+ or -] SE). Statistical analyses were performed using SPSS for Windows (version 17.0, USA). The Kolmogorov-Smirnov Test was used to normalize the distribution. The Dependent-Sample t Test was used to compare differences of parameter between before and after training within group. The ANCOVA was used to detect differences in parameters between groups. Statistical probability (p-value) less than 0.05 was considered as the statistical significance.

RESULTS

Subject Characteristics

Of the 105 potential women who were recruited for this study (given that 41 women did not meet the inclusion criteria and 5 subjects dropped out because of incomplete exercise program), 63 subjects finished the exercise training program (Figure 1). Subjects who were receiving medication did so for T2DM (n = 4), hypertension (n = 9), and dyslipidemia (n = 4), pharmacology therapies.

Anthropometry

After the exercise training program, the TASE group had the tendency to reduce weight (P = 0.06) and BMI (P = 0.07) compared with before the intervention. However, there was no significant weight change between groups after training program (Table 1). The subjects' WC was significantly lower after the training program in both groups (P<0.05) (Table 1).

Quality of life

Physical role, general health, social functioning, and emotional role aspect of the SF-36 score were significantly increased after exercise training in the TASE group, while after the MASE training there was the tendency to be increased in physical functioning (P = 0.09) and general health (P = 0.08). Moreover, social functioning of the SF-36 was higher in the TASE than in the MASE after exercise training (Table 2). There was no significant difference in dietary composition between groups both before and after training. At the end of 12-wk exercise training program, total energy expenditure was significantly higher in both groups, without difference between groups when compared to the beginning of the study (data not shown).

Hemodynamics

Heart rate and SBP were decreased in the TASE group after training. However, there were no significant differences in HR and BP between the groups (Table 3).

Compliance and Training Exercise

The subjects completed an average of a total of 59 [+ or -] 0.2 sessions in the TASE group and 58 [+ or -] 0.2 sessions in the MASE group during the 12 training program, which was approximately 81% compliance for both groups. The ASE intensity during training was not different between the two groups. Both the TASE intensity and the MASE intensity were around 50% to 49% of HRmax before and after exercise training, respectively.

DISCUSSION

This study was the first to our knowledge that investigated the effects of TASE and MASE on abdominal obesity, hemodynamics, and QOL in patients with MetS. The results of this study did not support our hypothesis because the MASE training did not have more beneficial effects on the research parameters. Moreover, the MASE training resulted in only a decrease in abdominal obesity; whereas, the TASE training improved both the subjects' physical and mental components (with a greater value in social functioning compared with MASE). The TASE training also decreased the subjects' abdominal obesity, HR, and SBP.

The decrease in the subjects' waist circumference with both patterns of ASE training was also reported by Phoemsapthawee et al. (19) and Prasertsri and colleagues (21). Either low-intensity exercise (180 to 300 kcal*[session.sup.-1]) training for 5 wks for women and men (23) or low-intensity activity (100 to 761 counts*[min.sup.-1]) have been reported to decrease the subjects' waist circumference (6).

According to the SF-36 score, there was an improvement in the subjects' physical and mental functioning with greater social functioning after exercise training in the TASE group versus the MASE group. Similarly, Maser and Lenhard (16) reported improvement in their subjects' mental component score (using the SF-36) after Tai Chi/Qigong exercise training that consisted of 1 to 1.5 hr*[session.sup.-1], 3 [sessions.wk.sup.-1] for 12 wks in adults with elevated blood glucose. Also, a recent study by Phoemsapthawee and Leelayuwat (20) has supported the beneficial effect of TASE on health-related quality of life in pre-frail elderly women. It is apparent that the weight loss-derived feeling of change in body shape (i.e., waist reduction) results in an improvement in social functioning.

Furthermore, a previous study by Phoemsapthawee et al. (19) showed improved cognitive performance, aerobic capacity, and oxidative stress in older women with mild cognitive Impairment (19). These are important mental and physiological changes that help to improve the subjects' mental well-being (1). Also, the improvement in cognitive performance, aerobic capacity, and oxidative stress may be the explanation that helps to explain the increase in the MetS subjects' SF-36 mental component scores in this study.

Although the present study shows ASE is safe and accessible to the public sector, there are no studies that have examined the effect of low-intensity ASE exercise on HR and BP in MetS patients. Only a previous study by Morvan et al. (17) examined the hypotensive effect, but the subjects in their study were male MetS Wistar rat. Most human studies examining the effect of low-intensity exercise on BP were performed in hypertensive subjects (5,7,10). Thus, this study is the first to explore the effect of ASE and low-intensity exercise on these parameters. The effects may be due to improvement in the function of the parasympathetic nervous system or a decrease in the sympathetic nervous system since the improvement of autonomic disturbances have been shown to improve control hemodynamics (15,24). This is supported by the report of previous studies that demonstrated low-intensity exercise training decreased the subjects' total peripheral resistance, increased vascularization, increased peripheral vasodilation, improved tissue perfusion (5), and improved baroreflex (17).

Moreover, the improvement in the subjects' parasympathetic function and/or the decrease in their sympathetic function may have been due to weight reduction since weight and BMI had the tendency to decrease in the TASE group only. It is noted the advantages of TASE training on changes HR and SBP are little because most subjects in this study had normal BP. The hypotensive effect may be harmful for the normotensive subjects. Thus, investigation of the hypotensive effect of the TASE training and the MASE training for hypertensive patients or MetS with hypertension is interesting and should be performed.

Limitations of this Study

One important limitation in this study seems to be the lack of a control group with subjects not involved in any regular exercise. However, several previous studies have shown that the typical response for a control group is no physical changes (3,23). Therefore, the design of the present study seems appropriate in terms of validating the new exercise mode as an alternative approach of exercise based on the traditional exercise approach for MetS patients. In addition, since the subjects in this study were females, the results may be not physiologically as accurate when referring to male subjects. Thus, further study exploring the effects of both modes of exercise on BP and QOL in male MetS patients is needed.

CONCLUSIONS

This study suggests that the 12 wks of TASE and MASE results in decreased abdominal obesity in women with MetS. The TASE training improved the subjects' hemodynamics and QOL with the greater value in social functioning compared to the MASE training. However, pattern of ASE did not influence either the abdominal obesity or the hemodynamics in these patients.

ACKNOWLEDGMENTS

This study was supported by Thai Health Promotion Foundation (Thai Health), and Thai Traditional Medical Knowledge Fund, Thailand. Ms. Benja Songsaengrit was also partially supported by Graduate School Research Grant, Exercise and Sport Sciences Development and Research Group and Faculty of Medicine Invitation Research Grant, Khon Kaen University. We wish to thank all the participants for their enthusiastic cooperation.

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Benja Songsaengrit (1,4), Paitoon Benjapornlert (2), Veeradej Pisprasert (3), Ploypailin Aneknan (4), Yupaporn Kanpettha (1,4), Arisa Sespheng (1,4), Naruemon Leelayuwat (4,5)

(1) Exercise and Sport Sciences program, Graduate School, Khon Kaen University, Khon Kaen, Thailand, (2) Department of Rehabilitation Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand, (3) Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen,Thailand, (4) Exercise and Sport Sciences Development and Research Group, Khon Kaen University, (5) Department of Physiology, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand

Address for correspondence: Naruemon Leelayuwat, PhD, Department of Physiology, Faculty of Medicine, and Exercise and Sport Sciences Development and Research Group, Khon Kaen University, 123 Mittraparb Highway, Nai Muang District, Umbhur Muang, Khon Kaen 40002, Thailand, Phone: +66 43363 185 Email: naruemon.leelayuwat@gmail.com
Table 1. Effects of MASE and TASE Training on Anthropometry and Body
Composition in MetS Subjects.

                                          MASE
                               Before              After (1)

Age (yrs)                 51.1 [+ or -] 7.0          -
Weight (kg)               66.4 [+ or -] 7.9  66.3 [+ or -] 7.9
BMI (kg*[m.sup.-2])       28.8 [+ or -] 3.3  28.8 [+ or -] 3.3
Waist circumference (cm)  92.9 [+ or -] 6.1  90.0 [+ or -] 7.8 (*)
Fat mass (kg)             27.5 [+ or -] 5.1  27.5 [+ or -] 5.2
Lean mass (kg)            35.8 [+ or -] 3.1  35.9 [+ or -] 3.4

                                           TASE
                                Before              After (1)

Age (yrs)                  47.6 [+ or -] 7.1          -
Weight (kg)               76.9 [+ or -] 13.7  76.1 [+ or -] 13.2
BMI (kg*[m.sup.-2])        31.6 [+ or -] 0.8   31.3 [+ or -] 4.7
Waist circumference (cm)   97.0 [+ or -] 9.4   95.0 [+ or -] 8.5 (*)
Fat mass (kg)              34.0 [+ or -] 8.9   33.5 [+ or -] 8.4
Lean mass (kg)             40.0 [+ or -] 6.4   39.5 [+ or -] 6.1

                           Mean difference    P value (2)
                               (95%Cl)

Age (yrs)                         -                -
Weight (kg)                0.24(-0.92, 1.41)      .67
BMI (kg*[m.sup.-2])        0.12(-0.34, 0.59)      .59
Waist circumference (cm)  -0.55(-2.91, 1.79)      .63
Fat mass (kg)              0.09(-0.82, 1.01)      .83
Lean mass (kg)             0.35(-0.38, 1.09)      .33

Data are expressed as mean [+ or -] SD, n = 32 in the MASE group and n
= 31 in the TASE group. Abbreviations: ASE = arm swing exercise, MetS =
Metabolic syndrome, MASE = modified arm swing exercise, TASE =
traditional arm swing exercise, 95%Cl = 95 percentage of confidence
interval, BMI = body mass index, (1) Test for significant differences
within group, (2) Test for significant differences between groups, (*)
P<0.05; Significantly different from before training within group

Table 2. Effects of MASE and TASE training on SF-36 score in MetS
subjects

                                          MASE
                                Before            After (1)

Physical Component Scale
 Physical Functioning     75.1 [+ or -] 19.1  80.1 [+ or -] 13.3
 Physical Role            72.6 [+ or -] 35.5  78.9 [+ or -] 30.5
 Bodily Pain              68.9 [+ or -] 22.0  72.9 [+ or -] 15.7
 General Health           61.4 [+ or -] 19.9  66.8 [+ or -] 20.5
Mental Component Scale
 Vitality                 68.9 [+ or -] 15.1  71.4 [+ or -] 13.6
 Social Functioning       82.8 [+ or -] 17.3  86.3 [+ or -] 16.3
 Emotional Role           65.6 [+ or -] 41.8  72.9 [+ or -] 35.3
 Mental Health            77.5 [+ or -] 11.6  79.3 [+ or -] 15.0

                                          TASE
                                Before               After (1)

Physical Component Scale
 Physical Functioning     79.1 [+ or -] 18.2  81.7 [+ or -] 14.6
 Physical Role            66.1 [+ or -] 36.2  79.0 [+ or -] 25.8 (*)
 Bodily Pain              69.1 [+ or -] 20.7  75.4 [+ or -] 22.8
 General Health           60.6 [+ or -] 19.9  68.0 [+ or -] 20.2 (*)
Mental Component Scale
 Vitality                 66.6 [+ or -] 12.8  69.3 [+ or -] 17.4
 Social Functioning       85.8 [+ or -] 19.5  95.1 [+ or -] 11.4 (**)
 Emotional Role           51.6 [+ or -] 36.3  73.1 [+ or -] 31.5
 Mental Health            74.4 [+ or -] 14.6  75.6 [+ or -] 14.0

                            Mean difference     P value (2)
                                (95%CI)

Physical Component Scale
 Physical Functioning      -0.11 (-6.50, 6.28)     0.97
 Physical Role             -1.69 (-15.5, 12.1)     0.80
 Bodily Pain               -2.48 (-12.2, 7.06)     0.60
 General Health            -1.67 (-9.81, 6.47)     0.68
Mental Component Scale
 Vitality                   0.55 (-5.90, 7.00)     0.86
 Social Functioning         7.53(-13.5, -1.52)    <0.05
 Emotional Role            -3.82 (-20.3, 12.7)     0.64
 Mental Health              1.60 (-4.08, 7.29)     0.57

Data are expressed as mean [+ or -] SD, n = 32 in MASE group and n = 31
in the TASE group. Abbreviations: ASE = arm swing exercise, MetS =
Metabolic syndrome, MASE = modified arm swing exercise, TASE =;
traditional arm swing exercise, 95%Cl = 95 percentage of confidence
interval, (1) Test for significant differences within group, (2) Test
for significant differences between groups, (*) P<0.05 and (**) P<0.01;
Significantly different from before training within group

Table 3. Effects of MASE and TASE Training on Heart Rate and Blood
Pressure in MetS Subjects.

                                   MASE
                        Before              After (1)

HR                  69.1 [+ or -] 9.1    67.4 [+ or -] 9.3
(b*[min.sup.-1])
SBP               122.6 [+ or -] 18.5   120.8 [+ or -] 11.5
(mmHg)
DBP                71.9 [+ or -] 11.2    73.8 [+ or -] 8.4
(mmHg)

                                   TASE
                        Before               After (1)

HR                 72.9 [+ or -] 11.0   69.1 [+ or -] 10.4 (*)
(b*[min.sup.-1])
SBP               122.2 [+ or -] 12.6  116.7 [+ or -] 9.4 (*)
(mmHg)
DBP                71.3 [+ or -] 12.3   71.8 [+ or -] 11.2
(mmHg)

                   Mean difference       P
                       (95%Cl)        value (2)

HR                0.83 (-2.90, 4.57)    0.65
(b*[min.sup.-1])
SBP               3.88 (-0.54, 8.32)    0.08
(mmHg)
DBP               1.63 (-2.05, 5.33)    0.37
(mmHg)

Data are expressed as mean [+ or -] SD, n = 32 in the MASE group and n
= 31 in the TASE group. Abbreviations: ASE = arm swing exercise, MetS =
Metabolic syndrome, MASE = modified arm swing exercise, TASE =
traditional arm swing exercise, 95%Cl = 95 percentage of confidence
interval, HR = heart rate, SBP = systolic blood pressure, DBP =
diastolic blood pressure, (1) Test for significant differences within
group, (2) Test for significant differences between groups, (*) P<0.05;
Significantly different from before training within group
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Author:Songsaengrit, Benja; Benjapornlert, Paitoon; Pisprasert, Veeradej; Aneknan, Ploypailin; Kanpettha, Y
Publication:Journal of Exercise Physiology Online
Article Type:Report
Date:Dec 1, 2017
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