Effects of 8-week combined training on body ...

Effects of 8-week combined training on body composition, isokinetic strength, and cardiovascular disease risk factors in older women Jin Seok Lee, Chang Gyun Kim, Tae Bum Seo, Hyo Gun Kim & Sung Jin Yoon

Aging Clinical and Experimental Research ISSN 1720-8319 Aging Clin Exp Res DOI 10.1007/s40520-014-0257-4

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Author's personal copy Aging Clin Exp Res DOI 10.1007/s40520-014-0257-4

ORIGINAL ARTICLE

Effects of 8-week combined training on body composition, isokinetic strength, and cardiovascular disease risk factors in older women Jin Seok Lee • Chang Gyun Kim • Tae Bum Seo Hyo Gun Kim • Sung Jin Yoon

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Received: 22 January 2014 / Accepted: 17 June 2014 Ó Springer International Publishing Switzerland 2014

Abstract Background and aims Decline in muscle endurance and strength as well as attenuated cardiac function with aging not only leads to overall physical function decline but also has a close relationship with cardiovascular disease occurrence. This study examined the effects of an 8-week combined training program (i.e., consisting of both aerobic and resistance training) on body composition, isokinetic strength, and cardiovascular disease (CVD) risk factors in older women. Methods Nineteen women, aged 65–75 years, were randomly assigned to either a combined training (CT, n = 9) or an aerobic training (AT, n = 10) group. Body composition and isokinetic strength were assessed before and after the exercise program. Blood samples were collected to identify CVD risk factors. Results At the end of the training program, body mass, body fat mass, percent body fat, and body mass index decreased significantly and lean mass increased significantly in the CT group compared with those in the AT group

(p \ 0.05). Isokinetic strength was also significantly greater in the CT group than in the AT group (p \ 0.05). In addition, the C-reactive protein level was significantly lower in the CT group than in the AT group, whereas interleukin-6, tumor necrosis factor-a, and total cholesterol levels were significantly lower in both groups (p \ 0.05). Conclusions An 8-week combined exercise program benefits body composition, especially lean mass, and positively affects isokinetic strength and CVD risk factors. Therefore, increasing lean mass and strength by continuously participating in a combined exercise program may be an effective treatment for preventing and improving CVD in older women. Keywords Combined training Cardiovascular disease Body composition Isokinetic strength Interleukin-6 Tumor necrosis factor-a C-reactive protein

Introduction J. S. Lee H. G. Kim Exercise Physiology Lab, Department of Physical Education, Graduate School, Korea University, Seoul, Republic of Korea C. G. Kim Department of Sports Science, Gachon University, Seongnam, Republic of Korea T. B. Seo Division of Sports Science and Engineering, Department of Biochemistry, Korea Institute of Sport Science, Seoul, Republic of Korea S. J. Yoon (&) Department of Physical Education, College of Education, Korea University, 145, Anamro, Seongbuk-gu, Seoul 136-701, Republic of Korea e-mail: [email protected]

With advancing aging, adults experience decline in muscle endurance and strength [1], as well as attenuated cardiac function that leads to overall physical function degradation [2]. In women, due to the rapid changes in the sex hormone levels during menopause, the overall degradation of physical function is more remarkable than that in men [3]. For older women, early diagnosis and prevention are most important owing to the risk of cardiovascular disease (CVD) that may seriously affect their physical condition. Previous studies have reported that the pathogenesis of CVD results from increased levels of cholesterol and C-reactive protein (CRP) which is affected by inflammatory cytokines [4, 5]. Interleukin-6 (IL-6) and tumor necrosis factor-a (TNF-a) are the typical inflammatory cytokines

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Author's personal copy Aging Clin Exp Res

involved in CVD pathogenesis; CRP, in particular, is used as a predictive and diagnostic marker for CVDs [6]. Several studies have found a close relationship between lean mass and CRP levels demonstrating that age-related decreases in lean mass cause increased levels of CRP [7, 8]. Thus, an effort to increase and maintain lean mass is necessary for preventing CVD. Studies concerning the prevention of CVD suggest that aerobic exercises stabilize blood pressure and lipoprotein density while increasing cardiovascular function and decreasing the inflammatory responses that decrease the risk of CVD [9, 10]. However, aerobic exercise is limited in its ability to increase lean mass. Thus, some studies have suggested that performing both aerobic and resistance exercises is effective for increasing lean mass while also decreasing body fat mass [11, 12]. In addition, Mascitelli and Pezzetta [13] suggested that combined exercise performed at a moderate intensity, rather than at a high intensity, is effective for producing an anti-inflammatory effect. Moreover, combined exercise consisting of aerobic and resistance exercises can be more effective in elderly individuals experiencing an overall decline in physical fitness. Exercises involving elastic bands that use an individual’s own body weight (BW) are suggested for improving muscle strength [14, 15]. Several studies have demonstrated that resistance exercises involving elastic bands are effective for increasing lean mass and strength [16–18]. Thus, a combined exercise program that utilizes aerobic and resistance exercises with elastic bands may have a positive effect on body composition, isokinetic function, and CVD risk factors in elderly women.

Fig. 1 Consort diagram for the present study

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Consequently, the purpose of this study was to provide an effective intervention for the prevention and improvement of CVD risk factors by determining the effects of an 8-week combined training program on body composition, isokinetic function, and CVD risk factors in elderly women.

Methods Subjects Initially, 40 older women (65–75 years of age) were recruited using print media in the Incheon city, Korea. Subsequently, 27 healthy older women were accepted for the study after a medical screening. The exclusion criteria were any history of (1) cardiovascular disease, (2) metabolic disease, (3) neuromuscular disease, (4) musculoskeletal disease and (5) body mass index (BMI) above 30 kg/m2. Twenty-seven participants who met the inclusion criteria (not meeting inclusion criteria, n = 13) were randomized into combined training group (CT, n = 14; age, 68.38 ± 2.93 years; height, 153.78 ± 2.54 cm; body mass, 57.39 ± 3.69 kg; BMI, 24.23 ± 1.33) or aerobic training group (AT, n = 13; age, 67.64 ± 2.82 years; height, 152.35 ± 3.47 cm; body mass, 55.92 ± 3.70 kg; BMI, 24.09 ± 1.28). During the intervention period, participants were advised to maintain their normal dietary intake throughout the study. After 8 week intervention, excluding 8 participants due to low level of adherence, final outcome data of 19 participants were analyzed. The consort diagram is shown in Fig. 1. All participants were


fully informed about the experiment procedures and gave written informed consent before participation. The study was approved by the ‘Korea university Ethic Committee’. Exercise protocol Combined training for the CT group consisted of aerobic exercise and resistance exercise with elastic bands three and two times per week, respectively, for 8 weeks. Aerobic exercise was performed on a treadmill by walking at 40–70 % of heart rate reserve (HRR) for 40 min. Resistance exercise with elastic bands was performed for 15–20 repetitions using Thera-Bands (Hygenic Corp., Akron, OH, USA). The exercise intensity was set between 10 and 13 on Borg’s scale using red bands (0.9–1.6 kg) initially and gradually increasing to green or blue bands (green, 1.1–1.0 kg; blue, 1.4–2.8 kg). Two sets were performed at a 60–90 s interval. The training program comprised ankle exercises (ankle dorsiflexion, ankle plantar flexion, ankle eversion, ankle inversion), knee exercises (leg press, knee extension, knee flexion), hip exercises (hip extension, hip flexion, hip abduction, hip adduction), abdominal exercises (crunches), and dorsal exercises (hyperextensions) [15]. The aerobic training for the AT group used the same aerobic exercise protocol on a treadmill, 5 times/week for 8 weeks by walking at 40–70 % of HRR for 40 min. Before and after training, 10 min of stretching exercises and light walking was performed for joint and muscle relaxation. Measurements Body composition Participants visited to laboratory by 9 am to measure the physical fitness and submit a consent form. Being fasted 10 h prior to the measurement, body composition was measured by Inbody 720 (Biospace Co., Seoul, Korea). Inbody 720 is a multifrequency impedance body composition analyzer which has great accuracy with high correlation coefficient of 0.98 with DEXA, the standard equipment for body composition analysis. Height and weight were measured with standard equipment, with the participants in stocking feet and underwear. Isokinetic strength Knee joint strength was measured using the Cybex NORM isokinetic system (Lumex, Ronkonkoma, NY, USA). Participants placed their dominant knee on the leg flexion– extension plate of the Cybex device, according to the manufacturer’s instructions for isolating leg flexion and extension, and the knee was secured to the device with Velcro straps [19]. Standard stabilization strapping was

placed across the distal thigh and chest. Before the test session, the participants were instructed to familiarize themselves with the testing device by performing three repetitions of active leg movement ranging from maximal flexion to maximal extension. Maximal strength was then measured during five trials of flexion and extension at 60°/ s. Peak torque (Nm) and relative peak torque (%BW) were computed during the test. In addition, muscle endurance, which is the total work (J) performed during the measurement, was tested and computed after 26 repetitions of flexion and extension at 240°/s. The range of movement for the measurement was set to 0–100°, and participants were instructed to give 100 % effort and they received positive feedback during the testing. Blood samples Fasting (C8 h) blood samples were collected 7 days before and 3 days after the exercise program. Blood samples (10 mL) were obtained from the antecubital vein and placed in serum separator tubes and ethylenediaminetetraacetic acid-containing tubes, 5 mL each. The blood samples were centrifuged for 20 min at 3,600 rpm, and stored at -70 °C until analysis. CRP levels were determined using a turbidimetric method in an ADVIA 2400 (Siemens, Munich, Germany) with a CRP reagent (Siemens). IL-6 and TNF-a were analyzed in a Molecular Devices (Sunnyvale, CA, USA) microplate reader using an enzyme immunoassay with a Quantikine IL-6 reagent (Biosource, Nivelles, Belgium) or a TNF-a reagent (Biosource), respectively. Total cholesterol was analyzed using an enzymatic method in an ADVIA 2400 (Siemens) with a cholesterol reagent (Siemens). Statistical analysis To determine the changes after the 8-week training program, two-way repeated measures analysis of variance was used to determine the main effects. If there was a significant interaction effect, an independent t test between groups or a paired t test between times was employed. Statistical significance was defined at p \ 0.05 for all tests. All values are expressed as mean ± standard deviation (SD). Data were analyzed using SPSS version 20.0 for Windows (SPSS, Chicago, IL, USA).

Results Body composition Changes in the body composition of the participants in the CT and AT groups, comparing between-group changes and

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changes occurring over time, are shown in Table 1. Body mass, body fat mass, percent body fat, and BMI showed no relative effects between the groups or over time (respectively, F = 2.994, p = 0.102; F = 0.297, p = 0.593; F = 0.439, p = 0.517; F = 17.000, p = 0.088). Lean mass appeared to have a relative effect (F = 6.995, p = 0.017), increasing significantly more in the CT group than in the AT group (p \ 0.05). Isokinetic peak torque and total work Changes in peak torque, between groups (AT vs CT) and over time are shown in Table 2. The absolute peak torque (Nm) during left knee extension at 60°/s showed a relative effect between groups and over time (F = 12.342, p = 0.003), increasing significantly in the CT group after training, but not in the AT group (p \ 0.05). The relative effect, between groups and over time, appeared in the absolute peak torque (Nm) of the right knee extension at 60°/s (F = 6.054, p = 0.025), increasing significantly more in the CT group than in the AT group (p \ 0.05).

The absolute peak torque (Nm) during left knee flexion at 60°/s showed a relative effect between the groups and over time (F = 17.000, p = 0.030), increasing significantly in the CT group after training, but not in the AT group (p \ 0.05). The absolute peak torque (Nm) during right knee flexion at 60°/s did not appear to have a relative effect between groups or over time (F = 2.662, p = 0.121), showing no difference in either group. The relative peak torque (%BW) during left knee extension at 60°/s showed a relative effect between the groups and over time (F = 17.000, p = 0.030), increasing significantly in the CT group after training, but not in the AT group (p \ 0.05). The relative peak torque (%BW) during right knee extension at 60°/s appeared not to have a relative effect between groups or over time (F = 4.144, p = 0.058), increasing significantly after training in both groups (p \ 0.05). The relative peak torque (%BW) during left knee flexion in 60°/s did not have a relative effect between groups or over time (F = 3.540, p = 0.077), increasing significantly after training in both groups (p \ 0.05). The relative peak

Table 1 Changes in body composition following an 8-week training program Variable

CT (n = 9) Pre

AT (n = 10) Post

Pre

Post

Body mass (kg)

57.71 ± 4.06

57.47 ± 3.90*

56.16 ± 3.96

54.72 ± 4.48*

BMI (kg/m2)

24.37 ± 1.24

24.27 ± 1.17*

24.00 ± 0.93

23.38 ± 1.08*

Fat mass (kg)

16.30 ± 1.62

15.09 ± 2.01*

15.90 ± 1.78

14.91 ± 2.11*

Lean mass (kg) Body fat (%)

41.41 ± 3.13 27.79 ± 1.84

42.38 ± 2.78*, 26.19 ± 2.55*

40.26 ± 2.25 28.24 ± 1.23

39.81 ± 2.50 27.15 ± 1.93*

WHR

0.932 ± 0.012

0.931 ± 0.009

0.929 ± 0.019

0.925 ± 0.015

Data are shown as mean ± SD CT combined training, AT aerobic training, BMI body mass index, WHR waist-to-hip ratio * Significant (p \ 0.05) difference between pre- and post-exercise

Significant (p \ 0.05) difference between groups

Table 2 Changes in isokinetic peak torque (60°/s) following an 8-week training program

Variable

CT (n = 9) Pre

AT (n = 10) Post

Pre

Post

Isokinetic peak torque (Nm)

Data are shown as mean ± SD CT combined training, AT aerobic training, BW body weight * Significant (p \ 0.05) difference between pre- and post-exercise Significant (p \ 0.05) difference between groups

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Left knee extension Left knee flexion

53.6 ± 7.7 31.8 ± 12.6

59.8 ± 6.7*, 36.6 ± 9.2*,

Right knee extension

53.9 ± 8.1

61.0 ± 6.5*,

Right knee flexion

32.5 ± 10.9

35.4 ± 6.5

53.6 ± 8.3 31.2 ± 10.1

54.2 ± 5.2 31.7 ± 8.2

54.7 ± 7.2

55.1 ± 6.2

31.8 ± 9.2

31.1 ± 7.1

96.1 ± 18.3

99.7 ± 13.5

Isokinetic peak torque (%BW) Left knee extension

93.4 ± 15.8

104.5 ± 13.6*,

Left knee flexion

55.6 ± 23.4

64.2 ± 18.2*

56.2 ± 19.4

58.6 ± 17.2*

Right knee extension

93.9 ± 16.4

106.7 ± 14.8*

98.3 ± 17.4

101.1 ± 13.6*

Right knee flexion

56.8 ± 20.4

62.0 ± 12.8

57.0 ± 17.7

57.4 ± 15.1

Author's personal copy Aging Clin Exp Res Table 3 Changes in isokinetic total work (240°/s) following an 8-week training program Variable

CT (n = 9)

AT (n = 10)

Pre

Post

Pre

Post

1,304.8 ± 172.1

Isokinetic total work (J) Left knee extension Left knee flexion Right knee extension Right knee flexion

1,495.4 ± 127.4*

1,367.1 ± 171.9

1,475.7 ± 150.6*

888.7 ± 109.5

898.7 ± 65.8*

895.3 ± 81.6

886.7 ± 74.5*

1,338.2 ± 162.4

1,576.3 ± 107.4

888.4 ± 66.3

891.2 ± 104.5

1,334.7 ± 164.5

1,473.9 ± 115.4

894.7 ± 85.3

894.3 ± 82.5

Data are shown as mean ± SD CT combined training, AT aerobic training * Significant (p \ 0.05) difference between pre- and post-exercise

Fig. 2 Changes in cardiovascular diseases risk factors following an 8-week training program. Data are shown as mean ± SD. CT combined training, AT aerobic training. *Significant (p \ 0.05) difference between pre- and post-exercise. Significant (p \ 0.05) difference between groups

torque (%BW) during right knee flexion at 60°/s also did not have a relative effect between groups or over time (F = 4.144, p = 0.058); however, no differences were discovered in either group. Changes in the total work performed by the women in the CT and AT groups between the groups and over time are shown in Table 3. The total work (J) performed by either knee during the extension at 240°/s showed no relative effect between the groups and over time (left: F = 0.621, p = 0.441; right: F = 1.488, p = 0.239), but it did increase significantly, after training, in both groups (p \ 0.05). CVD risk factors Between-group and time-related changes in the CVD risk factors for the CT and AT groups are shown in Fig. 2. CRP levels showed a relative effect between the groups and over

time (F = 4.519, p = 0.048), decreasing significantly after training in both groups. However, the CT group showed a larger decrease than the AT group (p \ 0.05). IL-6, TNF-a, and total cholesterol levels did not show a relative effect between the groups and over time (respectively, F = 0.736, p = 0.403; F = 0.015, p = 0.905; F = 0.887, p = 0.359), but did decrease significantly after training in both groups (p \ 0.05).

Discussion The purpose of this study was to determine the effect of an 8-week combined training program on body composition, isokinetic function, and CVD risk factors. As a result of combined training, the participants demonstrated a positive effect on body mass, body fat mass, percent body fat, and BMI. In addition, lean mass increased to a significantly

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greater extent as a result of combined training than after aerobic training only. Previous studies have reported that elderly men undergoing 12 weeks of combined training demonstrated a significant decrease in percent body fat [20]. Another study suggested that combined training was effective for increasing lean mass while decreasing percent body fat [21]. Moreover, Lee and Kim [22] demonstrated that the effects of combined training using aerobic and elastic band resistance exercises significantly increased lean mass, while also significantly decreasing overall body mass, body fat mass, and percent body fat. In addition, several studies have reported significant increase in lean mass and decrease in percent body fat after resistance exercise using elastic band [18, 23]. Aerobic exercise reduces body fat mass by oxidizing body fat directly into kinetic energy, and anaerobic exercise is well known to decrease body fat mass by increasing the basal metabolic rate. Therefore, the changes in body composition observed in this study may be the result of combined training, especially due to the resistance exercise inducing muscle protein synthesis in the CT group. In this study, the absolute peak torque in the CT group increased significantly more than it did in the AT group, whereas the relative peak torque and total work increased significantly in both groups after training (p \ 0.05). The CT group showed a significant increase in the 60°/s flexion after 8 weeks of combined training, supporting the results of previous studies on improvements to knee joint muscle through regular exercise [24, 25]. Furthermore, Degache et al. [25] reported similar results in patients with chronic heart failure, showing that their CT group had significantly larger increases in isokinetic strength than did the AT group. Older adults experience gradual age-related decreases in strength and muscle endurance, which rapidly decrease after the age of 60 years [26]. A previous study reported that, among the elderly, the loss of strength in the lower body is faster than in the upper body [27]. As lower body strength decreases, walking speed and stair climbing ability decrease and the frequency of falls increases [28]. Changes in these physical abilities negatively affect daily life activities such as walking and lifting [29, 30]. Thus, improving lower body strength and muscle endurance is important for the prevention of falls and reducing inconvenient disturbances to daily life activities among elderly women. According to the present results, improvements in the absolute peak torque in the CT group were followed by increases in muscle fiber size. In other words, there was an increase in the number of motor units, frequency of impulses, and muscle cross-sectional areas [31, 32]. In addition, the results suggest that the combined exercise program in this study had a positive effect on improving lower body strength. The oxidation ability related to total work can be improved through mitochondrial energy

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production and enhanced efficiency [33]. Both training programs applied in this study positively affected total work, presumably by enhancing the mitochondrial capacity. The levels of CRP decreased to a significantly greater extent in the CT group than in the AT group (p \ 0.05). A previous study reported a negative correlation between physically active individuals and levels of inflammatory markers [34], which was also demonstrated among older adults [35]. CRP was identified as the major cause of cardiovascular and cerebrovascular diseases, as well as of cardiac infarctions [36]. Moreover, CRP and IL-6 levels have been found to be closely correlated with mortality in a study tracking 362 older adults over a 4-year period [37]. King et al. [38] suggested that various kinds of exercise (jogging, swimming, cycling, etc.) can decrease CRP levels. Monzillo et al. [39] reported decreases in CRP levels after aerobic exercise. However, De Salles et al. [40] reported that CRP levels decreased as a result of resistance exercise, but not aerobic exercise. In our study, lean mass and isokinetic strength increased significantly more in the CT group than in the AT group after 8 weeks of training. This result indicates that decreases in CRP levels can be attributed to the increased lean mass and strength in the CT group. However, without having examined anabolic hormone levels in this study, we cannot conclude that there is a direct relationship between increased muscle mass and decreased CRP levels. Further studies investigating the specific relationship between lean mass and CRP levels are recommended to include an examination of anabolic hormones. Goto et al. [41] suggested that combined exercise may be effective for decreasing body fat mass while increasing lean mass and that combined training was an effective treatment for ameliorating the risk of CVD. In this study, IL-6 and TNF-a, cytokines closely related to increased CRP levels, decreased significantly in both groups after training; cholesterol levels also declined. IL-6 is a cytokine that is hormonally regulated, and is present at high levels in people with low physical activity levels [42] and in those who are obese [43]. In addition, IL-6 and TNF-a hypersecretion play a key role in decreasing myocardial contractile force and restraining insulin sensitivity [44, 45]. Mascitelli and Pezzetta [13] found that moderateintensity combined training is more effective for producing anti-inflammatory effects than is high-intensity combined training. A study examining combined training twice per week for 12 months reported a significant decrease in the levels of CRP, IL-6, and TNF-a [45]. Previous studies also reported significant decreases in cholesterol levels after 10–12 weeks of aerobic and combined training [46, 47]. Thus, regardless of the type of exercise, a regular exercise program produces a significant decrease in IL-6, TNF-a, and total cholesterol levels. Moreover, the CT group


showed greater decreases than did the AT group, as a result of an increase in lean mass. In conclusion, this study identified that increasing lean mass and strength would play a crucial role in decreasing CVD risk factor. Furthermore, rather than aerobic exercise alone, combining aerobic and resistance exercise was shown to be effective in decreasing CVD risk factors. Particularly, resistance exercise performed in this study applied elastic band exercise which can provide advantages such as convenience, portability, and cost savings to older women. However, there is couple of limitations in this study due to low number of participants in the final analysis and a bit short training period to clearly determine the effect of combined training. Further study should secure larger number of samples to improve reliability and apply longer period of exercise program in order to clearly determine the effect of combined training on CVD risk factors in older women. Conflict of interest On behalf of all authors, the corresponding author states that there is no conflict of interest.

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