Clinically Relevant

Accumulation of Physical Activity Reduces

Blood Pressure in Pre- and Hypertension
JAUME PADILLA, JANET P. WALLACE, and SAEJONG PARK
Clinical Exercise Physiology Laboratory, Department of Kinesiology, Indiana University, Bloomington, IN

ABSTRACT
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PADILLA, J., J. P. WALLACE, and S. PARK. Accumulation of Physical Activity Reduces Blood Pressure in Pre- and Hypertension.
Med. Sci. Sports Exerc., Vol. 37, No. 8, pp. 1264 –1275, 2005. Purpose: The effectiveness of lifestyle physical activity to reduce BP
in prehypertension/hypertension is unclear. The purpose of this study was: 1) to investigate the magnitude and duration of ambulatory
BP (AmBP) reduction after the accumulation of one day of lifestyle physical activity (PAaccum) in normotension, prehypertension, and
hypertension; and 2) to determine the relationship between energy expenditure (EE) and BP reduction. Methods: Subjects were eight
normotensive (112.3/73.1 ⫾ 1.6/1.9 mm Hg), 10 prehypertensive (124.3/79.3 ⫾ 1.2/1.6 mm Hg), and 10 hypertensive (139.7/83.3 ⫾
3.7/3.7 mm Hg) adults. EE was analyzed during the PA and corresponding control (C) treatment; AmBP was analyzed for 12 h after
the PAaccum and corresponding C. EE of the PA (EEPA) was calculated as the total EE for the duration of the PA. Steps to analyze and
compare the BP reduction after PAaccum were: 1) determination of the duration of the BP reduction (95% CI), 2) determination of the
magnitude of the BP reduction (paired t-tests of C vs PA), 3) determination of the area of the BP reduction, and 4) comparison of the
areas (independent t-test) between prehypertension and hypertension. Correlation between EE(PA-C) and BP reduction was examined
Results: No BP differences were found for normotension or for DBP in any group. Significant difference in SBP after the PAaccum were
found for prehypertensives (magnitude; area ⫽ 6.6 ⫾ 2.3 mm Hg; 21.7 ⫾ 15.2 mm Hg·h⫺1) for 6 h and for hypertensives (12.9 ⫾
4.3 mm Hg; 123.4 ⫹ 42.8 mm Hg·h⫺1) for 8 h; area was significantly different between groups. No correlation was found between
EE(PA-C) and BP reduction. Conclusion: The PAaccum reduces SBP in hypertension and prehypertension but does not appear to be
related to the EE(PA-C). PAaccum can be utilized as an approach to treat prehypertension and hypertension. Key Words: POSTEXER-
CISE HYPOTENSION, ACCELEROMETER, DOSE RESPONSE, LIFESTYLE PHYSICAL ACTIVITY

S
cientific evidence supports the chronic effects of which includes all leisure, occupational, or household ac-
20 – 60 min of dynamic cardiorespiratory exercise, tivities that are at least moderate to vigorous in their inten-
3–5 d 䡠 wk⫺1 at 40 –70% intensity in the treatment of sity (5). The role of physical activity in all cause morbidity
hypertension (16,25). More recently, however, the accumu- and mortality has been well established through epidemio-
lation of moderate physical activity on most, if not all, days logical methods (10,12).
of the week has been recommended as the exercise treat- There are a total of 74 groups comprising 1284 patients in
ment for hypertension (2,16) as well as for the prevention of clinical trials investigating the role of traditional exercise in
prehypertension progressing to hypertension (2). The scien- blood pressure reduction (9). The only clinical trial inves-
tific evidence existing to support this position stand is lim- tigating physical activity as treatment for hypertension was
ited, specifically on the use of physical activity and its that of Moreau and colleagues (13), who reported a reduc-
accumulation for the treatment of hypertension. tion in blood pressure in stage 1 hypertensive subjects after
Physical activity is defined as any bodily movement re- a 24-wk walking program (some accumulated) designed to
sulting from the contraction of the skeletal muscles (25). increase walking 3 km 䡠 wk⫺1. The efficacy of traditional
Lifestyle physical activity has been defined as the daily exercise on subjects with normal to high blood pressure has
accumulation of at least 30 min of self-selected activities, been well established by seven groups of investigators who
utilized 578 subjects (7). In terms of physical activity, two
studies exist observing subjects with normal to high normal
Address for correspondence: Jaume Padilla, Clinical Exercise Physiology
Lab, HPER 070, Indiana University, Bloomington IN 47405; E-mail:
blood pressures. Although not statistically significant, Mur-
[email protected]. phy and Hardman (14) found the reduction in systolic blood
Submitted for publication September 2004. pressure to be greater for women who walked three short
Accepted for publication March 2005. 10-min bouts (⫺7.4 ⫾ 7.3 mm Hg) than for those who
0195-9131/05/3708-1264/0 walked one long 30-min bout (⫺4.6 ⫾ 5.9 mm Hg) at
MEDICINE & SCIENCE IN SPORTS & EXERCISE® 70 – 80% for 10 wk. Dunn and colleagues (6) reported a
Copyright © 2005 by the American College of Sports Medicine similar reduction in systolic and diastolic blood pressures
DOI: 10.1249/01.mss.0000175079.23850.95 for adults who engaged in lifestyle physical activity (⫺3.63/
1264
 FIGURE 1— Energy expen-
diture (bottom panel) and
systolic blood pressure (top
panel) for the period of
physical activity (left pan-
els) and for the time after
the accumulation of physi-
cal activity (right panels)
for a representative prehy-
pertensive subject. The ver-
tical dotted line represents
the end of physical activity
for this subject. The energy
expenditure data used in
this study was taken from
the physical activity period
(lower left panel) whereas
the blood pressure data was
taken from the time after
the physical activity (upper
right panel).

5.38 mm Hg) versus structured exercise (⫺3.26/5.14 mm related to the energy expenditure of the physical activity
Hg) for 24 months. The energy expenditure goal for the accumulated.
physical activity (accumulation of 30 min of any type of
activity) was an increase in energy expenditure of 2
METHODS
kcal·kg⫺1·d⫺1, whereas for the structured exercise group
(50 – 85% of V̇O2 peak at 20 – 60 min) it was an increase of A repeated measures experimental design with two treat-
3 kcal·kg⫺1·d⫺1. No studies exist investigating the role of ments, 2–7 d apart, was given to three different groups of
physical activity in the treatment of prehypertensive adults subjects: normotensive, prehypertensive, and hypertensive
because the classification of prehypertension is new (2). adults. One treatment consisted of the accumulation of phys-
It is difficult to attribute any single component of exercise ical activity over an 8- to 12-h period, and the other was a
or physical activity to a resultant blood pressure reduction. control period of the same time on a separate day. Beginning
However, energy expenditure is the most common denom- at 0700 h, physical activity was measured using a three-
inator in describing both exercise and physical activity and dimensional accelerometer, and blood pressure was mea-
may be the single variable most related to a blood pressure sured by ambulatory monitoring for the next 24 h. Figure 1
reduction. In a meta-analysis of 57 exercise training studies, illustrates the energy expenditure and systolic blood pres-
Fagard (7) found no correlation between the energy expen- sure data collected on a representative prehypertensive sub-
diture and the reduction in systolic (r ⫽ 0.14) or diastolic (r ject. The physical activity period was considered to be the
⫽ ⫺0.02) blood pressure. No study exists relating the en- first 8 –12 h when the subject was performing or accumu-
ergy expenditure of physical activity and blood pressure lating the physical activity (left panels of Fig. 1), whereas
reduction. the second period was the time after physical activity (right
The role of the accumulation of physical activity, specif- panels of Fig. 1). The physical activity data used in this
ically lifestyle physical activity, in the treatment of prehy- study were from 0700 h to the end of the accumulation of
pertension and hypertension has not been well established. physical activity (lower left panel of Fig. 1). Although
Thus, the purpose of this study was: 1) to investigate the ambulatory blood pressures were recorded for 24 h during
magnitude and duration of ambulatory blood pressure re- both treatment days, only the period of time after the end of
duction after 1 d of lifestyle physical activity in normoten- the accumulation of physical activity (determined individ-
sive, prehypertensive, and hypertensive adults; and 2) to ually for each subject) was analyzed as the acute response to
determine the relationship between the energy expenditure the physical activity (upper right panel of Fig. 1). Activities
and the blood pressure reduction. It was hypothesized that: performed throughout the day were recorded in an activity
1) 1 d of lifestyle physical activity will reduce ambulatory diary. All procedures were previously approved by the In-
blood pressure in prehypertensive and hypertensive adults, diana University committee for the protection of human
and 2) the reduction in blood pressure will be directly subjects.
PHYSICAL ACTIVITY AND BP REDUCTION Medicine & Science in Sports & Exercise姞 1265
TABLE 1. Demographic information of subjects (mean ⫾ SEM).
Variable Normotensive Prehypertensive Hypertensive
N 8 10 10
Sex (men/women) 4/4 4/6 8/2
Age (yr) 42.2 ⫾ 4.5* 51.0 ⫾ 4.3 63.5 ⫾ 2.8
Height (cm) 174.1 ⫾ 3.7 166.7 ⫾ 3.1 171.2 ⫾ 3.0
Weight (kg) 75.6 ⫾ 2.8 77.0 ⫾ 5.1 95.8 ⫾ 8.2
BMI (kg䡠m⫺2) 25.1 ⫾ 1.0* 27.5 ⫾ 1.4 32.3 ⫾ 2.1
SBP a (mm Hg) 112.3 ⫾ 1.6*# 124.3 ⫾ 1.2¥ 139.7 ⫾ 3.8
DBP a (mm Hg) 73.1 ⫾ 1.9* 79.3 ⫾ 3.1 83.3 ⫾ 3.7
Antihypertensive medication b
None None ␤-blocker (3)
Diuretic (5)
Angiotensin II receptor
Antagonists (3)
ACE inhibitors (1)
Calcium channel blocker (2)
a
Average of six screening blood pressures.
b
Number of subjects taking the medication.
* Indicates significant difference (P ⬍ 0.05) in normotensive vs hypertensive.
# Indicates significant difference (P ⬍ 0.05) in normotensive vs prehypertensive.
¥ Indicates significant difference (P ⬍ 0.05) in prehypertensive vs hypertensive.

Subjects. Subjects were eight normotensive (N) adults, screening pressures. Ambulatory blood pressure screening
10 prehypertensive (P) adults, and 10 hypertensive (H) was not utilized in this study because there are no published
adults. All were experienced in exercise and/or physical standards for prehypertension.
activity. Demographics of these subjects are presented in Treatment conditions. Even though the order of the
Table 1. Prehypertensive subjects were defined by one of physical activity and the control treatments was established
the following (2): 1) having a mean systolic blood pressure according to subject’s convenience, the order was equally
ⱖ120 mm Hg and ⬍140 mm Hg, or 2) having a mean distributed among the three groups. Both the physical ac-
diastolic blood pressure ⱖ80 mm Hg and ⬍90 mm Hg tivity and control treatments began at the same time of day
measured by auscultation. Hypertensive subjects were de- (0700 h), and the time span between the two treatments
fined by one of the following (2): 1) having had a previous ranged from 2 to 7 d. The subject was scheduled to come to
diagnosis of hypertension by a primary physician, or 2) the laboratory 30 min before the 24-h data collection starting
having a mean systolic blood pressure ⬎140 mm Hg and/or time to place the ambulatory blood pressure monitor and
a mean diastolic blood pressure ⬎90 mm Hg measured by motion sensor and to instruct the subject about the treat-
auscultation. Exclusion criteria included: 1) known coro- ment, instruments, and how to fill out the activity diary.
nary artery disease, 2) orthopedic limitations for performing Control treatment. Subjects participated in their usual
physical activity, and 3) obesity to the extent that the am- activities of daily living. Subjects were asked to record
bulatory monitor could not fit the subject properly. Hyper- mode and duration of activities in the activity diary and were
tensive subjects continued to take antihypertensive medica- instructed to abstain from physical activity, exercise, and
tions for this study. Before the study, an approved informed sports.
consent was explained and signed by the subjects. Physical activity treatment. Subjects were instructed
Procedures. The procedures of the study consisted of to add physical activity to their daily routine. A variety of
1) completing the Par-Q health questionnaire, 2) recording home and gardening activities such as splitting logs, mow-
medications, 3) measuring height (cm) and weight (kg), 4) ing the lawn (walking), digging/spading, tilling, raking,
screening blood pressure, and 5) completing the physical laying sod, and brisk walking have been identified as meet-
activity and control treatments, with the measurement of ing the physical activity requirement (1). The subjects were
ambulatory blood pressure and energy expenditure. Subjects instructed to record each activity in the activity diary. The
reported to the Clinical Exercise Physiology Laboratory in target volume of physical activity was an accumulation of
the Human Performance Laboratories in the Department of 150 kcal·d⫺1 (23). The types of physical activities were
Kinesiology, School of HPER, Indiana University, Bloom- discussed and agreed to before the beginning of the physical
ington, IN. activity treatment.
Blood pressure screening. For all subjects, three Energy expenditure of physical activity. Two in-
blood pressure measurements were taken on two separate struments, one objective and one subjective, were used to
days, 3 d apart (a total of six measurements) with a mercury quantify the physical activity and energy expenditure. An
sphygmomanometer, according to the protocol described by RT3 accelerometer (Stayhealthy Inc., Monrovia, CA) was
the World Health Organization (29). On the first day, blood used to measure 24-h activity in all subjects. RT3, the latest
pressures were taken in both arms. The arm with the highest version of Tritrarc, is a battery powered three-dimensional
blood pressure was used for the screening on the second (triaxial) accelerometer (18,20). RT3, firmly attached to a
day. The three pressures from the arm with the highest belt on the hip at the anterior axillary line of the dominant
measurement on the first day were combined with the three leg, records data in three axes, and contains three separate
measurements on the second day, for the average of six accelerometers, positioned internally at 90º to one another.
1266 Official Journal of the American College of Sports Medicine http://www.acsm-msse.org
It measures motion as acceleration of the body. Thus, in- any energy expenditure above EEC. EEB (kcal) was calcu-
tensity of movement is reflected in the instrument’s output. lated as the total energy expenditure for that bout. The last
Output from each accelerometer is reported along with a hour of physical activity when the energy expenditure was
composite three-dimensional signal called the vector mag- greater than the EEC was considered the end of the accu-
nitude. The software also provides an estimation of activity mulation of physical activity. The EEPA was the sum of each
and total energy expenditure based on the subject’s age, EEB for the duration of the accumulation of the physical
height, weight, and gender. RT3 was programmed (using activity. PAmin was the sum of the duration of each bout of
mode 3) to sample data every second and average this data physical activity. The PAint (kcal·min⫺1) was calculated as
over 1-min periods for 24 h. Therefore, kilocalorie-per- EEPA/PAmin. When the EEPA was 150 kcal above EEC
minute values were obtained every minute. (EEPA-C), the criteria for physical activity was met for the
The activity diary was used to report mode and duration subject. The mode and frequency of physical activity bouts
(minutes) of activities performed during 24 h. Different were measured from the activity diary.
activity diaries were used for the physical activity and Ambulatory blood pressure data. For each test,
control treatments. For both days, we asked 1) time of sleep ambulatory blood pressure data were downloaded to the
and 2) predominant activities of daily living performed. For computer using AccuWin Pro v2.3 software. Data were
the physical activity treatment, we also asked 1) type of manually reviewed for missing and erroneous readings.
physical activity and 2) starting and ending time of each Readings were purged if 1) data were missing; 2) systolic
bout of physical activity performed. blood pressure was lower than diastolic blood pressure; 3)
Ambulatory blood pressure measurement. Accu- systolic blood pressure was ⬎240 mm Hg or ⬍50 mm Hg;
traker II (Suntech Medical Instruments, Inc., Raleigh, NC) 4) diastolic blood pressure was ⬎140 mm Hg or ⬍40 mm
was used to measure the 24-h ambulatory blood pressure in Hg; 5) heart rate was ⬎150 beats·min⫺1 or ⬍40
all subjects. The nondominant arm was used for all subjects.
beats·min⫺1; 6) systolic blood pressure and diastolic blood
The Accutraker II was programmed to take a measurement
pressure deviated ⫾50 and ⫾20 mm Hg, respectively, from
every 15 ⫾ 5 min for daytime hours (0600 to 2200 h) and
the surrounding values; and 7) heart rate deviated ⫾30
every 30 ⫾ 5 min for nighttime hours (2200 to 0600 h). One
beats·min⫺1 from the surrounding values as previously de-
repeat measurement was taken if the first measurement was
scribed (24). For each subject, systolic blood pressure and
unsuccessful during the daytime hours and two repeat mea-
diastolic blood pressure was averaged every hour.
surements were taken during the nighttime hours if the first
Four steps were utilized to analyze and compare the blood
measurement was unsuccessful. The inflation of the cuff for
pressure reduction after physical activity: 1) determination
each measurement was 30 mm Hg greater than the previous
reading. The cuff deflation rate was set at 3 mm Hg·s⫺1. of the duration of the blood pressure reduction, 2) determi-
Subjects were instructed 1) to abstain from exercise, 2) not nation of the magnitude of the blood pressure reduction, 3)
to take a shower, 3) to relax and straighten out the arm determination of the area of the blood pressure reduction,
during the blood pressure measurement, 4) to remove the and 4) comparison of the areas among the groups. These
accelerometer during sleeping period, 5) to replace the ac- four steps were completed on blood pressure variables dem-
celerometer to the correct location upon waking, and 6) to onstrating differences from the control treatment.
remove devices and turn off the ambulatory blood pressure The duration of the blood pressure reduction was deter-
monitor after the 24-h period. mined by calculating the accumulation of the blood pressure
Data processing. The energy expenditure from reduction over time with the following formula:
0700 h to the end of the physical activity was used to Accumulation of SBP reduction
represent the energy expenditure for both the control and
physical activity treatments. The determination of the end of ⫽ ⌺i⫽1
n
兵共SBPCONTROL ⫺ SBPPA兲i 其 , i ⫽ time h
physical activity is explained in the next section. The blood This accumulated reduction was then plotted for each
pressure data of interest for this investigation were the 12 h hour (Fig. 2) with the 95% confidence limits for the initial
after the end of physical activity. slope. The duration of the blood pressure reduction was
Physical activity and energy expenditure data. considered to be the time period in which the blood pressure
For each test, accelerometer data were downloaded to the reduction remained within the 95% confidence limits of the
computer using Stayhealthy software and transferred and regression of the initial slope of this relationship. It is
saved to a Microsoft Excel 0.5/95 spreadsheet. The energy possible for each group to have a different duration of
expenditure of the control treatment (EEc), the energy ex- reduction using this technique.
penditure of each bout of physical activity (EEB), the total The magnitude of the blood pressure reduction was based on
energy expenditure for the accumulation of the physical the corresponding duration of the blood pressure reduction
activity (EEPA), the total duration of the accumulation of found in the previous step. The blood pressures were averaged
physical activity (PAmin), and the intensity (kcal·min⫺1) of over the time period determined as the appropriate duration for
the physical activity (PAint) were calculated. EEc both the control and physical activity treatments for each
(kcal·min⫺1) was defined as the energy expenditure (base- group. The difference in these average blood pressures be-
line) during the waking hours (average ⫹ 1 SD) of the tween the control and physical activity treatments was consid-
control treatment. A bout of physical activity was defined as ered the magnitude of the blood pressure reduction.
PHYSICAL ACTIVITY AND BP REDUCTION Medicine & Science in Sports & Exercise姞 1267
 differences were found. Paired t-tests (control vs physical
activity treatments) were used to test the significance of the
magnitude of the blood pressure reduction for each group.
An independent t-test was performed to compare the blood
pressure area of reduction between the groups that demon-
strated a significant magnitude of blood pressure reduction
(i.e., the prehypertensive and hypertensive groups). Pearson
correlations were used to investigate the relationship be-
tween independent variables (i.e., BMI, age, etc.) and de-
pendent variables (the magnitude and area of blood pressure
reduction). Dependent variables were reexamined with co-
variates when significant correlations were found. Pearson
correlation was used to investigate the relationship between
the energy expenditure of the accumulation of physical
activity (kcal) and the reduction in systolic and/or diastolic
blood pressures (mm Hg) for each group. For all statistical
tests, the alpha level was set at 0.05. Statistical analyses
were performed with SPSS v.11.0f.

RESULTS
Subjects. The demographics of the subjects for each
group are summarized in Table 1. Significant differences
were found in: 1) age, BMI, and screening diastolic blood
pressures between normotensive and hypertensive groups;
and 2) for screening systolic blood pressures among all three
of the groups. Data were further examined with BMI and
age as covariates because significant differences were found
in BMI and age among the groups. Screening systolic blood
pressures remained significantly different among the three
groups accounting for differences in BMI and age (F ⫽
25.907; P ⫽ 0.0001). Only one subject was sedentary.
Time of day for starting the 24-h data collection was at
0740 ⫾ 0015 h for the normotensive group, 0749 ⫾ 0014 h
FIGURE 2—Regression (95% confidence limits) for the slope of the
initial blood pressure reduction for normotensive (top panel), prehy- for the prehypertensive group, and 0710 ⫾ 0009 h for the
pertensive (middle panel), and hypertensive (bottom panel) groups. hypertensive group. The difference between the times of day
See text for an explanation of the calculation used to determine the for the two treatments was 0018 ⫾ 0008 min for the nor-
plot. The duration of blood pressure reduction was determined to be
that period of time where the hourly blood pressure reduction re- motensive group, 0011 ⫾ 0009 min for the prehypertensive
mained within the 95% confidence limits. This was 6 h for prehyper- group, and 0012 ⫾ 0004 min for the hypertensive group.
tension and 8 h for hypertension as illustrated by the dotted lines. The length of time between the two treatments was 6.0 ⫾
0.6 d for the normotensive group, 4.1 ⫾ 0.6 d for the
The area under the blood pressure curve was defined as prehypertensive group, and 3.9 ⫾ 0.7 d for the hypertensive
the area between the control and physical activity blood group. Four of eight subjects (50%) in the normotensive
pressure curves for the duration of the blood pressure re- group, 6 of 10 (60%) in the prehypertensive group, and 6 of
duction. The area between the blood pressure curve and the 10 (60%) in the hypertensive group started with the control
time axis (x axis) was calculated by summing the area of treatment, whereas the remainder started with the physical
successive trapezoids, corresponding to each blood pressure activity treatment. Two of the 10 prehypertensive subjects
reading. The total area under the control curve was sub- (20%) did not meet the energy expenditure criteria of 150
tracted from the total area below the physical activity curve kcal of physical activity (noncompliers). The rate of blood
to obtain the area between the two curves. The areas be- pressure acquisition (measurements per hour) was similar
tween the control and physical activity blood pressure between the control (N ⫽ 3.3 ⫾ 0.1; P ⫽ 3.1 ⫾ 0.2; H ⫽
curves were used to compare the efficacy of the treatment 3.6 ⫾ 0.2) and physical activity (N ⫽ 3.4 ⫾ 0.1; P ⫽ 3.2 ⫾
among the groups. 0.1; H ⫽ 3.3 ⫾ 0.1) treatments.
Statistical analysis. Data are expressed as mean ⫾ Physical activity. The energy expenditure for both the
standard error of the mean (SEM). Descriptive statistics physical activity period and the time after the physical
were used for the demographics of the subjects, and an activity period is illustrated in the lower panels of Figures
analysis of variance (ANOVA) was used to compare the 3–5 for the physical activity and control treatments for all
three groups. Tukey post hoc test was used when significant three groups. The collection of energy expenditure data for
1268 Official Journal of the American College of Sports Medicine http://www.acsm-msse.org
 FIGURE 3—Energy expendi-
ture (mean ⴞ SEM) and sys-
tolic blood pressure (mean ⴞ
SEM) for the period of physical
activity (left panels) and for the
time after the accumulation of
physical activity (right panels)
for normotensive adults. Each
time period is standardized to
begin at time zero.

the time period after the physical activity period was dis- between the two treatments (control ⫽ 105.0 ⫾ 2.2 mm Hg vs
continued when the subject went to sleep and does not physical activity ⫽ 105.5 ⫾ 3.1 mm Hg). The duration of the
extend to the same time period the blood pressure was blood pressure reduction was found to be 6 h for prehyperten-
measured. Table 2 summarizes the total energy expenditure, sion and 8 h for hypertension.
total accumulated duration, and intensity of physical activity The magnitude of the blood pressure reduction was 6.6 ⫾
treatment for each group. The noncompliers were excluded 2.3 mm Hg for the 6 h for the prehypertensive group and
from this analysis of the energy expenditure data. Although 12.9 ⫾ 4.3 mm Hg for the 8 h for the hypertensive group.
the energy expenditure of the physical activity treatment The magnitude of these blood pressure reductions were
was not significantly higher than the control treatment (F ⫽ significant in both the prehypertensive (t ⫽ 2.864; P ⫽
0.839; P ⫽ 0.444), the criterion 150-kcal difference was met 0.024) and hypertensive (t ⫽ 2.819; P ⫽ 0.023) groups, as
and was not significantly different among the three groups detected by paired t-tests of control versus physical activity,
(one-way ANOVA with repeated measures; F ⫽ 2.475; P ⫽ respectively.
0.105). In addition, no significant differences were found The area between the control and physical activity treat-
among the three groups for total duration and intensity of ment curves is illustrated in Figures 4 and 5. The area
physical activity. Table 3 summarizes the distribution of the between the control and physical activity treatment curves
modes and frequencies of the physical activities performed was found to be significantly different between prehyper-
for each group during the physical activity treatment. All the tensive (21.7 ⫾ 15.2 mm Hg·h⫺1) and hypertensive (123.4
activities were distributed among the three groups indicating ⫾ 42.8 mm Hg·h⫺1) groups based on independent t-tests (t
similar types of activities for each. ⫽ ⫺2.263; P ⫽ 0.044). The magnitude of blood pressure
Blood pressure reduction. The two subjects who did reduction was not significantly correlated with either BMI (r
not reach the target energy expenditure of 150 kcal were ⫽ 0.214; P ⫽ 0.393) or age (r ⫽ 0.180; P ⫽ 0.476).
omitted from the analysis of the blood pressure reduction. The Similarly, Pearson correlations between area of blood pres-
hourly systolic blood pressures for the physical activity period sure reduction and BMI (r ⫽ 0.115; P ⫽ 0.648) or age (r ⫽
and the 12 h after physical activity are illustrated in the upper 0.634; P ⫽ 0.137) were not significant. Therefore, data were
panels of Figures 3–5 for all three groups. Figure 2 illustrates not reexamined with BMI and age as covariates for neither
the regression (with 95% confidence limits) of the initial slope the magnitude nor the area of blood pressure reduction.
of blood pressure reduction and the remaining hourly blood Relationship between the energy expenditure of
pressures. A blood pressure reduction was found only in the physical activity and the reduction in blood pres-
prehypertensive and hypertensive groups as illustrated in Fig- sure. Figure 6 illustrates the relationship between energy
ure 2. The findings of no reduction in the normotensive group expenditure and blood pressure reduction for prehyperten-
was confirmed by comparing the average 12-h blood pressures sion, hypertension and for the combined pre- and hyperten-
PHYSICAL ACTIVITY AND BP REDUCTION Medicine & Science in Sports & Exercise姞 1269
FIGURE 4 —Energy expenditure (mean ⴞ SEM) and systolic blood pressure (mean ⴞ SEM) for the period of physical activity (left panels) and for
the time after the accumulation of physical activity (right panels) for prehypertensive adults. The shaded areas in the upper right panel illustrate
the area of blood pressure reduction after physical activity. Each time period is standardized to begin at time zero.

sive groups. Data from the noncompliers were included in This is the first study of its kind to target prehypertensive
these correlations. No significant correlations were found subjects. Prehypertension has been identified as a critical
between the EE(PA-C) and the reduction in systolic blood population for the intervention to prevent progression to
pressure for prehypertension (r ⫽ ⫺0.09; N ⫽ 10), or hypertension (26). Lifestyle modification, including the ac-
hypertension (r ⫽ 0.09; N ⫽ 10), or in combined pre- and cumulation of physical activity, is the only recommended
hypertensive groups (r ⫽ 0.08; N ⫽ 20). treatment at this time (2). Thus, the observation of physical
activity for prehypertensive subjects is warranted.
A 1-d lifestyle physical activity was chosen for this study
DISCUSSION
because it may be the initial step to investigate the effec-
The purpose of this study was: 1) to investigate the tiveness of physical activity on blood pressure reduction
magnitude and duration of ambulatory blood pressure re- (22). Training or long-term treatment studies may not be
duction after 1 d of lifestyle physical activity in normoten- justified without first demonstrating an acute response. The
sive, prehypertensive, and hypertensive adults; and 2) to use of an acute approach is justified in this investigation
determine the relationship between the energy expenditure because existing long-term studies of physical activity as a
and the blood pressure reduction. Twelve-hour ambulatory treatment of blood pressure (13) are limited. Furthermore,
blood pressures after lifestyle physical activity were com- the utilization of acute responses allows for a more effica-
pared with the same period of time after a control treatment. cious study of possible variations in the accumulation of
As expected, no blood pressure reductions were found in physical activity in the treatment of hypertension. The acute
normotensive subjects. A significant reduction in systolic effects are considered to contribute to the chronic training
blood pressure was found for 6 h for the prehypertensive effects (22). Finding a blood pressure reduction after a
group (6.6 ⫾ 2.3 mm Hg) and for 8 h for the hypertensive single day of physical activity is advantageous for the in-
group (12.9 ⫾ 4.3 mm Hg) after the accumulation of phys- active patient, considering the immediate results may be
ical activity. However, neither of the systolic blood pressure motivating to continue incorporating lifestyle physical ac-
reductions found in prehypertensive or hypertensive adults tivity into their daily routine.
were correlated with the energy expenditure of the physical Although our blood pressure screening protocol con-
activity. The inclusion of prehypertensive subjects and the formed to the recommendations of the World Health Orga-
investigation of 1-d lifestyle physical activity are the first nization (29), two screening days to classify subjects as
unique aspects of this study. prehypertensive or hypertensive may be considered a limi-
1270 Official Journal of the American College of Sports Medicine http://www.acsm-msse.org
FIGURE 5—Energy expenditure (mean ⴞ SEM) and systolic blood pressure (mean ⴞ SEM) for the period of physical activity (left panels) and for
the time after the accumulation of physical activity (right panels) for hypertensive adults. The shaded areas in the upper right panel illustrate the
area of blood pressure reduction after physical activity. Each time period is standardized to begin at time zero.

tation of our study. On the other hand, the ambulatory data tensive group. The subjects were tested on their medications
supported the classification of the hypertensive subjects. to simulate real-world conditions even though it may be
The average daytime blood pressures (0600 –2200 h) in the considered a limitation of our study. According to the lit-
control treatment for the hypertensive patients was 136.3/ erature (4,8,11), when exercise/physical activity is com-
77.0 ⫾ 6.1/4.1 mm Hg, which is higher than the 135/85 mm bined with antihypertensive medication, there is no additive
Hg criteria for hypertension using ambulatory blood pres- blood pressure reduction. Even though the use of antihy-
sure monitoring (19). No standards exist for ambulatory pertensive medications may not confound the results found
pressures in prehypertension; however, the average daytime in training studies, the acute interaction of medications and
blood pressure for the prehypertensive group was 121.8/ physical activity on blood pressure reduction is unknown.
74.1 ⫾ 2.7/1.7 mm Hg. The treatment order was based on subject’s preference so
Subjects. The demographics of the prehypertensive that the subjects could incorporate their physical activity in
group cannot be compared with the literature because this is a single day. Sixty percent of the subjects began with the
the first study of its kind to include prehypertensive sub- control treatment, whereas 40% of subjects began with the
jects. The hypertensive subjects in this study were not dif- physical activity treatment. There were no order effects on
ferent from those reported in other blood pressure studies the blood pressure reduction using independent t-test (t ⫽
(15,24) except for taking antihypertensive medications. The ⫺0.092; P ⫽ 0.928).
use of the antihypertensive medications is probably respon- Overall, 96% of the subjects were experienced in exer-
sible for the lower screening pressures found in the hyper- cise; 39% were participants in the Indiana University Adult

TABLE 2. Total accumulated duration, total energy expenditure, and intensity of the physical activity treatment (mean ⫾ SEM).
Control Treatment Physical Activity Treatment
Total duration (min) Normotension — 300.1 ⫾ 32.4
Prehypertension — 272.8 ⫾ 48.7
Hypertension — 283.1 ⫾ 28.6
Energy expenditure for the accumulation of physical activity Intensity (kcal 䡠 min⫺1) Normotension 1.6 ⫾ 0.1 3.9 ⫾ 0.6
Prehypertension 1.6 ⫾ 0.5 4.1 ⫾ 0.9
Hypertension 1.8 ⫾ 0.5 4.7 ⫾ 0.6
Total above baseline control (kcal) Normotension — 646.0 ⫾ 226.7
Prehypertension — 536.9 ⫾ 115.9
Hypertension — 706.9 ⫾ 103.9

PHYSICAL ACTIVITY AND BP REDUCTION Medicine & Science in Sports & Exercise姞 1271
TABLE 3. Types and frequency of physical activities performed. The duration of the blood pressure reduction was consid-
Normotension Prehypertension Hypertension ered to be the time period in which the blood pressure
(N ⴝ 8) (N ⴝ 10) (N ⴝ 10)
reduction remained within the 95% confidence limits of the
Bicycling 7 4 5
Brisk walking 8 5 16
regression of the initial slope of this relationship. To ac-
Carrying heavy objects 4 4 2 complish this, the blood pressure reduction was added (ac-
Cleaning the house 6 4 2 cumulated) for each hour and plotted against time (h). The
Climbing stairs 3 1 7
Gardening 8 11 7 slope of the accumulated reduction increases rapidly as the
Mowing the lawn 3 3 3 blood pressure differs from the control pressures. When
there is little to no difference in the blood pressures between
the physical activity and the control, the blood pressure
Fitness Program, and the rest of the subjects reported to be reduction no longer accumulates and the slope no longer
currently exercising (on the PAR-Q). Two of the 28 subjects increases. The point where the slope levels off was deter-
(7%) who did not comply with the target energy expenditure mined to be the duration of the blood pressure reduction.
of 150 kcal were experienced in exercise; both were women Statistically, the time in which the blood pressure reduction
and both were prehypertensive. The discrepancy must have data points were within the 95% confidence limits of the
been in their physical activities because the energy expen- regression of the initial slope was considered to be the
ditures of their control treatment (1.6 ⫾ 0.3 and 1.2 ⫾ 0.1 duration of the blood pressure reduction. This technique is
kcal·min⫺1) were not different from the compliers (1.6 ⫾ similar to the cumulative sum technique used to emphasize
0.5 kcal·min⫺1). The physical activities of noncomplier the crests and troughs of the diurnal variation in blood
number 1 were climbing stairs (fq ⫽ 5), cleaning (fq ⫽ 1), pressure (21).
and bicycling (fq ⫽ 1), which added up to 109 kcal above A comparison of the absolute blood pressure reductions
the control. The physical activities of noncomplier number found in this study to existing physical activity and blood
2 were climbing stairs (fq ⫽ 1), carrying groceries (fq ⫽ 1), pressure studies cannot be made because no acute studies
cleaning (fq ⫽ 1), and gardening (fq ⫽ 1), which added up utilizing lifestyle physical activity exist in the literature. Our
to 133 kcal above control. These noncompliers either did not data do support physical activity as the low threshold phe-
perform enough physical activity or the accelerometer was nomenon described by Cornelissen and Fagard (3). On the
unable to quantify their activities. other hand, the magnitude of the blood pressure reductions
Blood pressure reduction. The uses of the area found in our study appear to be greater than reported in the
between the control and physical activity blood pressure literature for acute exercise studies, whereas the duration of
curves as well as the determination of the duration of blood our blood pressure reductions appear to be shorter. The
pressure reduction were additional unique aspects of this reduction in ambulatory blood pressure after a single exer-
study. The area is a good representation of the total volume cise treatment has been reported to be 5– 8 mm Hg for 11–12
(magnitude duration) of the blood pressure reduction. The h in systolic and 6 – 8 mm Hg for 6 – 8 h for diastolic blood
use of area is not new to ambulatory blood pressure analysis. pressure (25).
Area under the elevated blood pressure curve has been The duration reported in our study was based on the
utilized in a more accurate evaluation of blood pressure load cessation of the blood pressure reduction. We could have
(28). easily found significant reductions in average blood pres-
sures beyond the 6- and 8-h periods, which would have
inflated the durations and diminished the magnitudes. For
example, had we averaged the blood pressure for 12 h
instead of 8 h, we could have reported a significant reduc-
tion of 8.8 ⫾ 3.1 mm Hg for 12 h for the hypertensive group
instead of the 12.9 ⫾ 4.3 mm Hg found for the 8-h reduc-
tion. This inflation of the duration and the diminution of
magnitude would be because the initial blood pressure re-
duction was large enough to spread to subsequent time
periods even though it did not reflect the period of time of
the true blood pressure reduction.
Another source for the shorter duration of the blood
pressure reduction may be attributed to the time of day. The
ambulatory blood pressure measurements after the physical
activity period began at 1737 ⫾ 0040 h for prehypertensive
group and 1806 ⫾ 0031 h for hypertensive group. The
simple consequence of going to sleep may have compro-
FIGURE 6 —The relationship between the increase in energy expen- mised the duration of the blood pressure reduction because
diture during the physical activity and the reduction in systolic blood sleeping blood pressures are generally lower than waking
pressure in prehypertensive (solid circle; solid line), hypertensive (hol-
low circle; dashed line), and the prehypertensive and hypertensive blood pressures (2). The mean beginning sleep time was
combined groups (bold dashed line). 2222 ⫾ 0024 h for prehypertensive group and 2342 ⫾
1272 Official Journal of the American College of Sports Medicine http://www.acsm-msse.org
0030 h for hypertensive group. Thus, the period of time for not well documented. Thus, energy expenditure could only
ambulatory blood pressure measurements between the end be estimated from the accelerometer.
of physical activity and the beginning of sleep time was The intention of this study was to simulate the lifestyle
0445 and 0536 h, respectively. The control sleeping blood physical activity recommended in the guidelines reported in
pressures were 106.2 ⫾ 3.3 mm Hg for the prehypertensive the Surgeon General Report on Physical Activity (23) as
group and 118.6 ⫾ 4.3 mm Hg for the hypertensive group; well as the American College of Sports Medicine (16). That
neither group had significantly different sleeping blood is, the accumulation of physical activity on most, if not all,
pressures after the physical activity treatment (P ⫽ 107.1 ⫾ days of the week. An energy expenditure of 150 kcal·d⫺1
4.20 mm Hg (t ⫽ ⫺0.56; P ⫽ 0.591); H ⫽ 120.8 ⫾ 4.25 was reported as the minimum criterion to obtain health
mm Hg (t ⫽ ⫺1.02; P ⫽ 0.336)). These findings are benefits (23). In our study, the total energy expenditure of
consistent with other results in our laboratory in that patients the physical activity appeared to be approximately four
who exhibit normal sleeping blood pressures do not reduce times greater than the recommendations of the Surgeon
sleeping blood pressure after an exercise treatment (unpub- General’s report, most likely because the duration of the
lished data). accumulation of physical activity exceeded 4 h.
Finding differences in blood pressure reduction among The long duration as well as some of the modes of
the three groups was expected because the magnitude of a lifestyle physical activity accumulated throughout the day
blood pressure reduction after exercise is dependent on the by subjects in this study may be more applicable for week-
presenting blood pressure. That is, patients who present with ends, days off, or in stages of life in which the subject has
higher blood pressures exhibit greater blood pressure reduc- longer periods of time, such as retirement. In any case, these
tions (25). Indeed, this is the case in this study. Our hyper- types of scenarios can be incorporated into some aspects of
tensive subjects (137.3 ⫾ 7.2 to 124.4 ⫾ 5.2 mm Hg) daily living as an alternative to exercise with effectiveness
exhibited a greater blood pressure reduction than prehyper- in lowering blood pressure and can be integrated into pro-
tensive subjects (118.7 ⫾ 4.0 to 112.1 ⫾ 3.9 mm Hg). In grams utilizing a variety of physical activity strategies to
addition, a statistically significant correlation (r ⫽ 0.68; N ⫽ lower blood pressure. Further investigation needs to be
18) was found between average systolic blood pressure in conducted to investigate whether the accumulation of less
the control treatment and the systolic blood pressure reduc- (⬍1 h) and more applicable daily physical activity could
tion when both groups were combined. Pescatello and col- have the same beneficial effect on lowering blood pressure
leagues (17) also reported baseline blood pressure as a as well as the reproducibility of such activities.
predictor of postexercise hypotension. Similar to other stud- The intensity of the physical activity measured by the
ies (24), our subjects with normal blood pressure did not accelerometer (4.0 –5.0 kcal·min⫺1) appeared to be 30 –50%
exhibit a blood pressure reduction. below the estimated energy expenditure for the types of
Although the blood pressure during physical activity was physical activities recorded. The most common activities
not a focus of this study, it is interesting to note that the rise reported by our subjects were brisk walking, gardening, and
in blood pressure during the physical activity treatment was mowing the lawn, which according to Ainsworth and col-
not as high as during our typical exercise treatments. Nor leagues (1) should exhibit energy expenditures of 6.6, 4.5,
was the average 12-h blood pressure of the physical activity and 9.3 kcal·min⫺1, respectively (for the average weight of
significantly different from the corresponding control treat- our subjects). These discrepancies may be due to: 1) the
ment (N C ⫽ 114.1 ⫾ 2.26 mm Hg to N PA ⫽ 117.4 ⫾ 2.61 accuracy of the activity diary or 2) the utilization of the RT3
mm Hg (t ⫽ ⫺2.07; P ⫽ 0.078); PC ⫽ 121.4 ⫾ 1.85 mm Hg accelerometer. Most subjects failed to accurately record the
to PPA ⫽ 124.0 ⫾ 2.37 mm Hg (t ⫽ ⫺1.38; P ⫽ 0.20); HC duration of each activity they performed. The only way we
⫽ 134.2 ⫾ 5.74 mm Hg to HPA ⫽ 134.4 ⫾ 6.57 mm Hg (t could obtain activity duration was by the accelerometer
⫽ ⫺0.061; P ⫽ 0.95)). It was not unexpected for the data.
average activity pressures to be higher because upper body The RT3 accelerometer was used in this study because the
work elicits a higher blood pressure response than lower nature of physical activity is three dimensional. Two dimen-
body work. However, less than 50% of the activities were sional accelerometers adequately monitor walking or cy-
upper body activities, spread out over 10 –11 h, which cling, but our subjects were instructed to engage in all types
appears to be undetectable in these means. Thus, not only of physical activity in which a three-dimensional acceler-
does physical activity demonstrate a slight increase in blood ometer would be more suitable (27). On the other hand, the
pressure during the treatment, but it also appears to be as motion sensor RT3, although being the latest version of
effective in reducing blood pressure after the treatment as three-dimensional accelerometers, still appears to have
traditional exercise (9,25). some limitations (18,20). Like all types of accelerometers,
Caloric cost of the physical activity. Two measure- the accuracy of the estimation of the energy expenditure
ments of physical activity were utilized in this study: an may depend on the type of physical activity. When the
activity diary and the accelerometer. Subjects were asked to motion sensor is worn at the hip, the estimation of energy
record mode and duration of the physical activity in the expenditure for locomotion has been demonstrated to be
diary. The subjects adhered very well to recording the types accurate (27). However, the accelerometer appears to un-
of physical activities in the diary each time they were derestimate the energy expenditure for upper-body activities
performed; however, the duration of physical activity was such as cleaning windows or gardening. Overall, the motion
PHYSICAL ACTIVITY AND BP REDUCTION Medicine & Science in Sports & Exercise姞 1273
sensor RT3 underestimates energy expenditure between 30 Thus, the incorporation of these lifestyle physical activities
and 70% in field conditions (27). In our study, 42.5% of the in the treatment of prehypertension and hypertension may
physical activities recorded on the activity diary were upper- have a profound effect on hypertensive morbidity and mor-
body related (carrying heavy objects, cleaning, gardening). tality.
Thus, the accelerometer may not have estimated the energy
expenditure accurately.
Relationship between energy expenditure and CONCLUSION
blood pressure reduction. No correlations between the The novel approach of this investigation includes: 1) the
energy expenditure and the reduction in blood pressure were study of one day of lifestyle physical activity, 2) the incor-
found in our study. The primary correlations between en- poration of prehypertensive subjects, and 3) the approach to
ergy expenditure and blood pressure reduction were per- blood pressure data analysis. The lifestyle physical activity
formed on each group separately because the blood pressure in this study averaged 4 h in duration and 4 –5 kcal·min⫺1
reduction among the three groups was significantly differ- for intensity. Lifestyle physical activity reduces systolic
ent, yet the energy expenditures were not. Combining the blood pressure in both pre- and hypertensive adults, but not
groups would have compromised the correlations as illus- in normotensive adults. The reduction, however, does not
trated in Figure 6 in the combined data. In any case, the lack appear to be correlated with the energy expenditure of the
of a significant relationship between energy expenditure and accumulation of physical activity. The activities, as utilized
blood pressure reduction found in this study was also found in this study, can be incorporated into some aspects of daily
by Fagard (7), who, in a meta-analysis of 57 training studies, living with effectiveness in lowering blood pressure and can
found no correlation between the energy expenditure and be integrated into programs utilizing a variety of physical
the reduction in systolic (r ⫽ 0.14) or diastolic (r ⫽ ⫺0.02) activity strategies to lower blood pressure. Further investi-
blood pressure. gation needs to be conducted to investigate whether the
In terms of clinical significance, the type of lifestyle accumulation of less (⬍1 h) and more applicable physical
physical activity investigated in this study appears to be as activity could have the same beneficial effect on lowering
effective in lowering blood pressure as traditional cardiore- blood pressure.
spiratory exercise. Yet these lifestyle activities may be con-
sidered even more effective in lowering blood pressure than
We express thanks to David A. Tanner, Ph.D. for developing the
exercise considering that the adherence to lifestyle activities software to calculate the blood pressure area between the control
may be higher than for traditional exercise (5). In addition, and physical activity blood pressure curves.
the magnitude of the blood pressure reduction found in this This research was supported by the Clinical Exercise Physiology
Laboratory, Department of Kinesiology, Indiana University and the
study is the documented magnitude of the reduction found to Indiana University Adult Fitness Program. J. Padilla is supported by
reduce hypertensive mortality 9% over a 10-yr period (2). a fellowship from the Ministerio de Educación y Cultura de España.

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