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Year : 2020  |  Volume : 9  |  Issue : 2  |  Page : 80-85

Efficacy of moderate-intensity physical activity in lowering non- high-density lipoprotein cholesterol in stage 2 essential hypertensive patients

1 Department of Biochemistry, RUHS College of Medical Sciences and Associated Groups of Hospitals, Sector 11, Kumbha Marg, Pratap Nagar, Jaipur, Rajasthan, India
2 Department of Internal Medicine, SMS Medical College and Associated Group of Hospitals, Jawahar Lal Nehru Marg, Ashok Nagar, Jaipur, Rajasthan, India

Date of Submission30-Mar-2020
Date of Acceptance27-Apr-2020
Date of Web Publication18-Jul-2020

Correspondence Address:
Dr. Sonali Sharma
Department of Biochemistry, RUHS College of Medical Sciences and Associated Groups of Hospitals, Sector 11, Kumbha Marg, Pratap Nagar, Jaipur - 302 033, Rajasthan
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Source of Support: None, Conflict of Interest: None


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Background: Hypertension and non–high-density lipoprotein cholesterol (non-HDL-c) measure is a useful evaluation tool to assess heart disease risk. Increasing physical activity (PA) is considered to reduce blood pressure (BP) and non-HDL-c in patients with hypertension.
Objective: This study assesses the influence of moderate and regular PA on non-HDL cholesterol in essential hypertension.
Subjects and methods: We studied 100 patients of either gender, aged 40–69 years of stage 2 essential hypertension in this interventional study. Patients were enrolled for 12 weeks of PA intervention (10,000 footsteps per day) and were followed at 15 days interval in the first month and after that 1-month duration. Lipid profile was estimated at baseline and at the final assessment visit (after 12 weeks).
Results: The data included in this study confirm the beneficial effects of regular PA on non-HDL-c levels (P < 0.000001). It was found that after 12 weeks of intervention program, the cholesterol, triglycerides; low-density lipoprotein cholesterol (LDL), very low-density lipoprotein cholesterol (VLDL), and non-HDL-c were lowered from 276.53 to 194.19, 191.17 to 110.58, 196.07 to 120.72, 38.23 to 22.12, and 234.32 to 142.84, respectively. It was also noted that high-density lipoprotein cholesterol (HDL) was increased from 42.21 to 51.35 following the interventional program. All the results were highly significant (P < 0.000001).
Conclusions: A non-pharmacological activity like PA is beneficial for better management of hypertension to avoid cardiovascular co-morbidities. Twelve weeks of physical exercise program (walking of 10,000 footsteps/day) decreases the risk associated with BP elevation by improving non-HDL-c in hypertensive patients.

Keywords: Hypertension, low-density lipoprotein cholesterol cholesterol, non-HDL cholesterol, physical activity

How to cite this article:
Gupta B, Sharma S, Bhandari S, Jangir S. Efficacy of moderate-intensity physical activity in lowering non- high-density lipoprotein cholesterol in stage 2 essential hypertensive patients. J NTR Univ Health Sci 2020;9:80-5

How to cite this URL:
Gupta B, Sharma S, Bhandari S, Jangir S. Efficacy of moderate-intensity physical activity in lowering non- high-density lipoprotein cholesterol in stage 2 essential hypertensive patients. J NTR Univ Health Sci [serial online] 2020 [cited 2022 Jan 24];9:80-5. Available from: https://www.jdrntruhs.org/text.asp?2020/9/2/80/289889

  Introduction Top

Hypertension contributes majorly as a causative factor to the current epidemic of cardiovascular disease (CVD) in India as well as other low and middle-income countries.[1],[2] The estimated worldwide burden of hypertension is close to 1 billion adults in 2000 and assumed to grow up to 1.56 billion by the year 2025.[3] Multiple factors are associated with hypertension with an unpretentious contribution of genetic factors and environmental factors.

Hypertension is the most important, easily recognized risk factor for stroke, myocardial infarction, peripheral vascular disease, and heart failure. Comorbidities such as obesity, lipid derangements, and glucose intolerance are found in 80% hypertensive persons.[4] To understand the relation of hypertension to etiology and pathogenesis of arteriosclerosis, interrelationship between blood pressure (BP) and blood lipid levels might prove to be relevant.

The Third Adult Treatment Panel (ATP III) of the National Cholesterol Education Program (NCEP) has recommended the use of non–HDL-c as a target of assessing elevated coronary heart disease (CHD) risk. The potential use of non-HDL-c, that is, to predict risk of death due to CVD, has been exhibited in various studies.[5] Non-HDL-c has been proved as a predictor of mortality in men and women, just as good as LDL.[6] The non-HDL-cholesterol is defined by the value between total cholesterol and HDL, not only including LDL but also other lipoprotein fractions like intermediate-density lipoproteins (IDLs) and very low-density lipoprotein (VLDL).[7],[8]

According to World Health Organization guidelines, important components to prevent hypertension include physical activity (PA) and other lifestyle modifications.[9] PA is defined as any bodily movement produced by the contraction of skeletal muscles which results in increase in energy expenditure above resting levels. This includes routine daily tasks and health-enhancing activities.[10]

PA and other therapeutic lifestyle changes were recommended to reduce CVD risk in those with low HDL in ATP III guidelines and a subsequent report from the Coordinating Committee of the National Cholesterol Education Program.[11] Reports of meta-analysis showed significantly decreased BP (systolic and diastolic) in subjects who followed regular walking programs.[12],[13]

Supervised exercise in practice could be expensive and challenging. We hypothesized that intervention of moderate PA might improve lipid profile, especially non-HDL-c in patients with stage 2 essential hypertension. Therefore, the objective of this study was to determine the effectiveness of moderate and regular PA on non-HDL-c of subjects with stage 2 essential hypertension.

  Subjects and Methods Top

This was a clinical interventional study conducted on a total of 100 patients of either gender of age 40-69 years of stage 2 essential hypertension in a Government Medical College and associated hospital in Rajasthan. The study was conducted in the year 2017–2018. Institutional ethics committee approval (RUHS-CMS/Ethics Comm./2017/123) was taken on 29th Aug 2017. Prior to the study, all eligible patients were briefed about the study, and informed consent was taken of all enrolled participants.

Stage 2 hypertension was defined as [systolic blood pressure (SBP), 160 mmHg–179 mmHg or diastolic blood pressure (DBP), 100 mmHg–109 mmHg] (JNC 8).[14] Subjects of stage 2 essential hypertension, on the prescribed treatment of antihypertensive medicines, having a sedentary lifestyle (<3000 steps/day) and having a smart phone with pedometer step count application for the record were included in the study. Exclusion criteria included patients with nephropathy (proteinuria), patients with CVD (CAD, peripheral arterial disease, stroke), heavy alcoholics, with history of habitual smoking and pregnant and lactating women.


All enrolled study participants were put on 12 weeks physical exercise program that included, walking of 10,000 footsteps/day (moderate and regular physical activity). The steps were counted by pedometer/or pedometer smartphone application. Follow up of participants was done every 15 days for two months and then on a monthly basis regarding their compliance of physical activity level during the 12 weeks intervention period. Patient was motivated and monitored regularly to maintain PA as desired in the protocol of the study.

At baseline, anthropometric measurements and BP were noted and the lipid profile was estimated in all participants. Demographic information, lifestyle information, socioeconomic status, and personal and family history were collected through a proforma.

BP was recorded in sitting position after a 5 min rest period at baseline, every 15 days for 2 months, then after 1 month of intervention and at the time of final assessment (after 12 weeks of intervention). It was measured using a mercury sphygmomanometer from the left arm. SBP and DBP were defined as an average of 3 times readings obtained while supine position after a minimum 5-minute rest. A radial pulse was also recorded. Standard protocols with participants wearing light clothing without shoes were used to measure body weight and height. Body mass index (BMI) was calculated. Waist and hip circumferences were measured. All subjects were introduced to standard lifestyle measures.

After 12 weeks of PA intervention, serum lipid profile was reassessed to calculate non-HDL cholesterol. Serum lipid profile was estimated in all the participants on a fully automated analyzer Beckman coulter. Serum cholesterol, triglyceride, and HDL cholesterol were estimated by enzymatic method. Friedewald equation was used for the calculation of low-density lipoprotein (LDL) and very low-density lipoprotein (VLDL).[15] The non-HDL-c was calculated as follows: non-HDL-c = Total cholesterol minus HDL cholesterol.

Statistical analysis

In this study, parameters of lipid profile were measured by using suitable averages. Since the data was collected on a continuous scale, descriptive statistics (mean, standard deviation) were used to present the data. Also, appropriate graphical representation was done. For the discrete as well as qualitative variables, univariate and bivariate tables were prepared. Appropriate statistical tests (Paired 't' test) were applied to check whether there is a significant effect of treatment on a group. Correlation analysis was done. In multiple regression analysis, we used BP values as the dependent variable and lipid profile parameters (cholesterol, triglycerides, HDL, LDL, and VLDL) as independent variables.

  Results Top

The study was conducted on 100 stage 2 hypertensive subjects. Out of these participants, 77% were males and 23% were female. A decrease in both SBP and DBP was observed in essential hypertensive participants after 12 weeks of PA intervention. SBP in essential hypertension participants at baseline was 168.98 ± 3.76, which was significantly (P < 0.000001) improved (154.29 ± 7.48) after 12 weeks of the intervention of PA. DBP was also improved (89.08 ± 3.62) after 12 weeks of PA intervention from baseline (103 ± 2.46), which was found to be significant (P < 0.000001).

The results of this study show that after 12 weeks of intervention in the form of moderate PA, levels of serum cholesterol, triglycerides, LDL, and VLDL were decreased as compared to baseline values and it was statistically significant (P < 0.000001). Whereas, serum HDL levels of essential hypertensive participants were compared between baseline and postintervention, a significant (P < 0.000001) increase was noted [Table 1].
Table 1: LIPID Profile in Hypertensive Patients at Baseline and After 12 Weeks

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The multiple regression equations:

Multiple Regressions between Lipid profile and Blood pressure

  1. Sr. Cholesterol (mg/dl) = 2.38* Systolic BP - 0.54* Diastolic BP - 125.72
  2. Sr. Triglycerides (mg/dl) = 1.58* Systolic BP + 0.21* Diastolic BP – 151.32
  3. Sr. HDL (mg/dl) = 0.33* Systolic BP - 0.754* Diastolic BP + 67.39
  4. Sr. LDL (mg/dl) = 1.74* Systolic BP + 0.18* Diastolic BP – 162.85
  5. Sr. VLDL (mg/dl) = 0.32* Systolic BP + 0.424* Diastolic BP – 30.27
  6. Non-HDL-c (mg/dl) = 2.05* Systolic BP – 0.214* Diastolic BP – 58.33.

Multiple correlation analysis showed that cholesterol, triglycerides, LDL, and VLDL are positively associated with BP and the results are highly significant. HDL displayed a negative association with BP. This shows that there is a positive linear relationship between lipid profile and BP [Table 2].
Table 2: Multiple Correlation Analysis of Blood Pressure with Lipid Profile in Hypertensive Patients

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  Discussion Top

Hypertension being the most common modifiable risk factor for the prevention of CVD and death require clinical treatment and approach with less side effects and use of less invasive procedures. Modifiable risk factors of importance in the development of hypertension are lifestyle factors, which also include PA. Beneficial effects of exercise in hypertension resulting in a decrease of 5–7 mm/hg in both SBP and DBP has been reported by various researchers.[16],[17]

The use of PA has been widely researched as an efficient modality for the management of hypertension and for its various benefits. It has been proved that both low diurnal BP and low night BP levels are associated with high physical activity shown as an improved circadian pattern, which causes a reduction in cardiovascular co-morbid conditions.[18]

In this study intervention of 12 weeks of PA in the form of moderate and regular PA (walking of 10,000 footsteps/day) was done in a participant with essential hypertension. In our study, SBP and DBP in essential hypertension participants at baseline were improved after 12 weeks of PA intervention significantly (P < 0.000001) and the pedometer/or pedometer smartphone application we used was very effective to count steps. Our results are in accordance with a study done by Brouard B et al.[12] and they involved 19,000 pedometer and smartphone BP monitoring software users (hypertensive) who were walking 1,000 more steps per month. They observed that SBP reduced by 0.13 mmHg in males and 0.21 mmHg in females (P < 0.0001). The effect of regular PA, including daily walking on hypertension in 69 hypertensive patients with a follow-up period of 378 days studied by Okura T et al.[13] They found that in the high daily walking steps (DWS) group, morning BP (systolic and diastolic) and evening systolic BP were reduced. Cornelissen et al.[19] reported that moderate aerobic exercise cause reduction in BP (systolic and diastolic), which was found to be 3.5 mm Hg and 2.5 mmHg respectively, in hypertensive participants who were walking and jogging following moderate aerobic exercise 3–5 times per week, 30-60 minutes per se ssion for 4-52 weeks.

The reason behind the decrease in BP with PA, due to weakening in peripheral vascular resistance which in turn may be due to neurohormonal and structural responses with reductions in sympathetic nerve activity, Arterial Stiffness, Vascular responsiveness to adrenergic- and endothelin-receptor stimulation, Intima-media thickness and an increase in parasympathetic nerve activity, angiogenesis, arteriogenesis, arterial lumen diameters, respectively. Positive changes in oxidative stress, arterial compliance, endothelial function, inflammation, body mass, renin-angiotensin system activity, insulin sensitivity/glucose metabolism, renal function, Sodium metabolism results in a reduction in BP.[20] PA has been associated with paradoxical regression or prevention of left ventricular hypertrophy in hypertensive patients, which suggest a beneficial mechanism of exercise in hypertensive patients.[17]

Results of this study show a significant improvement in lipid profile in stage 2 hypertensive patients after the intervention of PA for 12 weeks. Effects of exercises in individuals with dyslipidemia and for reduction of cholesterol levels in relation to pathogenesis, symptoms, and levels of physical fitness have been reported as positive.[21] This study reports that 12 weeks of moderate and regular PA improved non-HDL cholesterol levels (P < 0.0001) as compared to baseline values. Our results are in accordance with a study that concluded non–HDL-c as a considerable risk component for cardiovascular disease and suggest that walking reduces non–HDL C in adults. A significant decrease of approximately 4% in non-HDL cholesterol levels was found in the walking group when compared to the control group.[22] Wong ND et al.[23] reported that increased BP confers increased risks for CVD in elderly persons across all lipid levels. Relationship of various lipid parameters (LDL, HDL, and non-HDL cholesterol) with BP categories to incident CVD was evaluated over 15 years in their studies. They found that when comparing these factors with those with BP <120/80 mmHg with either LDL-C <100 mg/dl or HDL-C >60 mg/dl, hazard ratios (HRs) for CVD events were 2.1, with similar results for non-HDL-C.

Activation of AMP-activated protein kinase in the skeletal muscle and enhancement of expressing lipoprotein lipase, which degrades triglycerides into free fatty acids and glycerol by increasing PPARγ1 levels) is a result of PA.[24] The increase in LPL activity following exercise increases the rate of TG clearance, resulting in decreased triglycerides levels, and an increase in glucose transporter 4 associated with PA may reinforce insulin sensitivity. Increased insulin sensitivity leads to decreased hepatic VLDL and Apo B secretion, as well as decreased free fatty acids in the liver.[25]

In this study, to examine the relationship between dependent variable BP and independent variables serum cholesterol, triglycerides, LDL, HDL, VLDL, and non-HDL cholesterol, correlation and multiple linear regression analysis were conducted. The descriptive statistics and analysis results are given in [Table 1]. As can be observed, each of the scores is positively and significantly correlated with the BP, except the HDL, which is negatively correlated with BP. The study outcomes have shown that there was a clear association between increased BP (systolic and diastolic) with increased cholesterol levels. Ammar T,[26] in their study, found that aerobic exercise results in an improvement in BP and lipid levels in overnight hypertensive postmenopausal women. Their study reported a statistically significant difference between the mean BP (diastolic and systolic) values and lipids (HDL, LDL, TG, and total cholesterol) in group A (received hypertensive medications), group B (received hypertensive medications and morning aerobic exercises), and group C (received hypertensive medications and afternoon aerobic exercises). The improvement in percentage in group C, group A, and group B were 30.97%, 5.99%, and 17.29%, respectively. Ohta Y et al.,[27] conducted a study to find out the effects of walking daily in office, home, and 24 hours ambulatory BP in hypertensive patients. The study reported lowered office (P < 0.05), home (P < 0.01), and 24 hours BP (P < 0.01) compared to the control period and improved 24 hours heart rate and lipid metabolism in hypertensive patients who walked daily. Choudhary et al.[28] studied the association of lipids and hypertension that hypertensive patients are more prone to having dyslipidemia, i.e., elevated TG, LDL, cholesterol and reduced HDL levels than normotensives.

These data support the concept of improving cholesterol levels by PA and exercise. The outcomes of this study highlight the beneficial effects of regular PA on non-HDL cholesterol levels in patients with hypertension. Further studies with prolonged PA intervention are required to better understand the response to PA on hypertension. A short-span moderate PA intervention study shows positive results in the lowering of non-HDL-c. However, for establishing this observation, more data would be needed with prolonged PA intervention.

  Conclusions Top

A nonpharmacological activity like PA is beneficial for better management of hypertension to avoid cardiovascular comorbidities. Twelve weeks of physical exercise program (walking of 10,000 footsteps/day) decreases the risk associated with BP elevation by improving non-HDL-c in hypertensive patients.

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Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2]


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