Hindawi
BioMed Research International
Volume 2019, Article ID 3081029, 12 pages
https://doi.org/10.1155/2019/3081029
Research Article
Feasibility and Health Effects of a 15-Week Combined
Exercise Programme for Sedentary Elderly: A Randomised
Controlled Trial
Tina-Thea Nielsen ,1,2 Trine K. Møller,3 Lars L. Andersen
Peter R. Hansen ,5 and Peter Krustrup 1,6
,4 Mette K. Zebis,2
1
Department of Nutrition, Exercise and Sports, University of Copenhagen, Copenhagen, Denmark
Department of Physiotherapy, University College Copenhagen, Copenhagen, Denmark
3
Department of Sports Science and Clinical Biomechanics, SDU Sport and Health Sciences Cluster (SHSC),
Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
4
National Research Centre for the Working Environment, Copenhagen, Denmark
5
Department of Cardiology, Herlev and Gentofte University Hospital, Gentofte, Denmark
6
Sport and Health Sciences, University of Exeter, Exeter, UK
2
Correspondence should be addressed to Peter Krustrup; pkrustrup@health.sdu.dk
Received 8 November 2018; Accepted 2 January 2019; Published 23 January 2019
Academic Editor: Imelda de Groot
Copyright © 2019 Tina-Thea Nielsen et al. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
cited.
There is strong evidence that considerable health benefits can be achieved even with small amounts of physical activity. However,
getting people to exercise regularly is a major challenge not least in the elderly population. This study investigated the feasibility
and physiological health effects of a pragmatic 15-week exercise programme for sedentary elderly. In a single-blind randomised
controlled trial, 45 sedentary 60-83-year-olds (25 women, 20 men) were randomly assigned (2:1 ratio) to a training group (TG,
n=30) or a control group (CG, n=15). The training in TG consisted of a combination of exercise modalities (i.e., strength, aerobic
fitness, stability, and flexibility training) performed once a week as supervised group-based training and a weekly home-based
training for 15 weeks. Feasibility outcomes were exercise intensity, adherence, and adverse events. The primary outcome was change
in aerobic fitness (VO2max /kg). Adherence was high (81%) for the supervised exercise and low (0%) for the home-based exercise.
No acute injuries occurred in TG, but 4 subjects (13%) reported considerable joint pain related to training. Average heart rate (HR)
during the supervised training was 104±12 beats/min (69.3±8.0%HRmax ), with 3.9±7.3% of training time >90%HRmax . Intentionto-treat analyses revealed no between-group differences for aerobic fitness (P=0.790) or any secondary cardiovascular outcomes at
15-week follow-up (resting HR or blood pressure; P>0.05). Compared to CG, bodyweight (-2.3 kg, 95% CI -4.0 to -7.0; P=0.006),
total fat mass (-2.0 kg, 95% CI -3.5 to -0.5; P=0.01), and total fat percentage (-1.6%, 95% CI -2.8 to -0.3; P=0.01) decreased in TG. The
group-based supervised training had high adherence and moderate exercise intensity, whereas the home-based training was not
feasible in this study population. This exercise programme performed once a week did not improve aerobic fitness. Thus, supervised
training with more vigorous intensity control appears advisable. Clinical Study registration number is H-15016951.
1. Introduction
Physical inactivity is a major risk factor for noncommunicable diseases and premature death [1], and low cardiorespiratory fitness (CRF) is an independent risk factor for
cardiovascular disease (CVD) and premature mortality [2].
Also, statutory retirement age is gradually increasing in most
European countries, and keeping elderly people fit for work
will be a major societal challenge. In Denmark, generations
born in 1974 have to work until they are 70 years old,
and retirement age will likely increase even more for future
generations. Meta-analyses have provided strong evidence
that exercise training significantly improves CRF and some
CVD biomarkers in adults without CVD, which assigns
2
an important role for exercise in the primary prevention
of CVD [3]. Furthermore, there is strong evidence that
exercise training is effective for prevention and treatment of
noncommunicable metabolic and musculoskeletal disorders
[4].
It is widely accepted that a dose-response relationship
exists between exercise volume and possible health effects,
but the minimum effective dose for eliciting positive health
effects is unclear [5]. Addressing this issue is of crucial importance, because getting people to exercise regularly is a major
challenge not least in the elderly population. A systematic
review and a meta-analysis have revealed that considerable
health benefits can be achieved even with small amounts
of physical activity [6]. Indeed, one or two sessions per
week of moderate- or vigorous-intensity leisure-time physical
activity was associated with reduced all-cause mortality and
death from CVD and cancer regardless of adherence to
prevailing physical activity guidelines [6]. Moreover, 1 hour
of recreational football per week over 12 weeks can produce
health benefits by improving aerobic fitness (VO2max ) and
blood pressure in middle-aged sedentary men [7]. Research
also indicates that women who did 1–1.5 hours of walking
per week had only half the risk of developing coronary heart
disease compared to sedentary women [8]. Furthermore, it
has been suggested that a combination of aerobic training
and strength training performed three times per week over 12
weeks can improve the aerobic fitness and muscle strength of
elderly subjects [9]. However, it remains unknown whether a
training programme consisting of a combination of exercise
modalities (i.e., strength, aerobic fitness, stability, and flexibility training) performed twice a week provides a sufficient
physiological stimulus to enhance the health of sedentary
elderly.
In 2016, the Danish Gymnastics and Sports Associations (DGI) designed a combined exercise programme
(combination of exercise modalities), namely, “DGI Senior
training”, targeting elderly subjects with and without functional disability and noncommunicable diseases. The aim
was to improve cardiovascular fitness and body composition (increase muscle mass and reduce fat mass) in the
elderly population [10]. DGI hosts 6,300 local sports clubs
across Denmark and by providing exercise programmes
with health-enhancing effects, DGI could serve as a unique
national platform with outreach also to the sedentary
elderly population. However, to be able to provide evidencebased recommendations for health-enhancing exercise programmes for prevention of chronic diseases, the first step
is to evaluate the effects of these programmes. Furthermore, to support the decision on whether an exercise programme is feasible on a population scale, this evaluation
should be conducted in a real-life setting. High applicability
makes it easier to extrapolate trial results into real life,
which also makes such effectiveness studies highly relevant
[11].
In the present study, the feasibility and physiological
health effects of the “DGI Senior training” programme were
evaluated in a randomised controlled trial. We hypothesised that this 15-week combined exercise programme could
improve the health of sedentary elderly.
BioMed Research International
2. Methods
2.1. Experimental Approach to the Problem. This study was
a randomised controlled trial that took place in the Capital
Region of Denmark from February to June 2016. The study
was conducted in a real-life setting in a local sports club
hosted by DGI. Forty-five sedentary elderly men and women
were randomised in a 2:1 ratio, to a training group (TG, n=30)
or a matched control group (CG, n=15), in line with a prior
intervention study in hypertensive patients [12]. After all
baseline tests had been conducted, three numbers referring
to three of the subjects, stratified by age, height, and sex, were
placed in a sealed envelope. A person without any knowledge
of the project performed the randomisation using following
procedure with every sealed envelope: The first and second
numbers drawn were placed in the training group and the
third number drawn was placed in the control group. TG
was offered the “DGI Senior training” programme which
consists of 15 weeks of once a week supervised exercise
training together with verbal advice and encouragement to
also perform 30 min of exercise per week at home during
this period as an integral part of the “DGI Senior training”
concept. CG was advised to maintain their normal lifestyle
behaviour during the intervention period and encouraged
to contact the project manager if any changes in their
normal activity and health occurred. The test personnel in
charge of the VO2max test after the 15-week intervention
were blinded to group allocation and all baseline results. No
other blinding procedure was possible due to financial constraints. The protocol was approved by the regional Ethical
Committee (reference no. H-15016951). The guidelines of the
Helsinki Declaration were followed and informed consent
was obtained.
2.2. Subjects. A total of 45 sedentary elderly aged 60–83
years (20 men and 25 women) were included in the study.
Baseline characteristics are presented in Tables 1 and 2.
The subjects were recruited through advertisements in local
newspapers and underwent a medical examination prior
to inclusion in the study. Inclusion criteria were sedentary
men and women above 60 years, who were healthy or with
lifestyle diseases such as hypertension, chronic obstructive
pulmonary disease, obesity, hyperlipidaemia, and/or CVD.
The medical doctor responsible for the study safety predefined the following exclusion criteria: blood pressure >180/110
mmHg, polypharmacy (more than three types of prescribed
medications), diabetes, ischaemic heart disease, blood donor
status, implanted cardiac pacemaker, and moderate to severe
dementia. The subjects were allowed to take prescribed medication and smoke during the intervention, but the medication
was required to remain the same during the intervention
period.
2.2.1. Training Intervention. The intervention is described
according to the Template for Intervention Description and
Replication checklist and guide [13]. “DGI Senior training”
consists of a 90 min supervised exercise programme once
a week for 15 weeks conducted in a gym on a prescheduled weekday. Additionally, the subjects are encouraged to
BioMed Research International
3
Table 1: Subject characteristics at baseline.
Men/women (n)
Age (years)
Weight (kg)
Height (cm)
Body Mass Index (kg/m2 )
Total fat percentage
Total fat mass (kg)
Android fat mass (kg)
Gynoid fat mass (kg)
Total muscle mass (kg)
Leg muscle mass (kg)
Total bone mineral density (g/cm2 )
Total bone mineral content (kg)
Resting heart rate (bpm)
Systolic blood pressure (mmHg)
Diastolic blood pressure (mmHg)
Mean arterial blood pressure (mmHg)
VO2max (mLO2 /min)
VO2max (mLO2 /min/kg)
VEpeak (L/min)
Time to exhaustion (s)
TG (n = 30)
baseline
13/17
71 ± 6
77.6 ± 17.0
168.0 ± 8.7
27.4 ± 5.2
34.5 ± 8.8
27.6 ± 11.2
2.7 ± 1.3
4.7 ± 1.8
46.4 ± 9.0
15.5 ± 3.3
1.149 ± 0.154
2.643 ± 0.707
62 ± 9
137 ± 15
77 ± 9
97 ± 10
1598 ± 76
20.7 ± 4.7
70.6 ± 25.0
384 ± 107
CG (n = 15)
baseline
7/8
70 ± 6
81.8 ± 10.3
173.4 ± 8.3
27.3 ± 3.4
35.9 ± 9.7
29.6 ± 10.1
2.9 ± 1.0
5.1 ± 2.0
48.3 ± 9.0
16.4 ± 3.6
1.187 ± 0.112
2.919 ± 0.615
60 ± 7
136 ± 17
79 ± 7
98 ± 9
1739 ± 24
21.3 ± 5.7
74.4 ± 15.0
421 ± 116
Between-group
P-value
0.620
0.307
0.050
0.931
0.628
0.549
0.715
0.585
0.503
0.424
0.406
0.205
0.647
0.901
0.417
0.692
0.380
0.718
0.628
0.307
Data are presented as mean ± SD. TG: training group. CG: control group. ∗ denotes significant difference between TG and CG (P2.78 m⋅s−2 ).
2.5. Statistical Analyses. Analyses were performed using SAS
statistical software (SAS version 9.4). The changes from
baseline to follow-up between the two groups were evaluated
using a linear mixed model. The change score was adjusted
for the baseline value of the outcome, age, and gender. The
estimation method was restricted maximum likelihood with
degrees of freedom based on the Satterthwaite approximation. P levels of 0.05 or less were accepted as statistically
significant. Outcomes are reported as within- and betweengroup least square mean differences with 95% confidence
intervals of the change score from baseline to 10-week followup.
2.4.4. Blood Pressure. After at least 10 min of rest in a dark,
temperate room, lying in a supine position, the resting blood
pressure was assessed using an automatic upper left arm
blood pressure monitor (OMRON-M7; OMRON; Illinois,
USA). Six measurements of systolic (SBP) and diastolic
blood pressure (DBP) were made and the mean arterial
blood pressure (MAP) was calculated. Simultaneous resting
HR was measured with Polar Team System, Polar Electro Oy and determined as the lowest average value over
1 min.
2.5.1. Sample Size. The a priori power calculation was based
on aerobic fitness (expressed relative to body mass) as the
primary outcome. To show an expected increase of 6% in
VO2max would require 15 participants in the control group
and 30 participants in the training group to detect betweengroup significance at a level of 0.05%, according to the 2:1
randomisation. The expected increase in VO2max was based
on an expected drop out of participants of 20% [12, 15]. No
power calculations were carried out for the remainder of the
variables.
2.4.5. Heart Rate Responses. HR was recorded every 5 sec
using a telemetric device (Polar Team System, Polar Oy,
Kempele, Finland). The variables used were percentage of
time spent in each intensity zone in percent of maximum
HR (%HRmax ) and relative values in relation to the mean
HR (%HRmean ). HRmax was obtained during the incremental
VO2max test or during training. In a few cases, higher HRmax
was measured during training sessions than during the
bicycle test. In all cases the highest achieved heart rate was
used as HRmax .
3. Results
2.4.6. Musculoskeletal Impact: Player Load Measurements.
To determine the musculoskeletal impact, player load (PL)
was obtained via accelerometry, combining the accelerations
produced in three planes of body movement by means
of a 100-Hz triaxial accelerometer. Accumulated PL (r)
is an estimate of physical demand combining the instantaneous rate of change in acceleration in three planes,
namely, forward/backward X, sideways Y, and up/down
Z, using the following formula presented in the following
equation:
3.1. Baseline Data. No baseline differences between TG and
CG were observed for aerobic fitness, body composition, or
blood pressure; see Table 1. Likewise, no baseline differences
were observed for blood lipids, HbA1c, or BTMs; see Table 2.
Participant flow is presented in Figure 1, and baseline characteristics for the participants included in the intention-to-treat
analysis are presented in Tables 1 and 2.
3.2. Feasibility. The total number of supervised training
sessions was 15, corresponding to one session per week over
the 15-week intervention period. The attendance rate was
81%. The attendance rate for the home-based training was
0%. The main reasons for the participants not performing
the home-based training were (1) lack of motivation to
train on their own and (2) uncertainty about what drills to
perform and how to perform them. Total average training
time was 72.9±4.3 min. Mean HR during training was
104±12 beats/min, corresponding to 69.3±8.0% of individual
HRmax .
6
BioMed Research International
Enrolment
Assessed for eligibility (n=47)
Excluded (n=2)
Diabetes (n=1)
Blood pressure> 180/110 mmHg (n=1)
Randomised (n=45)
Allocation
Intervention group (n=30)
Control group (n=15)
Follow-Up
Lost to follow-up (n=6)
Lost to follow-up (n=3)
Illness (n=2)
Illness (n=1)
Disappointment with the intervention (n=2)
No follow-up test (n=2)
Increasing musculoskeletal pain (n=2)
Analysis
n=30
n=15
Figure 1: Study flow chart.
60
Percentage of total training time (%)
55
50
45
40
35
30
25
20
15
10
5
0
90% HRmax (n=26). Three of the subjects
never reached an intensity >80% of HRmax , and seven of
the subjects never reached an intensity >90% of HRmax . On
average, total PL was 121±37 arbitrary units, corresponding
to 2±0 PL/min. The average fraction of time spent in PL zone
0–1 was 98±1%, while the average fraction of time spent in
PL zones 1–2, 2–3, and 4–6 was in each case 0±0. The total
numbers of jumps were 3±3, while the total numbers of low
accelerations, moderate accelerations, and high accelerations
were 7±4, 3±2, and 3±3, respectively. The fraction of time with
player load in the forward plane (1D Fwd), sideways plane
BioMed Research International
7
Table 3: Between-group difference after 15 weeks of training.
TG
Change
Body composition
Weight (kg)
-1.1
-0.5
Body Mass Index (kg/m2 )
Total muscle mass (kg)
0.4
Total fat percentage (%)
-1.4
Total fat mass (kg)
-1.4
Android fat mass (kg)
-0.2
Gynoid fat mass (kg)
-0.3
0.000
Total bone mineral density (g/cm2 )
Total bone mineral content (kg)
-0.004
Aerobic Fitness
15.5
VO2max (mLO2 /min)
0.7
VO2max (mL/min/kg)
Resting heart rate (bpm)
1
Blood pressure
Systolic blood pressure (mmHg)
-5
Diastolic blood pressure (mmHg)
-4
Mean arterial blood pressure (mmHg)
-4
Lipids
Total Cholesterol (mmol/L)
-0.2
HDL-Cholesterol (mmol/L)
0.0
LDL-Cholesterol (mmol/L)
0.0
Triglyceride (mmol/L)
-0.2
Total Chol/HDL ratio
-0.2
Glycemic control
Fasting insulin (pmol/L)
-27.7
HbA1c %
0.1
CRP (mg/L)
-0.4
eAG (mmol/L)
0.1
Bone markers
Osteocalcin (𝜇g/L)
1.5
P1NP (𝜇g/L)
11.5
CTX-1 (𝜇g/L)
-0.0
Sclerostin (ng/mL)
0.05
(n=30)
CG
(n=15)
Between-Group
Difference
(95% CI)
(95% CI)
Change
(95% CI)
(-2.0 to -0.2)
(-0.8 to -0.1)
(0.0 to 0.9)
(-2.1 to -0.7)
(-2.2 to -0.5)
(-0.3 to -0.1)
(-0.4 to -0.2)
(-0.001 to 0.011)
(-0.068 to -0.012)
1.3
0.4
0.5
0.2
0.6
0.1
0.0
0.012
-0.030
(-0.0 to 2.6)
(-0.1 to 0.8)
(-0.2 to 1.2)
(-0.8 to 1.2)
(-0.6 to 1.9)
(-0.1 to 0.2)
(-0.2 to 0.3)
(0.003 to 0.021)
(-0.071 to 0.010)
-2.3∗∗
-0.8∗∗
0.0
-1.6∗
-2.0∗
-0.3∗∗
-0.3∗
-0.007
-0.009
(-4.0 to -0.7)
(-1.4 to -0.3)
(-0.9 to 0.9)
(-2.8 to -0.3)
(-3.5 to -0.5)
(-0.4 to -0.1)
(-0.6 to -0.1)
(-0.018 to 0.004)
(-0.060 to 0.042)
0.006
0.004
0.974
0.014
0.010
0.003
0.010
0.220
0.712
(-75.3 to 106.4)
(-0.4 to 1.8)
(-1 to 3)
84.9
0.4
1
(-58.8 to 228.7)
(-1.3 to 2.1)
(-2 to 4)
-69.4
0.3
0
(-244.3 to 105.5)
(-1.8 to 2.3)
(-3 to 4)
0.423
0.790
0.895
(-9 to -1)
(-6 to -1)
(-7 to -1)
-4
-2
-3
(-10 to 2)
(-5 to 1)
(-7 to 1)
-1
-1
-1
(-9 to 7)
(-5 to 3)
(-6 to 4)
0.752
0.522
0.597
(-0.4 to 0.1)
(-0.1 to 0.1)
(-0.2 to 0.3)
(-0.3 to 0.0)
(-0.4 to 0.1)
0.1
0.1
0.3
-0.2
0.0
(-0.3 to 0.5)
(0.0 to 0.2)
(0.0 to 0.6)
(-0.4 to 0.0)
(-0.3 to 0.3
-0.3
-0.1
-0.2
0.0
-0.2
(-0.7 to 0.2)
(-0.2 to 0.0)
(-0.6 to 0.2)
(-0.3 to 0.3)
(-0.6 to 0.2)
0.254
0.165
0.264
0.919
0.404
(-38.4 to -17.0)
(0.0 to 0.1)
(-1.2 to 0.3)
(0.0 to 0.2)
-34.5
0.0
-0.6
0.1
(-49.1 to -19.9)
(0.0 to 0.1)
(-1.6 to 0.4)
(0.0 to 0.2)
6.8
0.0
0.2
0.0
(-11.4 to 25.0)
(-0.1 to 0.1)
(-1.1 to 1.4)
(-0.1 to 0.2)
0.451
0.810
0.794
0.669
(-0.4 to 3.5)
(5.1 to 18.0)
(-0.1 to 0.1)
(-0.0 to 0.1)
0.1
1.4
0.0
0.03
(-2.5 to 2.7)
(-7.2 to 10.0)
(-0.1 to 0.1)
(-0.1 to 0.1)
1.4
10.1
0.0
0.02
(-1.8 to 4.7)
(-0.7 to 20.9)
(-0.1 to 0.1)
(-0.1 to 0.1)
0.379
0.066
0.705
0.696
P- Value
TG: training group. CG: control group. Within-group data are presented as mean change (95% CI) and between-group data as estimated mean difference (95%
CI). ∗ denotes significant between-group effect (P
Purchase answer to see full
attachment
