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To investigate relationships between weight loss and weight loss maintenance with cardiac autonomic function and exercise in obesity, 39 adults (45.7±10.7 years; BMI: 34.2±3.4 kg/m2) participated in a 10-week, medical weight loss program combined with aerobic exercise. A subset (n=18) participated in an aerobic exercise weight loss maintenance program (550 or 970 MET minutes/week) for 18 additional weeks. Primary outcomes included markers of cardiac autonomic function assessed by heart rate variability (HRV) (i.e., SDNN, RMSSD, HFln). Following weight loss, we observed significant improvements for SDNN (48.2±19.1 vs. 55.1±25.9 ms, p=0.03) RMSSD (37.7±24.0 vs. 47.9±29.1 ms, p=0.002), and HFln (5.88±1.34 vs. 6.32±1.28 ms, p=0.001). Regression analyses showed fasting insulin concentration predicted 24% and 27% of the variance in RMSSD (r2=0.236, p=0.007) and HFln (r2=0.274, p=0.004), respectively. Following weight loss maintenance, no significant changes in HRV were observed. Changes in LDL (r=–0.54, p=0.04) and non-HDL (r=–0.77, p=0.001) were inversely associated with RMSSD changes. Clinically significant weight loss via caloric restriction and aerobic exercise improved HRV markers of cardiac vagal modulation. Following weight loss maintenance, we did not observe any further changes in HRV. Thus, our data suggests commonly prescribed exercise volumes contribute to maintenance of parasympathetic modulation following medical weight loss programming and exercise.

BACKGROUND: Little is known about predictors of activity participation that are objectively measured in cardiac rehabilitation (CR) graduates. This prospective observational study aimed to determine the predictors of objectively measured activity participation among adults with chronic cardiac conditions who have completed Phase II CR. METHODS: Twenty-five adults with chronic cardiac conditions graduating from traditional CR program participated in the study. The outcome variable was an activity participation level measured by light-to-vigorous intensity physical activity (LVPA) minutes using ActiGraph GT9X Link accelerometer after CR discharge. Covariates were collected at the discharge from CR, and outcome variables were collected at 1 month, 3 months, and 9 months post CR discharge. RESULTS: Gender, standardized LVPA at CR discharge, body mass index, and motivation for physical activity and leisure were significantly associated with the activity participation levels at 1 month, 3 months, and/or 9 months post CR discharge. Gender, standardized LVPA at CR discharge, highest education completed, and depressive symptoms significantly predicted the activity participation levels at 1 month (R2 = 0.69, p

Introduction: Clinically significant weight loss is associated with health benefits for overweight and obese adults. Participation in adequate amounts of physical activity is critical for weight maintenance. However, few studies in the literature have evaluated the amount of physical activity needed to promote weight maintenance in a supervised exercise training study with corresponding data on cardiovascular risk factors. Methods: Overweight and obese adults (N=39) completed a 10-week OPTIFAST ® weight loss program with supervised aerobic exercise training with the goal of achieving clinically significant weight loss (≥7%). Participants who met the weight loss goal were randomized to levels of aerobic training consistent with physical activity recommendations (PA-REC) (~550 MET minutes per week) or weight maintenance recommendations (WM-REC) (~970 MET minutes per week) for 18 additional weeks. Weight, body composition, and blood measures (e.g., fasting glucose, insulin, and lipids) were measured at baseline, after weight loss (10 weeks), and at follow-up (28 weeks). Results: Thirty-three of the 39 participants achieved clinically significant weight loss (~85%). There were reductions in weight (-8.8 kg), body fat (-2.1%), visceral fat (-120.4 g), along with other health indicators (systolic blood pressure [-6.8 mmHg], diastolic blood pressure [-5.9 mmHg], HOMA-IR [-2.4] and lipids) after the weight loss phase (all p’s< 0.05). Full data for the weight maintenance phase were available in 21 participants due to the COVID pandemic (PA-REC: 12, WM-REC:9). Larger improvements in cardiorespiratory fitness (as assessed by estimated METs [1.7 vs. 0 METs, p=0.01] and relative VO 2 peak [2.3 vs.0.5 ml/kg/min, p=0.04]) were observed in the WM-REC group compared to the PA-REC group, while changes in waist circumference (-2.4 vs. 0.5 cm, p=0.06), visceral fat (-45.7 vs. 8.2 g, p=0.06), and absolute VO 2 (0.1 vs. 0.2 L/min, p=0.09) approached significance. No significant changes were observed between groups for changes in weight, blood pressure, glucose metabolism, or lipid parameters during the maintenance phase (all ps>0.05). Discussion: Clinically significant weight loss combined with aerobic exercise resulted in improvements in cardiometabolic parameters. Exercise at levels associated with the weight maintenance guidelines resulted in greater improvements in cardiorespiratory fitness and may have the potential to improve measures of central adiposity to a greater extent than the minimum physical activity recommendations following weight loss. Future studies should evaluate the impact of different levels of aerobic exercise after clinically significant weight loss in long term interventions.

PURPOSE Epidemiological studies suggest that sedentary behavior is an independent risk factor for cardiovascular mortality independent of meeting physical activity guidelines. However, limited evidence of this relationship is available from prospective interventions. The purpose of the present study is to evaluate the combined effect of aerobic training and increasing nonexercise physical activity on body composition and cardiometabolic risk factors. METHODS Obese adults (N = 45) were randomized to 6 months of aerobic training (AERO), aerobic training and increasing nonexercise physical activity (~3000 steps above baseline levels; AERO-PA), or a control (CON) group. The AERO and AERO-PA groups performed supervised aerobic training (3-4 times per week). The AERO-PA group wore Fitbit One accelerometers and received behavioral coaching to increase nonexercise physical activity. RESULTS There was a larger increase in fitness in the AERO-PA group (0.27 L·min-1; confidence interval (CI), 0.16 to 0.40 L·min-1) compared with the AERO group (0.09 L·min-1; CI, -0.04 to 0.22 L·min-1) and the CON group (0.01; CI, -0.11 to 0.12 L·min-1). Although significant findings were not observed in the entire study sample, when the analysis was restricted to participants compliant to the intervention (n = 33), we observed significant reductions in waist circumference, percent weight loss, body fat, 2-h glucose, and 2-h insulin in comparison to the CON group (P < 0.05), but not the AERO group. Furthermore, linear regression models showed that change in steps was associated with 21% and 26% of the variation in percent weight loss and percent fat loss, respectively. CONCLUSIONS Increasing nonexercise physical activity with aerobic training may represent a viable strategy to augment the fitness response in comparison to aerobic training alone and has promise for other health indicators.

PURPOSE: To examine the impact of a community-based exercise training intervention on cardiometabolic outcomes in African American men who have a family history of type 2 diabetes. METHODS: The Aerobic Plus Resistance Training and Insulin Sensitivity in African American Men (ARTIIS) study randomized participants into either an exercise training intervention or an information only control group for 5 months. The exercise training intervention consisted of 150 minutes of moderate intensity aerobic activity and two days of resistance training per week, consistent with the current federal physical activity guidelines. Participants in the control group received monthly newsletters featuring topics focused heavily on type 2 diabetes education and prevention. Outcome data were analyzed using repeated measures analysis of covariance (ANCOVA) models and incorporating both intention-to-treat and per-protocol principles. RESULTS: Adherence to the aerobic and resistance training prescriptions were between 77% and 79%. Despite significant within group improvements in glucose and insulin levels (fasting, 2-hour, 2-hour minus baseline) and Homeostatic Model 2-Insulin Resistance, there were not significant between group differences. There was a marginally significant between group difference for Homeostatic Model 2-Beta (p < 0.06), and significant between group differences in peak cardiorespiratory fitness (p < 0.001) and waist circumference (p = 0.03). CONCLUSION: These findings suggest that exercise training in accordance with the current national recommendations is effective in improving some health parameters in middle-aged African American men who have a family history of type 2 diabetes, but did not have a significant impact on glycemic status. TRIAL REGISTRATION: The study is registered in clinicaltrials.gov [].

Background: Step-counting interventions with discrepant intensity emphases may elicit different effects. Methods: A total of 120 sedentary/low-active, postmenopausal women were randomly assigned to one of the following 3 groups: (1) 10,000 steps per day (with no emphasis on walking intensity/speed/cadence; basic intervention, 49 completers), (2) 10,000 steps per day and at least 30 minutes in moderate intensity (ie, at a cadence of at least 100 steps per minute; enhanced intervention, 47 completers), or (3) a control group (19 completers). NL-1000-determined steps and active minutes (a device-specific indicator of time at moderate+ intensity) were collected as process variables during the 12-week intervention. Outcome variables included systolic and diastolic blood pressure, anthropometric measurements, fasting blood glucose and insulin, flow-mediated dilation, gait speed, and ActiGraph GT3X+-determined physical activity and sedentary behavior. Results: The “basic group” increased 5173 to 9602 steps per day and 9.2 to 30.2 active minutes per day. The “enhanced group” similarly increased 5061 to 10,508 steps per day and 8.7 to 38.8 active minutes per day. The only significant change over time for clinical variables was body mass index. Conclusions: Interventions that use simple step-counters can achieve elevated volume and intensity of daily physical activity, regardless of emphasis on intensity. Despite this, few clinical outcomes were apparent in this sample of postmenopausal women with generally normal or controlled hypertension.

Purpose To investigate the changes in activities and participation, and mental and physical functions for 9 mo after cardiac rehabilitation (CR) among adults with chronic cardiac conditions. Methods Twenty-five adults with chronic cardiac conditions scheduled for discharge from CR were assessed at four different times: within 2-wk window of CR discharge date, 1 mo, 3 mo, and 9 mo after CR discharge. Nine assessments according to the International Classification of Functioning, Disability and Health were used to track the changes post-CR. Results Participants showed significant changes in the Cognitive Instrumental Activities of Daily Living adequacy of Performance Assessment of Self-Care Skills-Clinic (F = 8.10, P = .017) and improvements in the applied cognitive domain of the Activity Measure for Post-Acute Care Outpatient Short Form (F = 4.493, P = .016). Participants also showed significant decline in the CogState Detection test (F = 3.307, P = .045), the Physical Activity and Leisure Motivation Scale (PALMS) (F = 4.749, P = .005), and the affiliation subscale of the PALMS (F = 5.316, P = .002), and improvements in the 6-min walk test (F = 9.000, P = .011). Lastly, participants showed depressive symptoms for 3 mo post-CR. No other significant changes were detected among other outcome measures. Conclusions Adults with chronic cardiac conditions discharged from site-based CR maintained their activity and participation level following discharge with little improvement. They also showed depressive symptoms and decreased motivation for physical activity post-CR.

Background: Body composition and motor skill development are important for the engagement in physical activity and healthy development of children. This study examined the associations between body...

This study compared activity participation, and mental and physical functions of two different groups of adults with chronic cardiac conditions. Eleven participants were assessed at the immediate post-acute stage and 26 participants were at the distant post-acute stage. Participants at distant post-acute were significantly more physically active (

There is limited evidence on the impact of weight loss via caloric restriction and aerobic exercise on Life’s Simple 7 (LS7), a health assessment tool used by the American Heart Association to promote and track cardiovascular health (CVH) via modifiable risk factors and health behaviors. Individuals with obesity have a greater prevalence of traditional and non-traditional cardiometabolic risk factors than lean individuals. Objective: Examine the effect of a weight loss intervention on LS7 and assess predictors of change in adults with obesity. Methods: Twenty-six adults (44.9 ± 9.7 years; weight: 93.9 ± 11.1 kg; body mass index: 34.1 ± 3.4 kg/m 2 ) participated in a 10-week medical weight loss program (OPTIFAST) and supervised exercise training program (50-75% VO 2 max) to achieve clinically significant weight loss (≥7% body weight). Poor, intermediate, and ideal CVH categories were defined as scores 0 to 4, 5 to 9, and 10 to 14, respectively. Baseline and post-weight loss LS7 scores were calculated via participant demographics, smoking status, anthropometry, physical activity level, diet intake, and blood lab reports. Paired samples t-test and Pearson’s correlations were used. Results: Mean weight loss was significant (-9.2 ± 3.6 kg, p < 0.001). Mean LS7 score significantly increased from baseline to weight loss (7.3 ± 1.5 vs. 9.6 ± 1.2, respectively, p < 0.001) and 57.7% of participants (15 of 26) improved to ideal CVH following weight loss. A significant inverse association was observed between change in LS7 and systolic blood pressure ( r = -0.41, p < 0.05), total cholesterol ( r = -0.45, p < 0.05), and glucose ( r = -0.41, p < 0.05). There were no further significant relationships with LS7 (i.e. change in weight, body mass index, physical activity, diastolic blood pressure). Discussion: A combined caloric restriction and aerobic exercise training intervention improved a multitude of cardiovascular disease risk factors. Previous epidemiological studies indicate meeting the ideal LS7 metrics is associated with 78% and 49% reduced risk of cardiovascular disease morbidity and mortality, respectively. Thus, the long-term modification of health behaviors and cardiometabolic risk factors to achieve ideal cardiovascular health may reduce risks of cardiovascular morbidity and mortality in individuals with obesity.

Clinically significant weight loss is associated with health benefits for overweight and obese adults. Participation in adequate amounts of physical activity is critical for weight maintenance. However, the recommended amount of physical activity needed to promote weight maintenance is based primarily on retrospective studies that quantified physical activity levels through questionnaires which tend to overestimate physical activity levels. In addition, the present literature has provided little data on the impact of these physical activity levels on cardiovascular and diabetes risk factors, which may have equal or more clinical importance than weight changes. The Prescribed Exercise to Reduce Recidivism After Weight Loss-Pilot (PREVAIL-P) study will evaluate the effect of aerobic exercise training amount on weight maintenance following clinically significant weight loss in overweight and obese adults (BMI 25–40 kg/m2) age 30–65 years. Participants (N = 39) will complete a 10-week OPTIFAST® weight loss program with supervised aerobic exercise training. Individuals who achieve ≥7% weight loss from baseline will be subsequently randomized to levels of aerobic training consistent with physical activity recommendations (PA-REC) or weight maintenance recommendations (WM-REC) for 18 additional weeks. The primary outcome of the PREVAIL-P study will be change in weight from the completion of OPTIFAST® program to the end of the study. Notable secondary measures include changes in clinically relevant cardiometabolic risk factors between study groups (e.g. blood lipids concentrations, oral glucose tolerance, arterial stiffness). This pilot study will be used to estimate the effect sizes needed for a randomized controlled trial on this topic.

Objective: The OPTIFAST diet has known effects for weight loss, but little data exists on the effects of the diet on arterial stiffness. Methods: Overweight and obese (BMI: 34.5 + 4.0) adults (N=17) participated in a 10-week OPTIFAST™ weight loss program and supervised aerobic exercise training (50%-75% VO 2 max). The diet consisted of OPTIFAST meal replacement products with a goal of reducing total caloric intake to 800 kcals/day and attending a weekly weight management class. Aerobic exercise was performed 3 times per week and the exercise volume was progressed from 300 to 700 MET mins. per week at an intensity of 50%-75% VO2 max. The goal of study participants was to achieve a 7% weight loss. Carotid-to-femoral pulse wave velocity, blood pressure (aortic and brachial), vascular age, augmentation index and blood samples were measured in the morning after an overnight fast at baseline and follow-up. A paired t-test was performed to evaluate the change in outcomes variables. Results: The mean percent weight loss in the sample was 9.0% (-8.5 kg), with 83.3% of participants achieving 7% weight loss (94.1% achieving ≥5%). The adherence to the exercise program was 94.9% and attendance in the weight loss classes was 81.8%. There was a reduction in pulse wave velocity (-0.44 m/s, p=0.030), aortic systolic blood pressure (-10.5 mmHg, p0.05). Discussion: A hypo-caloric dietary program in combination with aerobic exercise training improves arterial stiffness, aortic blood pressure, and brachial blood pressure in overweight and obese adults An important limitation of the present study is that we cannot separate the health benefits of the diet from the exercise.

Obesity represents a major health problem in the United States and is associated with increased prevalence of cardiovascular (CV) disease risk factors. Physical activity (PA) and exercise training (ET) are associated with reduced CV risk, improved cardiometabolic risk factors, and facilitated weight loss through creating a negative energy balance. Clinicians need to counsel overweight and obese patients on how much PA/ET is needed to promote weight loss and weight loss maintenance. This will help establish realistic expectations and maximize improvements in CV risk factors. Although the minimum guidelines for aerobic PA (150 min of moderate or 75 min of vigorous physical activity per week) can improve CV health, these levels are generally inadequate for clinically significant weight loss or weight maintenance without caloric restriction. The purpose of this review is to evaluate the role of ET to promote clinically significant weight loss and promote weight maintenance. In particular, we will evaluate the likelihood of weight loss from ET programs composed of aerobic training only, resistance training only and programs that combine diet and ET. We will also explore the role of PA in promoting short-term and long-term weight maintenance.

African Americans (AAs) have a higher risk for cardiovascular disease (CVD) compared to their Caucasian American (CA) counterparts, which represents a major health disparity. Low cardiorespiratory fitness (CRF) is a well-established independent risk factor for all-cause and CVD mortality, which has been shown across many epidemiological and clinical trials to be lower in AAs compared to CAs. While much attention has been given to traditional health disparity risk factors (e.g. blood pressure, obesity, insulin resistance), the impact of racial differences in CRF on CVD mortality has not been widely considered. Thus, the purpose of this paper is to review the literature on: 1) the magnitude of racial differences in CRF and the potential clinical significance, 2) examine the relationships between CRF and mortality in AAs and CAs, 3) Potential physiological and behavioral etiologies for racial difference in CRF, and 4) the impact of exercise training on CRF and other cardiometabolic risk factors in AAs compared to CAs. Given that both CRF and change in CRF are associated with reduced CVD mortality, advocating aerobic exercise training or moderate to vigorous activities in AAs has the potential to reduce racial cardiovascular health disparities.

Objective This study examined relationships between specific types of physical activity (PA) and motor skill development in preschool-aged children. Design This study was completed using a cross-sectional study design. Methods Data from children 3−5 years old (N = 342, 51% males) who participated in the 2012 National Youth Fitness Survey were analyzed. PA was measured using a questionnaire by parent report and motor skill development determined by Test of Gross Motor Development-2nd Edition (TGMD-2). Multiple regression analyses were conducted to examine the relationship between PA type and overall Gross Motor Quotient (GMQ) controlling for age, sex, race, and parental socioeconomic status. Results Commonly reported activities were running (43%), playing outdoor games (35%), and riding a bike (34%). Based on the standard scores, participants’ motor skill development for Locomotor, Object Control, and overall GMQ were considered average. Participation in the following physical activities were positively associated with GMQ: riding a bike (β (SE) = 5.27 (2.02), p = 0.02), scooter riding (β (SE) = 9.83 (2.59), p = 0.002), swimming (β (SE) = 4.01 (1.17), p = 0.004), and jumping on a trampoline (β (SE) = 7.45 (3.09), p = 0.03). With the exception of riding a bike, the physical activities positively related to GMQ had a reported range of participation between 7–12%. Conclusions Participation in specific physical activities was related to higher GMQ in preschool-aged children. Also, with the exception of riding a bike, the activities that the children participated in the most were not the same as the activities that were positively related to motor skill development.

Background African Americans have a disproportionate prevalence and incidence of type 2 diabetes compared with Caucasians. Recent evidence indicates that low cardiorespiratory fitness (CRF) level, an independent risk factor for type 2 diabetes, is also more prevalent in African Americans than Caucasians. Numerous studies in Caucasian populations suggest that vigorous exercise intensity may promote greater improvements in CRF and other type 2 diabetes risk factors (e.g., reduction of glucose/insulin levels, pulse wave velocity, and body fat) than moderate intensity. However, current evidence comparing health benefits of different aerobic exercise intensities on type 2 diabetes risk factors in African Americans is negligible. This is clinically important as African Americans have a greater risk for type 2 diabetes and are less likely to meet public health recommendations for physical activity than Caucasians. The purpose of the HI-PACE (High-Intensity exercise to Promote Accelerated improvements in CardiorEspiratory fitness) study is to evaluate whether high-intensity aerobic exercise elicits greater improvements in CRF, insulin action, and arterial stiffness than moderate-intensity exercise in African Americans. Methods/Design A randomized controlled trial will be performed on overweight and obese (body mass index of 25–45 kg/m2) African Americans (35–65 years) (n = 60). Participants will be randomly assigned to moderate-intensity (MOD-INT) or high-intensity (HIGH-INT) aerobic exercise training or a non-exercise control group (CON) for 24 weeks. Supervised exercise will be performed at a heart rate associated with 45–55% and 70–80% of VO2 max in the MOD-INT and HIGH-INT groups, respectively, for an exercise dose of 600 metabolic equivalents of task (MET)-minutes per week (consistent with public health recommendations). The primary outcome is change in CRF. Secondary outcomes include change in insulin sensitivity (measured via an intravenous glucose tolerance test), skeletal muscle mitochondrial oxidative capacity (via near-infrared spectroscopy), skeletal muscle measurements (i.e., citrate synthase, COX IV, GLUT-4, CPT-1, and PGC1-α), arterial stiffness (via carotid-femoral pulse wave velocity), body fat, C-reactive protein, and psychological outcomes (quality of life/exercise enjoyment). Discussion The anticipated results of the HI-PACE study will provide vital information on the health effects of high-intensity exercise in African Americans. This study will advance health disparity research and has the potential to influence future public health guidelines for physical activity. Trial registration ClinicalTrials.gov identifier: NCT02892331. Registered on September 8, 2016. Electronic supplementary material The online version of this article (10.1186/s13063-019-3611-1) contains supplementary material, which is available to authorized users.

The combination of aerobic and resistance training (AER + RES) is recommended by almost every major organization to improve health-related risk factors associated with sedentary behavior. Since the release of the Physical Activity Guidelines for Americans in 2008, several large well-controlled trials and ancillary reports have been published that provide further insight into the effects of AER + RES on health-related outcomes. The current manuscript examines the literature on the effects of AER + RES on major clinical outcomes, including glucose homeostasis, cardiorespiratory fitness (CRF), and muscular strength, as well as other important clinical outcomes, including metabolic syndrome, hypertension, dyslipidemia, and quality of life. Collectively, research suggests that AER + RES and AER or RES alone improves glycemic control and insulin sensitivity compared with continued sedentary behavior. Significant changes in CRF are also observed, suggesting a reduction in cardiovascular disease-related mortality risk. Reduced adiposity, especially abdominal adiposity, and increased strength may also interact with CRF to promote additional health benefits associated with AER + RES. While findings from our review support current physical activity guidelines, a paucity of research limits the generalizability of the results.

Objective To determine response rates for clinically significant weight loss (CWL) following different aerobic exercise training amounts and whether enhanced cardiometabolic adaptations are observed with CWL compared to modest weight loss (MWL) or neither. Methods Participants (N = 330) performed 6 months of aerobic training at 4 kcal per kilogram per week (KKW), 8 KKW, or 12 KKW (50%, 100%, and 150% of recommended levels respectively). Weight loss was categorized as CWL (≥5%) or MWL (3.0% to 4.9%) or neither. Results The CWL response rate was greater in the 8 KKW group (20.2%, CI: 13.0% to 27.5%) compared to 4 KKW (10.3%, CI: 4.6% to 16.0%), but not compared to the 12 KKW group (14.6%, CI: 7.6% to 21.6%). Reductions in HOMA-IR were observed in participants with CWL (−0.60, CI: −0.98 to −0.22) and with MWL (−0.48, CI: −0.87 to −0.10), but not those who achieved neither (−0.06, CI −0.22 to 0.10). No changes between groups were observed for cholesterol, fitness, or blood pressure. Conclusions Low response rates for CWL were observed following training, even at levels above recommended levels. Achieving MWL with exercise may represent a reasonable initial weight loss target since the improvement in insulin resistance with MWL is similar to what is achieved with CWL.

Introduction: Previous studies have shown that lipoprotein particle size and lipoprotein subclasses are associated with cardiovascular and type 2 diabetes risk, and have independent prognostic value above traditional lipid concentrations. The impact of exercise training and increasing non-exercise physical activity on lipoprotein subclasses and size has not been previously investigated. Methods: In this pilot study, 35 obese adults were randomized to aerobic exercise training (50-75% of VO 2 max) (AERO, n=11), aerobic training and increasing non-exercise physical activity (AERO-PA, n=10, ~3,000 steps above baseline levels), or a non-exercise control group (n=14) for 6 months. Baseline and follow-up blood samples were analyzed for lipoprotein subclass, size, and lipoprotein insulin resistance score (LP-IR) using nuclear magnetic resonance spectroscopy (Liposcience, NC). Analysis of covariance was used to evaluate the change in outcome variables following the intervention across groups with adjustment for baseline value and age. Participants who changed lipid medications during the intervention (n=2) or who were non-adherent to exercise training (n=2) were excluded from the analysis. Results: Significant reductions were observed for mean VLDL size in the AERO-PA group (-4.7 nm, CI: -8.7 to -0.8) compared to control group (0.7 nm, CI: -2.7 to 4.4) and the AERO group (1.1 nm, CI: -2.9 to 5.0). Reductions in triglyceride concentrations were observed in the AERO-PA group (-28.3 mg/dL, CI: -50.3 to -6.4) compared to control (4.1 mg/dL, CI: -14.6 to 22.8). Additionally, we observed a trend for LP-IR index (p=0.055) and the concentration of small HDL particles (p=0.093) to decrease in the AERO-PA group compared to controls, with no differences compared to the AERO group (p>0.10). No significant changes were observed for other notable lipoprotein measures, such as LDL size, HDL size, concentration of small LDL particles, or chylomicron measures (p>0.05). In the AERO-PA group, the change in steps was associated with the change in LP-IR index (r= -0.71, p=0.013), but not with change in VLDL size (r= -0.24, p=0.463) or triglyceride concentrations (r=-0.28, p=0.388). Conclusions: Aerobic training combined with increasing non-exercise physical activity leads to favorable changes in the lipoprotein profile, specifically reductions in VLDL size and triglycerides, and may have promise for other lipoprotein traits (reductions in LP-IR and small HDL particles) that were not observed with aerobic training alone.

Purpose The purpose of this study is to evaluate the effect of exercise training with modest or greater weight loss (≥3%) or not (

Recent data has suggested that prolonged sedentary behavior is independent risk factor for cardiovascular and all-cause mortality independent of adequate amounts of moderate to vigorous physical activity. However, few studies have prospectively evaluated if exercise training and increasing non-exercise physical activity leads to greater reduction in cardiometabolic risk compared to aerobic training alone. The purpose of the Intervention Composed of Aerobic Training and Non-Exercise Physical Activity (I-CAN) study is to determine whether a physical activity program composed of both aerobic training (consistent with public health recommendations) and increasing non-exercise physical activity (3000 steps above baseline levels) leads to enhanced improvements in waist circumference, oral glucose tolerance, systemic inflammation, body composition, and fitness compared to aerobic training alone in obese adults (N=45). Commercially available accelerometers (Fitbits) will be used to monitor physical activity levels and behavioral coaching will be used to develop strategies of how to increase non-exercise physical activity levels. In this manuscript, we describe the design, rationale, and methodology associated with the I-CAN study.

Dyslipidemia is a treatable risk factor for cardiovascular disease. Epidemiological studies have demonstrated the importance of treatment for abnormalities in total cholesterol, LDL-cholesterol, HDL-cholesterol and triglycerides. Aside from pharmacotherapy, exercise and cardio-respiratory fitness have been shown to have beneficial effects on decreasing cardiovascular disease risk. Even though previous data regarding the benefits of exercise on plasma lipids have been somewhat conflicting, numerous studies have demonstrated that exercise increases HDL-cholesterol and reduces the triglyceride levels. Also, smaller, more atherogenic LDL particles seem to decrease with increases in cardio-respiratory fitness and exercise, and favorable blood lipid profiles seem to persist longer through the adult life span.

Substantial evidence has established the value of high levels of physical activity, exercise training (ET), and overall cardiorespiratory fitness in the prevention and treatment of cardiovascular diseases. This article reviews some basics of exercise physiology and the acute and chronic responses of ET, as well as the effect of physical activity and cardiorespiratory fitness on cardiovascular diseases. This review also surveys data from epidemiological and ET studies in the primary and secondary prevention of cardiovascular diseases, particularly coronary heart disease and heart failure. These data strongly support the routine prescription of ET to all patients and referrals for patients with cardiovascular diseases, especially coronary heart disease and heart failure, to specific cardiac rehabilitation and ET programs.

OBJECTIVE To evaluate the impact of exercise training (ET) on metabolic parameters among participants with type 2 diabetes mellitus (T2DM) who do not improve their cardiorespiratory fitness (CRF) with training. RESEARCH DESIGN AND METHODS We studied participants with T2DM participating in the Health Benefits of Aerobic and Resistance Training in Individuals With Type 2 Diabetes (HART-D) trial who were randomized to a control group or one of three supervised ET groups for 9 months. Fitness response to ET was defined as a change in measured peak absolute oxygen uptake (ΔVO2peak, in liters per minute) from baseline to follow-up. ET participants were classified based on ΔVO2peak into fitness responders (ΔVO2peak ≥5%) and nonresponders (ΔVO2peak RESULTS A total of 202 participants (mean age 57.1 ± 7.9 years, 63% women) were included. Among the exercise groups (n = 161), there was substantial heterogeneity in ΔVO2peak; 57% had some improvement in CRF (ΔVO2peak >0), with only 36.6% having a ≥5% increase in VO2peak. Both fitness responders and nonresponders (respectively) had significant improvements in hemoglobin A1c and measures of adiposity (ΔHbA1c: −0.26% [95% CI −0.5 to −0.01] and −0.26% [−0.45 to −0.08]; Δwaist circumference: −2.6 cm [−3.7 to −1.5] and −1.8 cm [−2.6 to −1.0]; Δbody fat: −1.07% [−1.5 to −0.62] and −0.75% [−1.09 to −0.41]). No significant differences were observed in the degree of change of these metabolic parameters between fitness responders and nonresponders. Control group participants had no significant changes in any of these metabolic parameters. CONCLUSIONS ET is associated with significant improvements in metabolic parameters irrespective of improvement in cardiorespiratory fitness.

Irisin is a recently discovered myokine that increases adipocyte metabolism, induces further "browning" of white adipose tissue, and enhances glucose metabolism. No study has ever determined how an acute bout of exercise impacts immediate post-exercise irisin concentration using a meta-analytic approach. The purpose of this study is to determine the impact of an acute bout of exercise on the magnitude of post-exercise irisin concentration in adults using meta-analytic procedures. Searches were performed on PubMed, EMBASE, CINAHL, PEDro, SCOPUS, and SPORTDiscus databases. Effect summaries were obtained using random-effects models. Random-effects single and multiple meta-regressions were performed to determine relationships between, and potential confounding effects of, variables of interest. Ten articles were retained for the final meta-analysis, producing 21 study estimates. An acute bout of exercise was accompanied by a post-exercise average increase in irisin concentration of 15.0 (95% CI: 10.8%-19.3%). There was no significant relationship between post-exercise irisin concentration and age, intensity of aerobic exercise, or type of exercise training session (resistance vs aerobic training). Fitness level and body mass index were identified as significant predictive variables for post-exercise irisin concentration. However, a multiple meta-regression model identified fitness level as the single best predictor, with being fit (21.1%±2.2%) associated with a nearly twofold increase in post-exercise irisin concentration, compared with being unfit (11.8%±2.1%). Immediately following an acute bout of exercise, irisin concentration increases substantially in adults, with fitness level as an important modifier for the effect.

Introduction: Cardiorespiratory fitness (CRF) is an independent risk factor for cardiovascular disease (CVD). Recent data suggests that African Americans (AA) have reduced levels of CRF compared to Caucasian Americans (CA). However, this viewpoint has not been widely accepted and it is unclear whether racial differences in CRF may be of a large enough magnitude to increase the risk of CVD. Methods: A literature review was conducted for studies comparing CRF levels between AA and CA adults. Studies were eligible for inclusion if CRF was assessed by an exercise test (submaximal or maximal), CRF was compared between AA and CA adults, examined an adult study population, and was published in a peer-reviewed journal. Potential studies were excluded if the sample included children or adolescents, the sample size was less than 15 participants in each racial group, or the study evaluated participants who had significant health conditions. Meta-analyses were performed comparing CRF between AAs and CAs in two analyses: 1) all studies compared using metabolic equivalents (METs) and 2) restricted only to studies that quantified CRF by directing measuring maximal oxygen consumption (considered the gold standard). Both fixed effects and random effects models were fit to these data. Because of the heterogeneity only results from the random effects models are reported. Analyses were performed using R (version 3.1, R Foundation for Statistical Computing, Vienna, Austria. URL https://www.R-project.org/) and the rmeta package (version 2.6). Results: There were 27 studies (n=131,084) that that met the criteria for the meta-analysis (23 studies excluded). In both the analyses for METs (27 studies, Summary effect: 0.91, CI: 0.8 to 1.0) and directly measured VO 2 max (16 studies, Summary effect: 3.2, CI: 2.1 to 4.3) as the criteria for CRF, AA had lower fitness compared to CA adults. Conclusions: The present study suggests that AAs have lower CRF compared to CAs based on epidemiological studies and clinical trials whether directly measured using indirect calorimetry or maximal METs estimated from exercise testing. A difference of 0.91 METs is associated with ~13.7% higher risk of CVD based on previous epidemiological data. Thus, lower CRF in AA adults may represent a health disparity risk factor and interventions to improve CRF in sedentary AAs may be warranted.

To evaluate the effectiveness of a 3-month treadmill desk intervention in eliciting changes in physical activity and sedentary behavior among overweight/obese office workers.A randomized controlled trial was conducted among overweight/obese office workers (n = 41; mean age = 40.1 ± 10.1 years) at a private workplace. Participants were randomly assigned to a shared-treadmill desk intervention (n = 21) or a usual working condition control group (n = 20). Accelerometer-determined physical activity and sedentary behavior were measured before and after the intervention.Compared with the control group, the intervention group increased daily steps (1622 steps/day; P = 0.013) and light physical activity (1.6 minutes/hour; P = 0.008), and decreased sedentary time (-3.6 minutes/hour; P = 0.047) during working hours.Shared-treadmill desks in the workplace can be effective at promoting favorable changes in light physical activity (specifically 40 to 99 steps/minute) and sedentary behavior among overweight/obese office workers.

We report experiences, observations, and general lessons learned, specifically with regards to participant recruitment and adherence, while implementing a 6-month randomized controlled treadmill desk intervention (the WorkStation Pilot Study) in a real-world office-based health insurance workplace. Despite support from the company’s upper administration, relatively few employees responded to the company-generated e-mail to participate in the study. Ultimately only 41 overweight/obese participants were deemed eligible and enrolled from a recruitment pool of 728 workers. Participants allocated to the Treadmill Desk Group found the treadmill desk difficult to use for 45 min twice a day as scheduled. Overall attendance averaged 45%–50% of all possible scheduled sessions. The most frequently reported reasons for missing sessions included work conflict (35%), out of office (30%), and illness/injury/drop-out (20%). Although focus groups indicated consistently positive comments about treadmill desks, an apparent challenge was fitting a rigid schedule of shared use to an equally rigid and demanding work schedule punctuated with numerous tasks and obligations that could not easily be interrupted. Regardless, we documented that sedentary office workers average ∼43 min of light-intensity (∼2 METs) treadmill walking daily in response to a scheduled, facilitated, and shared access workplace intervention. Workstation alternatives that combine computer-based work with light-intensity physical activity are a potential solution to health problems associated with excessive sedentary behavior; however, there are numerous administrative, capital, and human resource challenges confronting employers considering providing treadmill desks to workers in a cost-effective and equitable manner.

Concomitant type 2 diabetes (T2D) and metabolic syndrome exacerbates mortality risk; yet, few studies have examined the effect of combining (AER+RES) aerobic (AER) and resistance (RES) training for individuals with T2D and metabolic syndrome. Methods: We examined AER, RES, and AER + RES training (9 months) commensurate with physical activity guidelines in individuals with T2D (n = 262; 63% female, 44% black). Primary outcomes were change in, and prevalence of, metabolic syndrome score at follow-up (mean and 95% confidence interval [CI]). Secondary outcomes included maximal cardiorespiratory fitness (V·O2peak) and estimated METs from time-to-exhaustion (TTE) and exercise efficiency calculated as the slope of the line between ventilatory threshold, respiratory compensation, and maximal fitness. General linear models and bootstrapped Spearman correlations were used to examine changes in metabolic syndrome associated with training primary and secondary outcome variables. Results: We observed a significant decrease in metabolic syndrome scores (P for trend = 0.003) for AER (-0.59, 95% CI = -1.00 to -0.21) and AER + RES (-0.79, 95% CI = -1.40 to -0.35), both being significant (P P < 0.05), which was more strongly related to TTE (25%–30%;r = -0.38, 95% CI = -0.55 to -0.19) than V·O2peak (5%–6%; r = -0.24, 95% CI = -0.45 to -0.01). Conclusions: AER and AER + RES training significantly improved metabolic syndrome scores and prevalence in patients with T2D. These improvements appear to be associated with improved exercise efficiency and are more strongly related to improved TTE versus V·O2peak.

High levels of obesity among African American women have been hypothesized to be partially resultant from a lower resting metabolic rate compared with white women. The aim of the current study was to determine if differences in cardiorespiratory fitness and moderate-to-vigorous physical activity are associated with differences in resting metabolic rate among free-living young adult African American women and white women.Participants were 179 women (white women n = 141, African American women n = 38, mean age = 27.7 years). Resting metabolic rate was measured using indirect calorimetry, body composition using dual energy x-ray absorptiometry, cardiorespiratory fitness via maximal treadmill test, and moderate-to-vigorous physical activity using an activity monitor.African American women had higher body mass index, fat mass, and fat-free mass compared with white women but lower levels of cardiorespiratory fitness. No differences were observed between African American and white women in resting metabolic rate when expressed as kcal/day (1390.8 ± 197.5 vs 1375.7 ± 173.6 kcal/day, P = .64), but African American women had a lower resting metabolic rate when expressed relative to body weight (2.56 ± 0.30 vs 2.95 ± 0.33 mL/kg/min, P.001). After statistical adjustment for differences in body composition between groups using linear regression models, African American women had a lower resting metabolic rate compared with white women (1299.4 ± 19.2 vs 1400.4 ± 9.2 kcal/day, P.001). The addition of cardiorespiratory fitness reduced the differences among groups by 25%. The addition of moderate-to-vigorous physical activity did not improve the model.The present study confirms that African American women have a lower resting metabolic rate compared with their white peers, and low cardiorespiratory fitness explained 25% of this difference. Variables associated with resting metabolic rate, such as cardiorespiratory fitness, represent possible points of tailored interventions designed to address high levels of obesity seen in certain demographic groups.

There is substantial evidence that lipids are critical in the development and progression of atherosclerotic cardiovascular disease. In November 2013, the American College of Cardiology/American Heart Association in conjunction with the National Cholesterol Education Program IV developed new guidelines for the treatment of blood cholesterol. In this report, we review these new guidelines and emphasize the potential benefits of physical activity and exercise training on plasma lipids.

Date Presented 04/06/19 This prospective observational study investigates the changes people with chronic cardiac conditions may experience after discharged from cardiac rehabilitation. The findings advance OT practitioners’ knowledge on short-term and long-term changes in physical activity and participation level, cognition, motivation, and fatigue and understanding of OT roles for people with chronic cardiac conditions who are postacute and postcardiac rehabilitation. Primary Author and Speaker: Young Joo Kim Additional Authors and Speakers: Jonathan Reeve, Deena Walters, Molly Young Contributing Authors: Patricia Crane, Joseph Houmard, Damon Swift

OBJECTIVE Low cardiorespiratory fitness (CRF) is an independent risk factor for cardiovascular disease (CVD), especially in individuals with type 2 diabetes. Age-predicted, sex-stratified, and maximal MET cut points have been developed to determine the risk of CVD events and mortality in low CRF categories. We examined the proportion of Health Benefits of Aerobic and Resistance Training in Individuals With Type 2 Diabetes (HART-D) participants above these cut points before and after 9 months of aerobic training (AT), resistance training (RT), or a combination of both (ATRT). RESEARCH DESIGN AND METHODS Participants from the HART-D study (n = 196) who were randomly assigned to exercise training (AT, RT, or ATRT) or to a nonexercise control group between April 2007 and August 2009 were used in this ancillary study. Cut points were previously established for age-predicted METs (>100% and >85%, mean and increased CVD risk, respectively), age- and sex-stratified METs (Aerobic Center Longitudinal Study), and clinically discernible METs (men >8.0, women >6.5). RESULTS Baseline prevalence of participants above these cut points was similar for all intervention groups (P > 0.50) and ranged from 11.9% (>100% age predicted) to 55.1% (>85% age predicted). Baseline prevalence and age-, sex-, and race/ethnic group–adjusted percentage of participants above each cut point increased significantly after AT and ATRT (P < 0.05 for all). CONCLUSIONS Structured exercise training, especially the AT component, was associated with a greater number of participants moving above established cut points indicative of low CRF. These results have public health and clinical implications for the growing number of patients with type 2 diabetes at high risk for CVD.

Low cardiorespiratory fitness (CRF) is a well-established risk factor for all-cause and cardiovascular disease mortality. African Americans have higher rates of cardiovascular disease compared with their Caucasian counterparts. However, the extent to which lower CRF levels contribute to the excess risk in African Americans has not been fully explored. The purpose of this review is to: (i) explore the literature evaluating the relationship between CRF and mortality specifically in African American populations; and (ii) critically evaluate the studies which have compared CRF between African American and Caucasians in epidemiological studies and clinical trials. We have further discussed several potential mechanisms that may contribute to the observation of lower CRF levels in African American compared with Caucasian adults, including potential racial differences in physical activity levels, muscle fiber type distribution, and hemoglobin levels. If lower CRF is generally present in African Americans compared with Caucasians, and is of a clinically meaningful difference, this may represent an important public health concern.

OBJECTIVE To establish whether exercise improves quality of life (QOL) in individuals with type 2 diabetes and which exercise modalities are involved. RESEARCH DESIGN AND METHODS Health Benefits of Aerobic and Resistance Training in individuals with type 2 Diabetes (HART-D; n = 262) was a 9-month exercise study comparing the effects of aerobic training, resistance training, or a combination of resistance and aerobic training versus a nonexercise control group on hemoglobin A1c (HbA1c) in sedentary individuals with type 2 diabetes. This study is an ancillary analysis that examined changes in QOL after exercise training using the Short Form-36 Health Survey questionnaire compared across treatment groups and with U.S. national norms. RESULTS The ancillary sample (n = 173) had high baseline QOL compared with U.S. national norms. The QOL physical component subscale (PCS) and the general health (GH) subscale were improved by all three exercise training conditions compared with the control group condition (resistance: PCS, P = 0.005; GH, P = 0.003; aerobic: PCS, P = 0.001; GH, P = 0.024; combined: PCS, P = 0.015; GH, P = 0.024). The resistance training group had the most beneficial changes in bodily pain (P = 0.026), whereas physical functioning was most improved in the aerobic and combined condition groups (P = 0.025 and P = 0.03, respectively). The changes in the mental component score did not differ between the control group and any of the exercise groups (all P > 0.05). The combined training condition group had greater gains than the aerobic training condition group in the mental component score (P = 0.004), vitality (P = 0.031), and mental health (P = 0.008) and greater gains in vitality compared with the control group (P = 0.021). CONCLUSIONS Exercise improves QOL in individuals with type 2 diabetes. Combined aerobic/resistance exercise produces greater benefit in some QOL domains.

As an ancillary report to a large National Institutes of Health (NIH)–funded trial, we examined the effects of 6 months of exercise training at 50%, 100%, and 150% of the NIH Consensus Recommendations for physical activity (i.e., 4, 8, and 12 kcal/kg of energy expenditure/wk [KKW]) versus a nonexercise control group on the metabolic syndrome (MS) in sedentary, overweight, moderately hypertensive, postmenopausal women. We examined the clinically defined National Cholesterol Education Program MS, individual components scores, and summed z-scores, expressed as a continuous variable (zMS), using chi-square and general linear models to assess the clinical and progressive nature of MS, respectively. Our results showed significant improvements in zMS for all exercise groups and MS for the 8- and 12 KKW groups only (all, p for trend = 0.02). Post hoc analyses showed that 12 KKW for zMS and 8 and 12 KKW for MS was significant versus the control group (all, p

African American (AA) women have an elevated risk of cardiovascular disease and have been reported to have lower cardiorespiratory fitness (CRF) compared with Caucasian American (CA) women. However, little data exist that evaluate racial differences in the change in CRF following aerobic exercise training. CA ( n = 264) and AA ( n = 122) postmenopausal women from the Dose-Response to Exercise in Women study were randomized to 4, 8, and 12 kcal·kg body wt−1·wk−13 (KKW) of aerobic training or the control group for 6 mo. CRF was evaluated using a cycle ergometer. A greater increase in relative CRF was observed in CA compared with AA women in the 4 (CA: 1.00 vs. AA: 0.35 ml O2·kg−1·min −1, P = 0.034), 8 (CA: 1.59 vs. AA: 0.82 ml O2·kg−1·min −1, P = 0.041), and 12 (CA: 1.98 vs. AA: 0.50 ml O2·kg−1·min −1, P = 0.001) KKW groups. Similar effects were found in absolute CRF, with the exception of the 4-KKW (CA: 0.04 vs. AA: 0.02 l O2/min, P = 0.147) group. However, in categorical analyses, the percentages of women who improved in both relative (>0 ml O2·kg−1·min −1) and absolute (>0 l O2/min) CRF were not significantly different for CA and AA women in all exercise groups (all P > 0.05). AA postmenopausal women, in general, had an attenuated increase in CRF (both relative and absolute) following exercise training, but had similar response rates compared with CA women. Future studies should investigate the physiologic mechanisms responsible for this attenuated response.

There are substantial data demonstrating that regular physical activity has significant health benefits. However, until relatively recently, there has been no federally supported physical activity recommendations as there have been for decades for diet. In 2008, the first Federal Physical Activity Guidelines were released which recommend that adults should participate in at least 150 min (2 h and 30 min) a week of moderate-intensity, or 75 min (1 h and 15 min) a week of vigorous-intensity aerobic physical activity, or an equivalent combination of moderate- and vigorous-intensity aerobic activity. In addition to aerobic activity, adults should also participate in muscle-strengthening activities (resistance training) that involve all major muscle groups on 2 or more days a week. While there remain many areas that need more research, the available literature strongly supports the current guidelines, and these guidelines should serve as foundation for a clinical exercise prescription.

Background Exercise training reduces adiposity and risk of cardiovascular disease. However, the combined effects of habitual free-living physical activity and aerobic training on waist circumference, weight, fitness, and blood pressure in postmenopausal women are unknown. Purpose To evaluate the effects of habitual physical activity levels during aerobic training on weight, waist circumference, fitness, and blood pressure. Design Secondary analysis of an RCT. Original data collected April 2001 to June 2005 and analyzed in 2012. Setting/participants Postmenopausal women in a supervised exercise trial. Intervention Women ( n =325) were randomized to 4, 8, or 12 kcal/kg per week of aerobic training or a control group for 6 months. All outcome measures were collected at baseline and follow-up. Changes in dependent variables within each training group were evaluated across tertiles of pedometer-determined habitual physical activity outside exercise training sessions. Main outcome measures Changes in waist circumference and weight. Results Reductions in waist circumference were significantly greater with higher steps/day accumulated outside exercise training compared to lower levels in the 4 (high: −4.8 cm vs low: −1.4 cm, p =0.03); 8 (high: −4.2 cm vs low: −0.4 cm, p =0.03), and 12 kcal/kg per week groups (high: −4.1 cm vs low: −0.7 cm, p =0.05). For all groups, p -trend≤0.03. A trend was observed for greater weight reduction with higher steps/day in the 4 kcal/kg per week group ( p -trend=0.04) but not for the other exercise doses. No effects were observed for blood pressure or fitness measures (all p >0.05). Conclusions In postmenopausal women, higher habitual physical activity while participating in aerobic training was associated with greater reductions in central adiposity, and was supportive of weight loss compared to lower levels.

Excess weight is a strong predictor of incident breast cancer (BC) and survivorship. A limited number of studies comparing strategies for promoting successful weight loss in women with remitted BC exist.CASTLE was a pilot study comparing the effectiveness/feasibility of in-person and telephonic behavioral-based lifestyle weight loss interventions in BC survivors.Fifty-two overweight/obese women (BMI = 25-45 kg/m(2)) with remitted BC (stages I-IIIa) who recently completed cancer treatment were assigned to either an in-person group (n = 24) or an individual telephone-based condition (n = 11). Both interventions focused on increasing physical activity and reducing caloric intake. The phase I intervention lasted 6 months. The in-person condition received 16 group-based sessions, and the telephone condition received intervention calls approximately weekly. Phase II lasted 6 months (e.g., months 6-12), and all participants received monthly intervention calls via telephone.Participants were predominately Caucasian (80 %) with a mean age of 52.8 (8.0) years and BMI of 31.9 (5.4) kg/m(2). Mixed models ANOVAs showed significant within group weight loss after 6 months for both the in-person (-3.3 kg ± 4.4, p = 0.002) and the telephonic (-4.0 kg ± 6.0, p = 0.01) conditions with no between group differences. During phase II, the in-person group demonstrated significant weight regain (1.3 kg ± 1.7, p = 0.009).Our pilot study findings demonstrated that telephone-based behavioral weight loss programs are effective and feasible in BC survivors and that telephonic programs may have advantages in promoting weight loss maintenance.