96 Kyung-A Shin, et al. Exercise Capacity and Cardiovascular Risk Factors ORIGINAL ARTICLE Korean J Clin Lab Sci. 2013, 45(3):96-101 pissn 1738-3544 eissn 2288-1662 Association between Exercise Capacity and Cardiovascular Risk Factors among Obesity Types in Adult Man Kyung-A Shin 1, Hye-Young Kim 1, and Nam-Jeong Kim 2 1 Department of Clinical Laboratory Science, Shinsung University, Dangjin 343-861, Korea 2 Department of Occupational Health Center, Hospital of Ulsan University, Ulsan 682-714, Korea Increased waist circumference has shown to be more strongly associated with cardiovascular disease risk factors. The purpose of this study is to investigate the association between exercise capacity and cardiovascular risk factors among obese types in adult men. The subjects of this study were a total fifty-four obese persons and obesity criteria is body mass index (BMI) 25 kg/m 2. Diagnostic criteria for obesity was defined as a waist circumference of 90 cm. The BMI in the obese subjects, as judged by the presence or absence of abdominal obesity, were classified into two groups (non-ao: without abdominal obesity group, AO: with abdominal obesity group). AO presented lower total exercise time, metabolic equivalents (METs) than Non-AO. AO showed slow HRR (heart rate recovery) response. HRR was negative correlated with BMI, body fat mass, waist circumference. AO had a high heart rate and a low cardiac output in submaximal exercise stage 1 2. In conclusion, AO s (with abdominal obesity groups) total exercise time, METs and HRR are lower than Non-AO. HRR is related with BMI, body fat mass and waist circumference. Keywords: Waist circumference, Obesity, Cardiovascular risk factors, Heart rate recovery Corresponding author: Kyung-A Shin Department of Clinical Science, Shinsung University, Dangjin 343-861, Korea Tel: 82-41-350-1408 E-mail: mobitz2@daum.net This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Copyright 2013 The Korean Society of Clinical Laboratory Science. All rights reserved. Received: August 29, 2013 Revised: September 11, 2013 Accepted: September 11, 2013 서론비만은체내의과다한지방축적으로인해고혈압, 당뇨병, 심혈관계질환등의만성질환을유발하는위험요인으로알려져있으며 (Must 등, 1999), 최근신체활동의감소와식습관의변화에따른비만인구의급격한증가로인해세계적으로심각한건강상의문제로대두되고있다 (Haslam과 James, 2005). 비만의예방, 관리및치료를위해서는비만을정확하게판정하고평가하는것이중요하지만, 비만을평가하는다양한지표들중어떤방법이가장타당한지에대해서는아직까지논란이되고있다 ( 고와김, 2007). 비만을평가하는지표중체질량지수 (body mass index: BMI) 가보편적으로많이사용되고있으나, 체질량지수가정상이더라도복부비만을평가하는허리둘레, 허리둘레-엉덩이둘레비 (waist-hip ratio: WHR) 가높은중심성비만의경우인슐린저항성및당뇨병, 심혈관질환, 대사증후군등의발병위험이증가한다는결과들이제시되면서단순한체중과체지방량에의한비만이외에지방의분포부위, 특히복부비만에대한관심이높아지고 있다 (Must 등, 1999; Zhu 등, 2002). 또한비만유형중에서체질량지수에의한비만판정보다상대적으로허리둘레가증가된복부비만의경우고혈압과당뇨병, 대사증후군, 고콜레스테롤혈증등의위험도가증가하며 ( 강등, 2007; 이등, 2009), 복부지방은체질량지수보다좌심실비대의지표인좌심실질량과연관성이큰것으로보고되고있다 ( 임등, 2007). 특히심폐체력이높은사람은낮은사람에비해복부지방량, 내장지방량, 피하지방량이낮게나타나며, 비만과호흡순환기능은음의상관관계를보이는것으로알려져있다 (Wong 등, 2004). 그러나현재까지우리나라에서복부비만과관련된연구들은비만유형에따른안압, 지질대사, 신체구성, 운동, 식사및생활습관을비교한연구가주를이루고있으며, 비만유형에따른운동능력과심혈관위험요인간의관련성에관한연구는부족한실정이다 ( 김등, 2003; 고와김, 2007; 안등 ; 2007; 박등, 2010). 이에본연구에서는체질량지수에의해비만으로평가된피험자중복부비만이동반되는지의유무에따라운동부하검사중나타나는운동능력의지표들과심혈관위험요인의차이를확인하고그관련성을통해비만
Korean J Clin Lab Sci. Vol. 45, No. 3, Sep. 2013 97 의예방과관리에도움이되고자한다. 재료및방법 1. 연구대상자이연구는경기도 J 종합병원건강증진센터에서건강검진을실시한비만남성 54명을연구대상으로하였으며, 비만의진단기준은 WHO 서태평양지역회의에서정한체질량지수 25 kg/m 2 이상으로정의하였다 (WHO, 2000). 복부비만진단기준은대한비만학회의기준에의한남성허리둘레 90 cm 이상으로정의하였으며 ( 이등, 2006), 체질량지수에서비만으로판정된피험자를대상으로복부비만의유무에따라두집단으로분류하였다 (non-ao: 복부비만동반하지않은군, AO: 복부비만동반군 ). 고혈압, 당뇨병, 심혈관질환의과거력이있는대상자는이연구에서제외하였으며, 연구대상자들에게연구목적과방법을설명하고동의서를받고연구를진행하였다 (IRB no.: D-1207-008-2386). 2. 신체계측및체성분분석신체계측은생체전기저항분석법 (Bio-electrical impedance analyzer) 을이용한 Inbody 4.0 (Biospace Co., Seoul, Korea) 으로공복상태에서신장, 체중, 체지방량을측정하였다. 체질량지수는체중 (kg)/ 키 (m 2 ) 의공식을적용하였으며, 허리둘레는늑골하단부와장골능상부의중간지점에서숨을내쉰상태에서직립자세로양발을벌리고허리가완전히노출되게한후측정하였다. 엉덩이둘레는엉덩이에서둘레가가장넓은부분을측정하였으며, 혈압은앉은자세에서 10분간안정을취한뒤수은혈압계로측정하였다. 3. 혈액검사비만유형에따른심혈관위험요인을알아보기위한혈액검사는 8시간이상공복상태에서아침에상완정맥 (antecubital vein) 에서채혈을실시하였다. TBA-200FR NEO (Toshiba, Japan) 를이용하여호모시스테인, hs-crp (high sensitive C-reactive protein), HDL콜레스테롤, LDL콜레스테롤, 총콜레스테롤, 중성지방 (triglyceride), 공복혈당 (glucose), 요산 (uric acid) 을측정하였으며, Apolipoprotein A1, Apolipoprotein B는 Immunoturbidimetric 법 (KAMIYA, U.S.A) 에의한혈청분석방법으로측정하였다. 당화혈색소 (hemoglobin A1c) 검사는 Variant II (Bio Rad, U.S.A) 를이용하여고성능액체크로마토그래피 (high performance liquid chromatography, HPLC) 법으로측정하였다. NT-proBNP (B-type natriuretic peptide) 는 Cobas E601 analyzer (Roche Diagnostics, Germany) 장비를이용하여전기화학적발광면역분석법 (ECLIA) 으로측정하였다. 인슐린은 Modular analytics E-170 (Roche, U.S.A) 으로측정하였으며, 인슐린저항성을나타내는 Homeostasis Model Assessment of Insulin Resistance index (HOMA-IR) 는 [fasting insulin (μiu/ml) fasting plasma glucose (mmol/l)]/22.5 로계산하였다. 4. 말초혈관동맥경화도검사말초혈관동맥경화도의평가를위해좌우측발목상완지수 (ankle-brachial index, ABI) 와좌우측동맥혈관벽탄력도지표 (cardio-ankle vascular index, CAVI) 를 VaSera VS-1000 (Fukuda Denshi, japan) 을이용하여측정하였다. 측정방법은환자를앙와위에서 15분간안정시킨후 sensor를가진측정커프를좌우측상완과발목에감고측정하였다. 대상환자의우측 ABI와좌측 ABI는통계적으로유의한차이가없어서, 우측발목상완지수를환자의발목상완지수로이용하였다 (1.15±0.10 vs 1.15±0.10, p=0.923). 또한 CAVI 도환자의우측과좌측에유의한차이가없어서우측 CAVI를지표로사용하였다 (7.04±0.96 vs 6.97±0.95, p=0.056). 5. 점증적운동부하검사운동부하검사는트레드밀 (Medtrack ST 55, Quinton Instrument Co., U.S.A) 을이용하여 Bruce 프로토콜에따라운동중 3분간격으로경사도와속도를증가시켰으며, 운동중지속적으로 12유도심전도를감시하였다. 운동직전과운동중 1분간격으로심전도를기록하였으며, 프로토콜매단계 (3분간격 ) 마다심박수와혈압을측정하였다. 운동후회복기반응은 30 40 초간경사도를 0% 로하여가볍게걷다가트레드밀이완전히멈춘후피험자를침대에눕히고 1분, 3분, 5분동안심전도, 혈압, 심박수를측정하였다 (American College of Sports Medicine, 2009). 심박수회복 (heart rate recovery, HRR) 은운동중도달한최대심박수에서운동부하검사후회복기 1분대의심박수를뺀값으로정의하였으며 (Cole 등, 1999), 운동능력을나타내는대사당량 (metabolic equivalents: METs) 은경사도와회전속도를이용해추정하였다. 심근산소요구량을간접적으로나타내는지표인심근부담도 (rate pressure product, RPP) 는심박수와수축기혈압의곱으로나타냈다. 6. 심초음파검사심초음파검사는 Sequoir 256 (Acuson, Mountainview, CA, USA) 장비를이용하여 5 MHz 탐촉자를사용하여 M-mode 심초음파
98 Kyung-A Shin, et al. Exercise Capacity and Cardiovascular Risk Factors 도를기록하면서 1회박출량 (stroke volume, SV), 심박출량 (cardiac output, CO) 을 ASE (American Society Echocardiography) 에서권유하는방법에따라측정하였다. 7. 자료처리방법 본연구의모든자료는 SPSS 12.0 통계프로그램 (SPSS Inc, Chicago, IL, U.S.A) 을이용하여기술통계치 (mean, SD) 를산출하였으며, 비만유형에따른운동능력및심혈관위험요인의차이를검증하기위하여일원변량분석 (One way ANOVA) 을실시하였다. 또한운동능력과심혈관위험요인간의관련성을검증하기위해 Pearson's correlation analysis 를실시하였으며, 통계적유의수준은 p<0.05 로설정하였다. 결과 1. 비만유형에따른신체적특성의차이 비만유형에따른대상자의신체적특성은 Table 1과같다. 체질량지수에의해비만으로판정된피험자중복부비만을동반한군 (AO) 은 18명, 복부비만을동반하지않은군 (Non-AO) 은 36명이었다. 비만판정자중복부비만의유무 (AO vs Non-AO) 에따른연령, 키, 몸무게는차이가없었으나, 체질량지수, 체지방량은 Non-AO 군보다 AO군에서유의하게높게나타났다 (p<0.05). 또한허리둘레, 엉덩이둘레, 허리 / 엉덩이둘레비는 Non-AO 군보다 AO군에서유의하게높았다 (p<0.001). 2. 비만유형에따른심혈관위험요인의차이 비만유형에따른심혈관위험요인의차이는 Table 2와같다. 비만판정자중복부비만의유무 (AO vs Non-AO) 에따른인슐린, 당 Table 1. Physical characteristics of the subject according to the obesity types Variable Non-AO (n=36) AO (n=18) Age (years) 48.7±9.7 52.3±9.6 Height (cm) 170.4±6.0 169.2±5.5 Weight (kg) 76.2±9.2 78.8±8.6 BMI (kg/m 2 ) 26.2±2.1 27.5±1.9* Body fat mass (kg) 18.4±4.2 21.2±3.4* Waist circumference (cm) 84.4±3.1 89.8±14.3* Hip circumference (cm) 94.9±3.6 100.8±4.1 WHR 0.93±0.03 0.97±0.03 Obesity was defined as body mass index 25.0 kg/m 2, abdominal obesity was defined as waist circumference 90 cm. Values are Mean±SD. AO, abdominal obesity; BMI, body mass index; WHR, waist-hip ratio. *p<0.05, p<0.001. 화혈색소, 혈당, HOMA-IR는집단간차이가없었다. 복부비만을동반한비만군 (AO) 과복부비만을동반하지않은비만군 (Non-AO) 간의 HDL콜레스테롤, LDL콜레스테롤, 총콜레스테롤, 중성지방, 요산, hs-crp, 호모시스테인은집단간차이가없었다. 또한 Apolipoprotein A1, Apolipoprotein B, NT-pro BNP, CAVI, ABI 도집단간차이가없는것으로나타났다. 심박출량은집단간차이가없는반면, 1회박출량은 Non-AO 군에서유의하게높게나타났다 (p<0.05). 3. 비만유형에따른운동능력의차이 비만유형에따른운동시간은 Non-AO 군이 AO군보다긴것으로나타났으며 (p<0.001) (Table 3), METs 도 Non-AO군이 AO군보다높게나타났다 (p<0.001) (Fig 1). 프로토콜 1단계와 2단계에서의심박수는 Non-AO 군보다 AO군에서높게나타났으나 (p <0.05) (Table 3), 안정시심박수, 안정시수축기와이완기혈압, 안정시심근부담도는집단간차이가없는것으로나타났다. 또한최대심박수, 최대수축기와이완기혈압, 최대심근부담도는집단간차이가없었으나, 심박수회복은 AO군보다 Non-AO 군이높게나타났다 (p<0.05) (Fig 1). Table 2. Cardiovascular risk factors of the subject according to the obesity types Variable Non-AO (n=36) AO (n=18) Insulin (uu/ml) 6.3±4.6 7.1±2.5 HbA1c (%) 5.7±0.5 5.9±0.6 Glucose (mg/dl) 94.9±18.1 99.9±15.5 HOMA-IR 1.5±1.33 1.7±0.59 HDL-cholesterol (mg/dl) 50.4±13.5 48.3±9.5 LDL-cholesterol (mg/dl) 127.7±28.9 127.8±34.3 Total cholesterol (mg/dl) 200.1±31.8 197.7±36.6 Triglyceride (mg/dl) 164.6±100.9 169.2±72.9 Uric acid (mg/dl) 6.2±1.2 5.8±1.1 hs-crp (mg/dl) 0.34±1.1 0.12±0.10 Homocysteine (umol/l) 15.2±10.4 12.9±3.9 Apolipoprotein A1 (mg/dl) 133.2±19.8 130.6±21.3 Apolipoprotein B (mg/dl) 102.4±19.6 100.3±21.1 NT-pro BNP (pg/ml) 19.8±20.3 10.6±4.5 CAVI 6.88±0.96 7.41±0.91 ABI 1.15±0.11 1.16±0.08 SV (ml) 83.6±13.8 73.8±15.6* CO (L) 4.9±0.7 4.8±1.1 Values are Mean±SD. AO, abdominal obesity; BMI, body mass index; SBP, systolic blood pressure; DBP, diastolic blood pressure; HbA1c, hemoglobin A1c; HOMA-IR, homeostasis model assessment of insulin resistance; HDL, high density lipoprotein; LDL, low density lipoprotein; hs-crp, high sensitive C-reactive protein; BNP, B-type natriuretic peptide; CAVI, cardio-ankle vascular index; ABI, ankle-brachial index; SV, stroke volume; CO, cardiac output. *p<0.05.
Korean J Clin Lab Sci. Vol. 45, No. 3, Sep. 2013 99 4. 운동능력과심혈관위험요인간의상관관계운동능력과심혈관위험요인간의관련성에서운동시간은체질량지수 (r=-0.272, p<0.05), 허리둘레 (r=-0.300, p<0.05) 와음의상관관계를보였으며, METs 역시허리둘레 (r=-0.293, p<0.05) 와통계적으로유의한음의상관관계를나타냈다. 심박수회복은체질량지수 (r=-0.327, p<0.05), 체지방량 (r=-0.365, p<0.05), 허리 Table 3. Exercise capacity of the subject according to the obesity types Variable Non-AO (n=36) AO (n=18) Total exercise time (min) 10.2±1.2 8.2±1.9 Resting HR (beats/min) 60.1±8.0 64.0±10.9 Resting SBP (mmhg) 121.1±13.2 120.3±13.8 Resting DBP (mmhg) 76.5±12.8 79.0±10.3 Resting RPP (mmhg bpm) 7,280.9±1,240.4 7,696.9±1,671.8 Stage 1 HR (beats/min) 100.1±11.8 108.3±12.1* Stage 2 HR (beats/min) 117.0±14.1 126.9±13.9* Maximum HR (bpm) 159.9±19.1 154.8±9.6 Maximum SBP (mmhg) 172.3±23.3 164.3±17.2 Maximum DBP (mmhg) 82.4±11.5 82.7±13.2 Maximum RPP (mmhg bpm) 22,283.9±5,072.7 22,758.4±3,748.0 Values are Mean±SD. AO, abdominal obesity; HR, heart rate; RPP, rate pressure product; SBP, systolic blood pressure; DBP, diastolic blood pressure. *p<0.05, p<0.001. 둘레 (r=-0.327, p<0.05) 와통계적으로유의한음의상관관계를보였다 (Table 4). 고찰 2001년미국국립콜레스테롤교육프로그램 3차개정 (National Cholesterol Education Program Adult Treatment Panel III, NCEP ATP III) 과 2005년세계당뇨병연맹 (International Diabetes Federation: IDF) 에서대사증후군진단의필수항목으로허리둘레를복부비만의진단기준에포함시켜그중요성이강조되고있다 Fig. 1. Difference of the METs, HRR according to the Non-AO and AO in obesity adult man. AO, abdominal obesity; METs, metabolic equivalents; HRR, heart rate recovery. **p<0.001, *p<0.05. Table 4. Correlation between exercise capacity and cardiovascular risk factors Exercise capacity Variable Total exercise time METs HRR1 Maximum RPP r p r p r p r p BMI (kg/m 2 ) -.272.046* -.261.057 -.327.018*.075.605 Body fat mass (kg) -.257.063 -.239.084 -.365.007*.058.688 Waist circumference (cm) -.300.031* -.293.035* -.327.018*.075.605 Insulin (uu/ml).114.482 -.260.116.014.934 -.260.116 HbA1c (%) -.296.046 -.287.053 -.229.126 -.063.681 Glucose (mg/dl) -.165.234 -.150.278 -.071.610 -.136.335 HOMA-IR.063.690.088.579.027.864 -.295.064 HDL-cholesterol (mg/dl).150.279.128.356.248.071 -.029.837 LDL-cholesterol (mg/dl).048.730.061.662.191.166.051.720 Total cholesterol (mg/dl).083.552.099.476.154.266.071.615 Triglyceride (mg/dl) -.062.654 -.047.736 -.310.022*.119.401 Uric acid (mg/dl).147.290.161.245.017.902.071.616 hs-crp (mg/dl).090.552.123.417 -.187.213 -.301.047* Homocysteine (umol/l).074.600.089.529 -.297.032*.099.490 Apolipoprotein A1 (mg/dl).175.225.160.249.204.139 -.124.379 Apolipoprotein B (mg/dl) -.007.960.014.919.041.769.046.745 NT-pro BNP (pg/ml).040.780.040.781.110.445 -.097.509 CAVI -.222.267 -.247.213 -.032.873.004.983 ABI -.091.653 -.121.548.183.361 -.017.934 METs, metabolic equivalents; HRR, heart rate recovery; RPP, rate pressure product; BMI, body mass index; HbA1c, hemoglobin A1c; HOMA-IR, homeostasis model assessment of insulin resistance; HDL, high density lipoprotein; LDL, low density lipoprotein; hs-crp, high sensitive C-reactive protein; BNP, B-Type Natriuretic Peptide; CAVI, cardio-ankle vascular index; ABI, ankle-brachial index. *p<0.05.
100 Kyung-A Shin, et al. Exercise Capacity and Cardiovascular Risk Factors (Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults, 2001; Alberti 등, 2005). 또한비만으로판정되었더라도허리둘레가증가된중심성복부비만인경우고혈압, 당뇨병, 대사증후군, 고콜레스테롤혈증등의위험도가더높은것으로보고된다 ( 강등, 2007; 이등, 2009). 본연구에서는체질량지수에의해비만으로판정된성인남성피험자중복부비만의동반여부에따라운동능력과심혈관위험요인의차이및그관련성을분석하였다. 비만판정자중복부비만의동반여부에따라체질량지수, 체지방량, 허리둘레, 엉덩이둘레, 허리둘레-엉덩이둘레비는뚜렷한차이를나타냈으며, 복부비만을동반한비만군에서높게나타났다. 또한심혈관위험요인은 1회박출량을제외하고는복부비만동반여부에따른차이는없었으며, 1회박출량은복부비만을동반한비만군에서낮게나타났다. 운동능력의지표인심폐체력 (cardiorespiratory fitness) 이높은사람은낮은사람에비해복부지방이낮은것으로나타났으며, 심폐체력과복부비만은음의상관관계를보이는것으로보고된다 (Wong 등, 2004). 본연구에서도복부비만을동반한비만군에서운동능력을대표하는운동시간, 대사당량 (metabolic equivalents: METs) 이낮게나타났으며, 이는대사능력의향상을통한높은운동능력이비만지표개선에긍정적인영향을미치는것으로생각된다. 또한심폐체력의저하는심혈관계질환의위험을증가시키며, 운동능력 1 METs의증가는생존률을 12% 향상시키는것으로보고된다 (Myers 등, 2002). 그러므로비만한사람이라도운동을통해심폐체력을증가시키면심혈관질환의발생위험이감소된다는결과가보고됨으로써비만치료에서심폐체력의개선이중요하게인식되고있다 (Gill과 Malkova, 2006). 심박수는비관헐적 (noninvasive) 으로심혈관계기능을알수있는유용한지표이다 ( 김과신, 2007). 운동에의한자율신경계반응을보면운동강도증가에따른심박수증가는부교감신경활성화감소와교감신경의활성화에의한반응이며, 운동직후 1분이나 2분대에심박수회복 (heart rate recovery: HRR) 은부교감신경의재활성도를나타내는지표로써심혈관계사건발생과관련이있다 (Arai 등, 1989; Imai 등, 1994). 특히체중증가는교감신경의활성도는증가하고부교감신경활성도는저하되어느린심박수회복반응과같은자율신경계조절능력에이상반응을보인다 (Zahorska- Markiewicz 등, 1993; Shishehbor 등, 2004). 본연구에서도복부비만을동반한비만군에서느린심박수회복반응을보였으며, 심박수회복은체질량지수, 체지방량, 허리둘레와음의상관관계를보였다. 이는대사증후군에서허리둘레가증가 할수록느린심박수회복을보인다는선행연구와일치하는결과이다 ( 신, 2011). 이와같은자율신경계기능이상은관상동맥질환자뿐만아니라일반인에서도심혈관질환의독립적인위험요인으로제시되고있어복부비만을동반한비만군에서심혈관질환에더취약한것으로나타났다 (La Rovere 등, 1998; Schwartz, 1998). 심폐체력또는지구력이좋은사람일수록운동강도에따른심박수는서서히증가하는반면운동후에는빠른심박수회복반응을보이것이일반적인특징이다 (Tuttle과 Horvath, 1957). 본연구에서는프로토콜 1단계와 2단계의운동중심박수는복부비만을동반한비만군에서높게나타났으며, 최대심박수는집단간차이가없는것으로나타났다. 심박출량은 1회박출량과심박수의곱으로나타내는데, 복부비만을동반하지않은비만군에비해복부비만을동반한비만군에서최대하운동 (submaximal exercise) 인 1 2 단계의심박수는높고 1회박출량은낮은상대적으로비효율적인운동능력을보이는것으로나타났다. 또한최대심박수는집단간차이가없으면서운동시간은복부비만을동반한비만군에서짧게나타났다는것또한비효율적인운동능력을대별해주는결과라고할수있다. 결론적으로복부비만을동반한비만의경우비효율적인운동능력에의해결과적으로낮은운동능력을보였으며, 느린심박수회복반응으로알수있는자율신경계조절능력의저하가나타났다. 본연구의제한점으로는후향적인연구라는점이며, 향후복부비만의감소가운동능력및심박수회복의향상, 심혈관위험요인을감소시키는지에대한전향적연구가필요하리라사료된다. 참고문헌 Alberti KG, Zimmet P, Shaw J; IDF Epidemiology Task Force Consensus Group. The metabolic syndrome-a new worldwide definition. Lancet. 2005, 366:1059-1062. American College of Sports Medicine. ACSM s guidelines for exercise testing and prescription. 8th eds, 2009, p18-39. Lippincott Williams & Wilkins, Philadelphia. Arai Y, Saul JP, Albrecht P, Hartley LH, Lilly LS, Cohen RJ, et al. Modulation of cardiac autonomic activity during and immediately after exercise. Am J Physiol. 1989, 256:H132-141. Cole CR, Blackstone EH, Pashkow FJ, Snader CE, Lauer MS. Heart-rate recovery immediately after exercise as a predictor of mortality. N Engl J Med. 1999, 341:1351-1357. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Executive Summary of The Third Report of The National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, And Treatment of High Blood Cholesterol In Adults (Adult Treatment Panel III). JAMA. 2001, 285: 2486-2497. Gill JM, Malkova D. Physical activity, fitness and cardiovascular dis-
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