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Objective: In the last years, a debate exists about type, intensity and frequency of physical exercise that is really indicated to protect healthy subjects from cardiovascular disease. Regular physical training has been associated with an improved cardiovascular risk profile, but it has also been demonstrated that strenuous and uncontrolled physical exercise could be dangerous, in terms of increased cardiovascular morbidity and mortality. In the present study, we evaluated a group of 35 amateur half-marathon runners, who were likewise studied 10 years before (B). The results of B suggested that an increased cardiac sympathetic modulation could potentially represent a negative prognostic factor. The aim of this follow-up was to assess the medium-long-term effects of moderate to vigorous physical training on the cardiovascular neural control, cardiac function and occurrence of cardiovascular diseases., Methods: Each enrolled subject underwent: (1) an interview and physical examination to ascertain the presence of cardiovascular disease; (2) standing test to evaluate the cardiovascular neural control by means of heart rate variability (HRV), arterial blood pressure (AP) variability and baroreflex sensitivity (BRS); (3) transthoracic echocardiography to evaluate cardiac function., Results: At 10-year follow-up (FU), in this group of middle-aged athletes the occurrence of cardiovascular diseases was low, not unlike that of the overall population. The results of HRV analysis showed a decreased sympathetic and increased vagal modulation directed to the heart, compared with B. In addition, HRV, AP variability and BRS indices showed a physiological response to active standing. Finally, athletes had normal echocardiographic measures., Conclusion: We conclude that in our group of athletes a regular moderate-vigorous physical training through the 10 years was quite beneficial as the prevalence of sympathetic cardiac modulation observed at B was not accompanied by increased cardiovascular risk, on the contrary a slight prevalence of vagal indices was observed at FU., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

It is well recognized that regular physical activity may improve cardiac autonomic regulation preventing chronic non-communicable diseases. Accordingly, the assessment of cardiac autonomic regulation (CAR) with non-invasive techniques, such as RR interval Variability (V) might be of practical interest. We studied 56 soccer players (21.2 ± 4.2 years.) and 56 controls (22.2 ± 1.5 years.) and used a ranked Autonomic Nervous System Index (ANSI), resulting from the combination of multivariate statistical methodologies applied to spectral analysis derived indices from RRV. We hypothesized that ANSI would be higher in soccer players as compared to controls ( p < 0.001) and that values would be greatest in defenders and midfielders, who are known to run longer distances during competitions. Conversely in the intrinsically stationary goalkeepers ANSI would be similar to controls. Our data show that it is possible to assess the overall level of autonomic performance in soccer players as compared to the general population, using a ranked composite autonomic proxy (ANSI). This approach suggests as well that CAR is better in those players who during competitions run for a greater distance. We conclude that it is possible to highlight the differences in autonomic profile due to distinct exercise routines, using ANSI, a simple ranked, composite autonomic proxy.

Background: Long term endurance training, as occurring in elite athletes, is associated to cardiac neural remodeling in favor of cardioprotective vagal mechanisms, resulting in resting bradycardia and augmented contribution of cardiac parasympathetic nerve activity. Autonomic assessment can be performed by way of heart rate variability. This technique however provides multiple indices, and there is not yet complete agreement on their specific significance. Purpose of the study was to assess whether a rank transformation and radar plot could provide a unitary autonomic index, capable to show a correlation between intensity of individual work and quality of autonomic regulation., Methods: We studied 711 (23.6±6.2 years) elite athletes that took part in the selection procedure for the 2016 Rio Olympic Games for the National Italian Olympic Committee (CONI). Indices from Heart Rate Variability HRV obtained at rest, during standing up and during recovery from an exercise test were used to compute a percent ranked unitary autonomic index for sport (ANSIs), taken as proxy of quality of autonomic regulation., Results: Within the observed wide range of energy expenditure, the unitary autonomic index ANSIs appears significantly correlated to individual and discipline specific training workloads (r=0.25, P<0.001 and r=0.78, P<0.001, respectively), correcting for possible age and gender bias. ANSIs also positively correlates to lipid profile., Conclusions: Estimated intensity of physical activity correlates with quality of cardiac autonomic regulation, as expressed by a novel unitary index of cardiac autonomic regulation. ANSIs could provide a novel and convenient approach to individual autonomic evaluation in athletes.

Introduction: Aerobic fitness seems to provide extra protection to the cardiovascular system beyond changing the traditional risk factors, a phenomenon referred to as the risk factor gap model. Aerobic fitness may possibly lead to improved autonomic regulation. The Task Force of the American Heart Association supports a national campaign to reach specific cardiovascular health goals considering various metrics, including recommended physical activity (PA) volumes. It may be clinically relevant to assess whether autonomic remodeling occurs in those who adhere to the PA recommendations., Methods: We studied 39 healthy subjects (22 males and 17 females), subdivided into two groups, according to whether they were meeting or not meeting PA recommendations (150 min/week of moderate aerobic activity, or 75 min/week of vigorous aerobic activity, or a combination of both). For each group, we evaluated aerobic capacity (VO2 Peak), body composition (Fat Mass) and autonomic nervous system profile, by way of mono and bivariate spectral analysis of cardiovascular beat by beat variability., Results: Subjects following PA recommendations show higher RR period, higher RR variance, greater absolute power of the respiratory component of RR variability (HFRR) and higher index alpha (a measure of spontaneous baroreflex). Moreover, as expected, the group that was meeting or exceeding current PA recommendations had higher VO2 peak, less fat mass and greater weekly energy expenditure., Conclusion: Data show that subjects meeting current PA recommendations present a phenotype suggestive of enhanced parasympathetic drive to the SA node. This finding is compatible with the hypothesis that a more favorable autonomic profile is part of the mechanisms of the risk factor gap.

Purpose: The dynamics of vagal withdrawal and reactivation during pulses of exercise are described by indices computed from heart period (RR) variations, which may be sensitive to duration and load. We sought to assess the consistency over time of these indices, which is not well established., Methods: We recorded continuous electrocardiogram during series of five successive bouts (2 min) of submaximal exercise (at 40 and 70% of VO(2peak), different days). Autonomic responsiveness was inferred from quantification of onset and offset of RR dynamics of each individual bout. Consistency of results was assessed with intraclass correlation (ICC)., Results: During exercise bouts, indices from tachycardic and bradycardic transients reach lower levels in response to higher exercise loads and progression of exercise. There is a significant effect of load and time (i.e., bout repetition) for all examined variables, with a clear interaction. However, no interaction is observed with the 60 s change in heart rate. ICC analysis demonstrates that various indices are characterized by large differences in stability, which is generally greater within the same day (e.g., tachyspeed ICC at 40% = 0.751, at 70% = 0.704, both days = 0.633; bradyspeed, respectively, = 0.545, 0.666, 0.516)., Conclusions: Intensity and duration of exercise modulate vagal withdrawal and reactivation. Analysis of RR variations, during successive brief exercise bouts at lower and higher intensity, ensures a consistency similar to that reported for autonomic cardiac regulation at rest and might guide the choice among multiple indices that are obtained from the tachogram.

Considering that changes in exercise routines might have relevance in treatment of adolescents with type 1 diabetes mellitus, we sought to assess whether spontaneous modifications to weekly exercise habits might occur in these patients and whether such variations would be accompanied by alterations in autonomic profile. In this observational study, we examined 77 patients (age 15.0 ± 0.6 years.) who in addition to a tailored optimal insulin treatment were invited to perform at least 1 h a day of moderate, aerobic exercise, as suggested by recent guidelines. Patients were studied at baseline (T0) and after 15.8 ± 0.7 months (T1). They were divided into three subgroups according to increased, unchanged and diminished total estimated weekly METs between T0 and T1. Autonomic profile was evaluated by assessing spontaneous baroreflex gain and low-frequency oscillation in arterial pressure, using spectral analysis of RR and systolic arterial pressure time series. Insulin therapy and biochemical data were similar among the 3 groups at T0 and T1, while body mass index standard deviation score was slightly reduced (p < 0.04) and markers of autonomic performance were improved (alpha index, from 17 ± 1 to 20 ± 2 ms/mmHg, p < 0.002) in the group who increased the amount of exercise (from 1627 ± 250 to 3582 ± 448 METs min wt(-1), p < 0.001). Furthermore, the change in total weekly METs significantly correlates with changes of key indices of autonomic regulation. The favourable autonomic effects of moderate increase in spontaneous exercise load suggest testing more formally this intervention in adolescents with type 1 diabetes.

Objective: Aim of the study was to assess the role of family history, physical activity and parental smoking in the prediction of BMI, SBP and hypertension risk in children., Participants and Methods: In a paediatric primary care setting, a sample of 1310 children aged 5-14 years was systematically selected by 48 family paediatricians in northern Italy. BMI, waist circumference-to-height ratio (WtHr), SBP and DBP were measured and the information on the presence of small birth weight for gestational age (SGA) and early adiposity rebound (EAR) was collected. Data concerning exercise, video time, family history for cardiovascular diseases and parental smoking were derived from parental interview. Data were collected using an 'ad hoc designed' electronic sheet available online., Results: Multiple linear regression showed that the presence of EAR, low exercise (<2 h/week), high video time (>2  h/day TV/videogames/computer) and parental smoking were associated to higher BMI (z-score; P < 0.005). Age, BMI (z-score), WtHr, presence of SGA, low exercise, high video time and family history of cardiovascular diseases were associated to SBP values (P < 0.03). Logistic regression analysis showed that factors related to risk of hypertension and prehypertension were BMI (z-score; odds ratio, OR 2.63; 95% confidence interval, CI 2.12-3.28), WtHr (OR 1.13; 95% CI 1.10-3.28) and low exercise (OR 1.58; 95% CI 1.12-2.24; P <0.01)., Conclusion: Our study demonstrates that a simple tool like a cardiovascular multi-item sheet can provide useful information to paediatricians for child health. Physical exercise plays a pivotal role in obesity prevention and protection from hypertension risk.

Overweight (OW) and obesity in children are important forerunners of cardiovascular risk, possibly through autonomic nervous system (ANS) dysregulation, while physical exercise exerts a beneficial influence. In this observational study we hypothesise that OW might influence ANS profile even in a population performing high volume of supervised exercise. We study 103 young soccer players, homogeneous in terms of gender (all male), cultural background, school, age (11.2 ± 1 years) and exercise routine, since they all belong to the same soccer club, thus guaranteeing equality of supervised training and similar levels of competitiveness. ANS is evaluated by autoregressive spectral analysis of heart rate and systolic arterial pressure (SAP) variabilities. We estimate also the accumulated weekly Metabolic Equivalents and time spent in sedentary activities. We subdivide the entire population in two subgroups (normal weight and OW) based on the International Obesity Task Force criteria. In OW soccer players (10.7% of total group) we observe an altered profile of autonomic cardiovascular regulation, characterised by higher values of SAP (113 ± 4 vs 100 ± 1 mm Hg, 39.7 ± 3 vs 66.2 ± 10%), higher Low Frequency variability power of SAP (an index of vasomotor sympathetic regulation) (12 ± 3 vs 4.5 mm Hg(2)) and smaller spontaneous baroreflex gain (an index of cardiac vagal regulation) (19 ± 3 vs 33 ± 3 ms/mm Hg) (all (p < 0.02)). Moreover Correlation analysis on the entire study population shows a significant link between anthropometric and autonomic indices. These data show that OW is associated to a clear autonomic impairment even in children subjected to an intense aerobic training.

This brief review summarizes current knowledge on the neural mechanisms of cardiovascular regulation during exercise in space, with specific emphasis on the role of the arterial baroreflex and the muscle metaboreflex, with the attendant modifications in autonomic nervous system activity, in determining the cardiovascular responses to exercise in microgravity conditions. Available data suggest that the muscle metaboreflex is enhanced during dynamic exercise in space and that the potentiation of the muscle metaboreflex affects the vagally mediated arterial baroreflex contribution to HR control.

In the literature, several methods have been proposed for the assessment of the baroreflex sensitivity from spontaneous variability of heart period and systolic arterial pressure. The present study compares the most utilized approaches for the evaluation of the spontaneous baroreflex sensitivity (i.e. sequence-based, spectral, cross-spectral and model-based techniques) over a protocol capable of inducing a progressive decrease of the baroreflex sensitivity in the presence of a relevant respiratory drive (i.e. a stepwise dynamic bicycle exercise at 10%, 20% and 30% of the maximum nominal individual effort) in 16 healthy humans. Results demonstrated that the degree of correlation among the estimates is related to the structure of the model explicitly or implicitly assumed by the method and depends on the experimental condition (i.e. on the physiological mechanisms contemporaneously active with baroreflex, e.g. cardiopulmonary reflexes). However, even in the presence of a significant correlation, proportional and/or constant biases can be present, thus rendering spontaneous baroreflex estimates not interchangeable. We suggest that the comparison among different baroreflex sensitivity estimates might elucidate physiological mechanisms responsible for the relationship between heart period and systolic arterial pressure.

Ten estimates of baroreflex sensitivity (BRS) were compared during progressive graded exercise: they were computed from sequence method, spectral and cross-spectral analysis methods, and parametric model-based methods. Results showed baroreflex control of heart rate (HR) changes as a function of the intensity of exercise, as well as the resetting phenomenon. Sequence, spectral and cross-spectral methods generally provided higher estimates than parametric model-based ones. This bias was particularly evident during exercise, and in the high frequency (HF) respiratory band. Results may suggest that the interaction of respiration and baroreflex function play an important in the cardiovascular adaptation from rest to exercise and from exercise to the recovery period.

Spontaneous baroreflex function and vascular changes were assessed in young adults during dynamical mild exercise. Windkessel time constant was assessed by two different methods: two-element windkessel model, and by an autoregressive (AR) model, while the baroreflex sensitivity (BRS, ms/mmHg) was assessed by the sequence method. Results showed a change in the baroreflex control of heart rate (HR) with the severity of exercise, as well as the resetting phenomenon. Methods used to estimate the windkessel time constant were poorly correlated. Subject by subject correlation was found between the BRS and the time constant derived from the AR model within exercise and recovery period. These results may suggest that reflex mechanisms controlling HR may also participate in controlling peripheral circulation or, viceversa, BRS is influenced by vascular tone.

One of the most important features of prolonged weightlessness is a progressive impairment of muscular function with a consequent decrease in exercise capacity. We tested the hypothesis that the impairment in musculo-skeletal function that occurs in microgravity results in a potentiation of the muscle metaboreflex mechanism and also affects baroreflex modulation of heart rate (HR) during exercise. Four astronauts participating in the 16 day Columbia shuttle mission (STS-107) were studied 72-71 days before launch and on days 12-13 in-flight. The protocol consisted of 6 min bicycle exercise at 50% of individual V(o2,max) followed by 4 min of postexercise leg circulatory occlusion (PECO). At rest, systolic (S) and diastolic (D) blood pressure (BP), R-R interval and baroreflex sensitivity (BRS) did not differ significantly between pre- and in-flight measurements. Both pre- and in-flight, SBP increased and R-R interval and BRS decreased during exercise, whereas DBP did not change. During PECO preflight, SBP and DBP were higher than at rest, whereas R-R interval and BRS recovered to resting levels. During PECO in-flight, SBP and DBP were significantly higher whereas R-R interval and BRS remained significantly lower than at rest. The part of the SBP response (delta) that was maintained by PECO was significantly greater during spaceflight than before (34.5 +/- 8.8 versus 13.8 +/- 11.9 mmHg, P = 0.03). The tachycardic response to PECO was also significantly greater during spaceflight than preflight (-141.5 +/- 25.2 versus - 90.5 +/- 33.3 ms, P = 0.02). This study suggests that the muscle metaboreflex is enhanced during dynamic exercise in space and that the potentiation of the muscle metaboreflex affects the vagally mediated arterial baroreflex contribution to HR control.

Purpose: A decrease of electrocardiographic T-wave voltage with increasing training loads has been reported in elite endurance athletes and ascribed to training-related adaptation in sympathetic activity to the ventricles. A switch from vagal to sympathetic predominance in sino-atrial node regulation on going from low to peak training load has been reported in world-class rowers. In this study on world-class endurance athletes, we tested the hypothesis that training-induced variations in T-wave amplitude at higher training loads are paralleled by changes in HR spectral profile., Methods: We studied eight male rowers of the Italian national team in the season culminating with the Rowing World Championship. Athletes were evaluated at 50 and 100% of training load, approximately 20 d before the World Championship, and during the World Championship, when the intensity was markedly reduced. We assessed T-wave maximum amplitude in chest lead V6 and cardiac autonomic regulation by power spectral analysis of R-R interval variability., Results: The increase in training load from 50 to 100% was accompanied by a significant decrease in high frequency and a significant increase in low-frequency R-R variability (in normalized units) with a concomitant significant decrease in T-wave amplitude (microV). Reduction in training load during the World Championship resulted in a return of spectral profile to the level observed at 50% training load and in a partial recovery of T-wave amplitude. HR did not change significantly., Conclusions: In high-performance world-class athletes, training load simultaneously affects both ventricular repolarization and HR variability patterns possibly through variations in cardiac sympathetic modulation to the ventricles and the sino-atrial node. Information on concomitant changes in ventricular repolarization and autonomic cardiac regulation might be employed to tailor training protocols of elite athletes.

We examined on 56 (age 38+/-2 [range: 16-60] years) healthy subjects the effects of aging on cardiovascular autonomic responses to progressive supine bicycle exercise of light intensity. Autoregressive spectral analysis of RR interval and systolic arterial pressure (SAP) variabilities provided measures of the exercise-induced changes in baroreflex gain (by index alpha) and in sympathetic and vagal modulation of the SA node (by the normalized low [LF] and high frequency [HF] component of RR interval variability, respectively), as well as of changes in sympathetic vasomotor control (LF(SAP)). For each hemodynamic and autonomic variable, the gain of the response was expressed both as individual step increments, and as the slope of the linear regression of the sequential data points from rest and during the three steps of exercise. Age resulted significantly correlated to changes in spectral derived markers of SA modulation (LF(RR), HF(RR) and index alpha). Conversely, no significant relationships were found with changes in RR interval, in SAP and indices of vascular regulation (LF(SAP)). In addition, exercise-induced changes in indices of SA node regulation were more evident in the youngest tertile (age 25+/-1 years), compared to the oldest tertile (age 52+/-1 years). In conclusion, we have observed that aging progressively and selectively reduces the cardiac autonomic excitatory response to light exercise, while hemodynamic and vascular responsiveness are maintained.

Background: Benefits of moderate endurance training include increases in parasympathetic activity and baroreflex sensitivity (BRS) and a relative decrease in sympathetic tone. However, the effect of very intensive training load on neural cardiovascular regulation is not known. We tested the hypothesis that strenuous endurance training, like in high-performance athletes, would enhance sympathetic activation and reduce vagal inhibition., Methods and Results: We studied the entire Italian junior national team of rowing (n=7) at increasing training loads up to 75% and 100% of maximum, the latter approximately 20 days before the Rowing World Championship. Autoregressive power spectral analysis was used to investigate RR interval and blood pressure (BP) variabilities. BRS was assessed by the sequences method. Increasing training load up to 75% of maximum was associated with a progressive resting bradycardia and increased indexes of cardiac vagal modulation and BRS. However, at 100% training load these effects were reversed, with increases in resting heart rate, diastolic BP, low-frequency RR interval, and BP variabilities and decreases in high-frequency RR variability and BRS. Three athletes later won medals in the World Championship., Conclusions: This study indicates that very intensive endurance training shifted the cardiovascular autonomic modulation from a parasympathetic toward a sympathetic predominance. This finding should be interpreted within the context of the substantial role played by the sympathetic nervous system in increasing cardiovascular performance at peak training. Whether the altered BP and autonomic function shown in this study might be in time hazardous to human cardiovascular system remains to be established.

Obesity is associated with an increased risk of several chronic comorbidities, which may also be determined by dysfunctional autonomic nervous system (ANS). The influence of bariatric surgery (BS) on ANS balance was explored in previous studies, but with high heterogeneity in both the assessment timing and methods employed. In the present observational study, we applied a clinical protocol which considers two subsequent phases. Twenty-nine non-diabetic obese subjects were studied at baseline (T0), after one month of lifestyle modification (prehabilitation) (phase 1-T1), and after eight months following BS (phase 2-T2). ANS regulation was assessed across the three study epochs by means of ANSI, a single composite percent-ranked proxy of autonomic balance, being free of gender and age bias, economical and simple to apply in a clinical setting. The aim of the present study was to investigate the effects of the clinical protocol based on prehabilitation and subsequent BS on the ANS regulation by means of ANSI. Potential intertwined correlations with metabolic parameters were also investigated. Notably, we observed a progressive improvement in ANS control, even by employing ANSI. Moreover, the reduction in the markers of sympathetic overactivity was found to significantly correlate with the amelioration in some metabolic parameters (fasting glucose, insulin levels, and waist circumference), as well as in stress and tiredness perception. In conclusion, this study provides convincing evidence that a unitary proxy of cardiac autonomic regulation (CAR) may reflect the progressive improvement in autonomic regulation following behavioral and surgical interventions in obese patients. Intriguingly, this might contribute to reducing cardiovascular and metabolic risk. [ABSTRACT FROM AUTHOR]

The increased cardiometabolic risk observed in breast cancer survivors (BCS) is due to multiple mechanisms: Hormonal and immunological dysfunction are well-identified ones, while cardiac autonomic regulation (CAR) is less recognized but may play a new complementary role particularly relevant when considering conditions and behaviors associated with a better prognosis in BCS, such as physical training. This observational study investigated a group of consecutive (172) BCS subdivided in two groups: those who reached the physical activity goals above 600 (MET·min/week) and those who did not. We assessed CAR by autoregressive spectral analysis of cardiovascular variabilities (considering in particular the unitary autonomic nervous system index—ANSI), body mass composition, stress perception and lifestyle in order to verify possible differences due to execution of physical activity. Subjects who spontaneously met physical activity recommendations presented a better autonomic, metabolic and psychological profile compared to those who did not. Lower physical activity volume, poor metabolic parameters, increased stress and fatigue perception may cluster together, leading to worsened CAR. This control mechanism may play a complementary role in determining the increased cardiometabolic risk observed in BCS. Furthermore, it may also explain, albeit in part, the better prognosis observed in patients following interventions aiming to improve the sympathetic–parasympathetic balance, such as physical training, using a personalized medicine approach. [ABSTRACT FROM AUTHOR]

In order to analyze the information carried by arterial blood pressure (ABP) variability, a multivariate parametric model of interactions involving systolic ABP (SAP), diastolic ABP (DAP), pulse pressure (PP), heart period (HP), and respiration is proposed. The model defines SAP as sum of the preceding DAP and PP values; DAP model accounts for arterial baroreflex, diastolic runoff; PP reflects changes in stroke volume related to respiration and HP, afterload; equation residuals reveal other vascular and cardiac output modulations. The model was applied to data from nine young volunteers (aged 29±6 years) during supine cycling at 10%, 20%, and 30% of their maximum effort. Significant basal values and changes across the epochs of the experiment were found in all hemodynamic parameters describing fast, beat-by-beat responses; in SAP and PP total power, DAP low- and high-frequency power (LF, HF), PP very low frequency (VLF), and LF and HF power. A primary role of vascular control through DAP and PP was em- phasized by the considered feedbacks and the model residuals. The model proved to be able to assess beat-by-beat cardiovascular interactions and offer a comprehensive view of arterial tree control. [ABSTRACT FROM AUTHOR]

Lifestyle modification programs (LMP) represent a new approach to cardiometabolic/oncologic risk reduction. Successful LMP in clinical practice must be feasible, cost effective, efficacious and consider home-based exercise. Likewise, multiple mechanisms implied in cardiometabolic risk reduction such as cardiac autonomic regulation (CAR) should be easily evidenced, in spite of the computational complexity involved. This goal could be facilitated by employing novel, friendlier, simpler techniques, such as the Autonomic Nervous System Index (ANSI), which can be treated as a proxy of CAR. In this observational study, we introduce a simple LMP (based on cognitive behavioral strategies and patient-tailored prescription of nutrition and home-based exercise, managed by a single physician) into the currently existing clinical practice of secondary cardiometabolic prevention. In 26 subjects, we assessed CAR (autoregressive spectral analysis of cardiovascular variabilities), body mass composition (bioelectrical impedance analysis) and stress perception (questionnaires). After LMP, ANSI and lipid profile were improved; % of fat mass, waist circumference and stress perception were reduced. We conclude that this preliminary, proof of concept study provides significant evidence in favor of the hypothesis that it is possible to introduce a convenient, cost effective LMP into the currently existing clinical practice of secondary cardiometabolic prevention. Findings suggest a successful comprehensive behavioral change, possibly facilitated by the simplified approach employed in this study, capable of improving cardiac autonomic regulation in addition to body mass composition and stress perception. [ABSTRACT FROM AUTHOR]

Background Chronic non-communicable diseases represent the major drivers of disease burden, being responsible for the majority of health care cost and deaths. Almost half of premature deaths is due to behaviors amenable to change. Accordingly, addressing behavior might represent a strategic change in the health delivery system. Improving lifestyle requires a specific strategy embedding the active collaboration of individuals with a multilevel team-oriented medical practice. With the present study we sought to assess whether the implementation of cognitive-behavioral strategies, following the principles of lifestyle medicine in an outpatient clinic provides better results in weight reduction as compared to simpler strategies as presently executed in General Practitioners' offices. Methods This is an observational study on 173 subjects (age 53.1 ± 11.5), comparing three different groups of preventive practice: a personalized lifestyle medicine, combining cognitive behavioral strategies with patient tailored prescription of exercise and nutrition (Group A); a semi-structured approach with generic counseling (Group B); and an unstructured advice (Group C). Results At the end of the intervention period (17–20 months), group A showed an average weight loss of 5.4 ± 5.1 kg, which was significantly (p < 0.001)more than observed in group B (2.8 ± 5.1 kg) and group C (1.2 ± 4.8 kg). Likewise BMI and waist were progressively more reduced from A to C. Conclusions It is possible to implement preventive cognitive-behavioral lifestyle strategies in outpatient internal medicine clinics. This methodology appears more efficacious in inducing weight reduction after more than a year as compared to usual family medicine approaches. [ABSTRACT FROM AUTHOR]