Cardiorespiratory Prevention and Rehabilitation Program (PROCOR)
Phase: NA
Conditions: Risk Factors Cardiovascular Disease
Sponsor: Universidade Federal de Santa Catarina

 
 
 
 
 
 
 
 
 
EFFECT OF DIFFERENT WEEKLY COMBINED TRAINING FREQUENCIES 
ON FUNCTIONAL CAPACITY, HEMODYNAMIC AND ANTHROPOMETRIC 
ASPECTS OF ELDERLY PEOPLE WITH CARDIOMETABOLIC RISK 
FACTORS 
 
 
 
 
 
 
 
 
March 03, 2024 

Abstract 
Objective: The objective of this study was to compare the effects of two different weekly 
frequencies of a 12-week combined training period on functional capacity, hemodynamic, 
and biochemical profile in older people with cardiometabolic risk factors. Methods: This 
is a pragmatic clinical trial. Functional, hemodynamic, and biochemical outcomes were 
assessed at baseline and after 12 weeks. Participants were divided into two groups: G2x 
(trained twice a week), and G3x (trained three times a week). Both groups performed the 
same training program, which consisted of strength and aerobic training with progressive 
intensity. Data analysis was performed using intention to treat (ITT), employing a 2-way 
analysis of covariance (ANCOVA) for repeated measures, with the baseline values used 
as covariates. The significance adopted was 0.05. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

1. 
INTRODUCTION 
 
The population ageing is a global trend that brings significant challenges for 
promoting health and quality of life, since the prevalence of cardiometabolic risk factors 
and gradual loss of functional capacity, reduced aerobic fitness, strength, and agility in 
older adults is more pronounced(1). The presence of risk factors, such as hypertension, 
diabetes, and dyslipidemia, increases the susceptibility of older people to cardiovascular 
diseases, which remain one of the leading causes of morbidity and mortality worldwide(2). 
In addition, older adults with cardiometabolic risk factors exhibit lower functional 
capacities, such as muscle strength, mobility, lower and upper limb power and flexibility, 
compared to older adults without cardiometabolic risk factors(3,4). 
 
Exercise is consolidated as a valuable tool for improving functional capacity(5), 
cardiovascular health(6,7), and metabolic and biochemical markers(8,9) in older adults with 
cardiometabolic risk factors(10). Although there is a consensus regarding the benefits of 
exercise for the older population with cardiometabolic risk factors, determining the dose-
response of the training for this population still generates uncertainty. Current 
recommendations suggest performing multicomponent training two to three times per 
week(5); however, this variation still raises questions about the most effective weekly 
frequency to optimize health outcomes in this population. 
 
In this sense, comparisons between strength training frequencies were conducted 
in postmenopausal women with osteoporosis, showing better outcomes for three sessions 
per week compared to twice-weekly sessions and a control group(11). On the other hand, 
a clinical trial comparing one, two, and three weekly sessions of combined training in 
women over 60 years old found no significant differences between the training groups(12). 
However, no studies were found comparing different weekly session frequencies of 
combined training involving individuals with cardiometabolic risk factors. 
 
Thus, the optimization of training prescription through the manipulation of 
different training variables, such as weekly frequency, still requires further investigation 
from a functional, cardiovascular, and metabolic perspective. Therefore, this study aims 
to investigate the effects of two different weekly frequencies of combined training on 
functional capacity, blood pressure, and biochemical profile in older adults with 
cardiometabolic risk factors. We hypothesized that performing three weekly sessions of 

combined training would lead to better adaptations in cardiovascular risk factors and 
functional capacity than performing two weekly sessions. 
 
1.1 OBJECTIVES 
1.1.2 General Objective 
 
To compare the effect of two different weekly frequencies of combined training 
on functional capacity, hemodynamic and anthropometric aspects of elderly individuals 
with cardiometabolic risk factors. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

2. METHODS 
2.1. EXPERIMENTAL APPROACH TO THE PROBLEM 
 
This study was a pragmatic clinical trial with two intervention groups. Initially, 
an anamnesis was conducted to collect sociodemographic data and information about the 
participants health, as well as to investigate their engagement in other physical activities. 
Subsequently, anthropometric, functional, hemodynamic, and biochemical assessments 
were performed for two weeks. After these baseline assessments, participants were 
divided into two groups: one group performed combined training twice a week (G2x), 
and the other group three times a week (G3x). Both groups followed the same training 
program, which lasted 12 weeks, with the total exercise volume being higher in the group 
that trained three times per week due to the increased session frequency. All the 
assessments performed at baseline were repeated after 12 weeks. 
2.2. ETHICAL APPROVAL 
 
The research was performed in accordance with the Declaration of Helsinki. This 
study was approved by the Ethics Committee for Research Involving Human Beings of 
the Federal University of Santa Catarina, Brazil (CAAE: 3.615.659), in accordance with 
Resolution 466/12 of the National Health Council on research involving human subjects. 
2.3. SUBJECTS 
 
The participants in this study were individuals enrolled in the Cardiopulmonary 
Prevention and Rehabilitation Program (PROCOR) which is a community program for 
individuals with cardiometabolic risk factors offered by the Federal University of Santa 
Catarina (UFSC). This program provides specialized support for the safe practice of 
physical exercises and the promotion of cardiovascular health. Due to the structure of the 
program and the prior enrollment of participants, it was not possible to randomize the 
groups. 
 
The inclusion criteria were being enrolled in the PROCOR program, having 
medical clearance to perform physical exercises, presenting one or more cardiometabolic 
risk factors, and having no physical limitations that could impair the execution of the 
proposed exercises.  

2.4. PROCEDURES 
2.4.1. Training Protocol 
 
The intervention was conducted with two groups following the same supervised 
combined training protocol, differing only in weekly frequency. The G2x group 
performed sessions on Tuesdays and Thursdays, while the G3x group participated in 
sessions on Tuesdays, Thursdays, and Fridays. The training program was carried out at 
the UFSC rehabilitation center and the strength training room, under the supervision of 
Physical Education professionals and students. 
 
Initially, the participants underwent two weeks of familiarization aimed at 
introducing them to the Borg scale (6-20) and providing guidance on the correct execution 
of strength exercises. This process also sought to ensure proper adaptation to the protocol. 
The program was structured into three mesocycles, each lasting four weeks, with the goal 
of progressively increasing training intensity from one mesocycle to the next. 
 
During strength training, participants performed four exercises: bench press, leg 
press, seated row, and hip abduction machine. Additionally, at the beginning of each 
mesocycle, load assessments were conducted, in which participants performed the first 
set at the lower limit of the repetition zone and in the second set, they were instructed to 
perform the maximum number of repetitions, both with the same load used during the 
previous mesocycle. As a safety precaution, the number of repetitions was limited to a 
maximum of 20. Based on the number of repetitions exceeding the lower repetition limit 
(RE), the load was adjusted to the mesocycle as follows(13). 
 
Upper limb exercises: Final weight (Kg) = weight used in the test (Kg) + RE/2 
Lower limb exercises: Final weight (Kg) = weight used in the test (Kg) + RE 
 
 
 
The aerobic training consisted of interval and pyramid workouts performed on 
treadmills. Intensity was prescribed using the Borg rating of perceived exertion scale (6-
20), and higher intensities were achieved through variations in speed or incline. For those 

training three times per week, two sessions were focused on speed variation, and one on 
incline variation. Participants trained twice per week, alternating between sessions of 
speed variation and incline variation. 
2.5. PRIMARY OUTCOME (FUNCTIONAL CAPACITY) 
2.5.1. Strength 
 
Lower limb strength was measured using the 30-second sit-to-stand test. The test 
result used was the number of repetitions performed in this time, in one attempt(14). Upper 
limb strength was assessed using the 30-second arm curl test, with a 2.0 kg dumbbell for 
women and a 4.0 kg dumbbell for men. The test result was the total number of curls 
completed in a single attempt with the dominant arm(14). 
2.5.2. Balance/Agility 
 
Agility/dynamic balance was measured using the Timed Up and Go (TUG) test(15). 
The test result was the shortest time to stand up from a seated position, walk 3.00 meters, 
turn around, and return to the seated position. The TUG was performed at two walking 
speeds (maximum and usual), with two attempts for each, and the shortest time of each 
speed was recorded.  
2.5.3. Flexibility 
 
Flexibility was assessed using the sit-and-reach test, in which participants sat on 
a mat with their legs fully extended and their feet placed against a box used for the test, 
reaching forward(16). The total distance reached represented the final score, with two reach 
attempts recorded. 
2.5.4. Cardiorespiratory Fitness 
 
Aerobic capacity was evaluated using two tests:  the 6-minute walk test (6MWT), 
which participants completed one attempt, and the result was the total distance covered 
in that time(14); and the 1000-meter test (1000m), that was developed due to the presence 
of a ceiling effect observed in the 6MWT in many participants in previous PROCOR 
training semesters, in which participants also made one attempt, and the score was the 
total time in seconds to complete the distance, allowing walking and/or running. 

2.6. SECONDARY OUTCOMES 
2.6.1. Hemodynamic profile 
Three blood pressure measurements were obtained using a portable automatic 
monitor (OMRON, model HEM-7200, Brazil). Each participant remained seated and in 
silence for 10 minutes, and then three measurements of blood pressure and heart rate were 
taken, with a one-minute interval between each. The same procedure was repeated on a 
second day, resulting in a total of six systolic blood pressure (SBP) and diastolic blood 
pressure (DBP) measurements (in mmHg) and six heart rate measurements. The final 
values were determined by calculating the arithmetic mean of the measurements from 
both days, resulting in the final average. Additionally, mean arterial pressure (MAP) was 
calculated using the standard equation: MAP = (SBP + 2 × DBP) / 3(2). 
2.6.2. Biochemical Profile 
Participants were instructed to fast for 12 hours and retain their usual medication 
intake. Blood samples were collected through venipuncture using serum separator tubes 
without anticoagulant. The analyzed biochemical parameters included the lipid profile 
(total cholesterol, low-density lipoprotein (LDL), high-density lipoprotein (HDL), and 
triglycerides) and fasting glucose, all expressed in mg/dL. The analyses were performed 
at the Clinical Biochemistry Laboratory of UFSC. Triglycerides, total cholesterol, and 
HDL were measured using an enzymatic colorimetric method, while LDL was calculated 
using Friedewald's formula: LDL-c = CT - (HDL-c + TG/5), where TG/5 represents the 
cholesterol associated with VLDL. All analyses were conducted using the Mindray BS-
120 biochemical automation equipment, following the manufacturer's instructions. Renal 
function was assessed by measuring creatinine levels using a modified Jaffé method.  
2.7. STATISTICAL ANALYSES 
The data were analyzed using JASP (Version 0.19.3) [computer software]. The 
characterization variables had their normality and homogeneity tested using the Shapiro-
Wilk and Levene tests, respectively. Variables classified as normal are presented as the 
mean and standard deviation. Categorical variables for characterizing the sample are 
presented as absolute frequency (sample n) and relative frequency (%). For comparing 
baseline characteristics between groups, the independent t-test was used for continuous 

data and Fisher's exact test for categorical data. To compare adherence between groups, 
the Wilcoxon rank sum test was used, and data are presented as median and interquartile 
range (P25-P75). 
For the comparison of the group (G2x and G3x) and time (pre-intervention and 
post-intervention), a 2-way analysis of covariance (ANCOVA) for repeated measures was 
performed, with the baseline values used as covariates. Outcomes were analyzed by 
intention to treat (ITT), which included all patients, once randomized, and missing data 
were imputed with simple imputation, replacing missing values with the last observed 
value. The significance adopted was 0.05. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

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1;64A(1):96–102.  
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Vieira DCL, Tibana RA, Tajra V, Nascimento D da C, de Farias DL, Silva A de O, et 
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Izquierdo M, Merchant RA, Morley JE, Anker SD, Aprahamian I, Arai H, et al. 
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Cao L, Li X, Yan P, Wang X, Li M, Li R, et al. The effectiveness of aerobic exercise for 
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HbA1c, blood pressure and functional outcomes of patients with type 2 diabetes: A 
systematic review with meta-analysis. Diabetes Res Clin Pract. 2023 Mar;197:110575.  
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Exercise for Type 2 Diabetes: A Systematic Review and Meta-Analysis. Sports 
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Wu ZJ, Han C, Wang ZY, Li FH. Combined training prescriptions for improving 
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Fisher G, McCarthy JP, Zuckerman PA, Bryan DR, Bickel CS, Hunter GR. Frequency 
of Combined Resistance and Aerobic Training in Older Women. J Strength Cond Res. 
2013 Jul;27(7):1868–76.  
12. 
Borba-Pinheiro CJ, Dantas EHM, Vale RG de S, Drigo AJ, Carvalho MCG de A, 
Tonini T, et al. Resistance training programs on bone related variables and functional 
independence of postmenopausal women in pharmacological treatment: A randomized 
controlled trial. Arch Gerontol Geriatr. 2016 Jul;65:36–44.  

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Jones CJ, Rikli RE, Beam WC. A 30-s Chair-Stand Test as a Measure of Lower Body 
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APPENDIX 
APPENDIX A – FREE AND INFORMED CONSENT FORM 
 FREE AND INFORMED CONSENT FORM 
 
Title: EFFECTS OF COMBINED TRAINING ON HEALTH PARAMETERS IN 
INDIVIDUALS WITH CARDIOVASCULAR RISK FACTORS. 
Principal Investigator: Prof. Dr. Aline Mendes Gerage da Silva (CDS/UFSC) 
Dear Sir/Madam, you are being invited to participate in a research project to be conducted 
by the Federal University of Santa Catarina, whose objective is to analyze the effects of 
a low-cost and easily applicable combined physical training program on health 
parameters in individuals with cardiovascular risk factors. This project is based on 
Resolution 466/2012 of the National Health Council, and the researchers commit to 
complying with all its provisions. 
Justification: Combined training (aerobic + strength) is considered one of the main non-
pharmacological strategies used in the prevention and treatment of cardiometabolic 
diseases. Understanding the short-, medium-, and long-term effects of this type of training 
helps clarify the risks and benefits of this practice in individuals who already present risk 
factors for cardiovascular diseases. 
Inclusion criteria: Being between 45 and 80 years old, having at least one 
cardiometabolic risk factor (Hypertension, Diabetes, and/or other cardiovascular disease), 
and being fit to engage in physical exercise. 
Exclusion criteria: Not properly using medication for an existing chronic condition; 
presenting severe complications of the existing chronic condition (e.g., severe autonomic 
neuropathy in individuals with Diabetes); and having muscular and/or joint impairments 
that prevent the performance of physical exercise. 
Procedures: By agreeing to participate in the study, you will undergo the following 
procedures: 
a) measurement of body mass, height, and body composition assessment; 
b) evaluation of functional capacity (strength, muscular endurance, flexibility, agility, and 
cardiorespiratory fitness in field and laboratory); 
c) assessment of psychosocial outcomes (quality of life, sleep, depressive symptoms) and 
cognitive health; 
d) measurement of blood pressure and capillary blood glucose before and after some 
sessions; 
e) blood tests for cardiometabolic biomarkers; 
f) heart rate measurements; 
g) dietary habits assessment; 
h) internal and external training load monitoring; 
i) aerobic and strength training, with possible inclusion of non-conventional modalities 
(stretching, Yoga, etc.) or nutritional intervention; 
j) scheduled open interviews. 
Risks and discomforts: The procedures are low risk and similar to those already 
performed in the extension project. Possible mild discomfort during blood tests or fatigue 
during exercise may occur. Questionnaires may cause minor emotional discomfort. 
Participants may stop at any time. Full support will be provided in case of any adverse 
event. 

Benefits: Participants may benefit from monitoring of blood pressure and glucose, health 
education, and individualized exercise prescription. 
Confidentiality: Participant identity will be preserved. Data will be used only for 
scientific purposes. Participants may withdraw at any time without penalty. 
Compensation and indemnification: There are no costs or payments. In case of 
expenses or damages, compensation is guaranteed according to regulations. 
 
The participant may withdraw consent at any time without penalty and without affecting 
participation in the extension project. 
 
 
 
 
Participant signature: __________________________ 
Date: ___/___/_____ 
 
 
 
Sincerely, 
 
Prof. Dr. Aline Mendes Gerage da Silva (UFSC) 
Phone: (48) 3721-3860 
Email: alinegerage@yahoo.com.br 
Address: Rua Itapiranga, 156, apto 901 C, Itacorubi, Florianópolis – SC 
 
 
 
Research Ethics Committee 
Rectorate II Building, UFSC, Florianópolis/SC 
Street: Desembargador Vitor Lima, nº 222, room 701, Trindade, Florianópolis/SC, CEP 
88.040-400, Contact: (48) 3721-6094, cep.propesq@contato.ufsc.br 
 
 
 

APPENDIX B – Anamnesis 
 
I) SOCIODEMOGRAPHIC PROFILE 
I.1) Full Name:__________________________________________________________________________ 
I.2) Address: ____________________________________________________________________________  
I.3) CEP: ________________ I.4) Contact Phone: __________________ I.5) Mobile: __________________ 
I.6) In case of emergency, notify (name and phone): ___________________________________________ 
I.7) Date of birth: ____/____/____  
I.8) Marital status: (0) Married/partnered                                  (2) Single  
                                             (1) Separated/divorced                (3) Widowed 
I.9) Education level: (0) Incomplete elementary school          (1) Incomplete high school 
 (2) Elementary school completed      (3) High school completed      (4) Incomplete higher education      
(5) Higher education completed 
II)  HEALTH HISTORY 
II.1) Has a doctor ever told you that you have or have had:  
II.1.1) Coronary artery disease                                             (0) No        (1) Yes      How long?__________ 
II.1.2) Hypertension / high blood pressure                                   (0) No        (1) Yes      How long?__________ 
II.1.3) Diabetes (high blood sugar)                                             (0) No        (1) Yes      How long?__________ 
II.1.4) High cholesterol and/or triglycerides (blood fat)            (0) No        (1) Yes     How long?__________ 
II.1.5) Pulmonary disease (asthma, emphysema, COPD, etc.)           (0) No        (1) Yes     How long?______ 
II.1.6) Enlarged heart or history of heart transplant             (0) No        (1) Yes     How long?__________  
II.1.7) Arrhythmias, dysrhythmias, or heart failure                           (0) No        (1) Yes     How long?_____ 
II.1.8) Aneurysm, stroke, or cerebrovascular accident     (0) No        (1) Yes     How long?__________  
II.1.9) Heart valve disease                                                  (0) No        (1) Yes     How long?__________  
II.1.10) Chagas disease                                                               (0) No        (1) Yes     How long?__________  
II.1.11) Blocked artery, myocardial infarction (heart attack), or coronary bypass surgery     (0) No        (1) Yes  
How long?______ 
II.1.12) Other diseases or health problems?___________________________________________________ 
____________________________________________________________________________________ 
II.1.13) Are you under medical supervision?                               (0) No            (1) Yes       
 
II.2) Do you feel chest pain (angina)? If yes, how often? 
________________________________________________________________________________________ 
      
II.3) Which medications do you regularly use (Include name, dose, weekly frequency, and time of day)?  
_________________________________________________________________________________________ 
 
II.4) Do you have any physical limitation (pain, injury, or surgery involving bones, muscles, or joints) 
that limits or prevents physical activity? 
_________________________________________________________________________________________ 
_________________________________________________________________________________________ 
_________________________________________________________________________________________ 
II.5) During physical activity have you ever experienced any of these symptoms? 
1. 
Chest pain or discomfort                 (0) No            (1) Yes                     
2. 
Shortness of breath during light exercise         (0) No            (Yes)                     
3. 
Dizziness or fainting                                (0) No            (1) Yes                     
4. 
Palpitations or tachycardia                      (0) No             (1) Yes                     
5. 
Leg pain when walking          (0) No            (1) Yes                     
6. 
Severe fatigue during light activities (0) No            (1) Yes                     

II.6) Has any first-degree relative had heart disease?   (0) No            (1) Yes                    (7) Don’t know 
II.7) Do you currently smoke? (0) No       (1) Yes  
II.7.1) If yes, on average how many cigarettes do you smoke per day? ___ cigarettes (7) Don’t know (8) Not 
applicable 
II.8) Have you had COVID-19? (0) No       (1) Yes 
 
 
V. QUALITY OF LIFE ASPECTS 
Please answer all questions. If you are unsure about how to respond, choose the option that seems most 
appropriate. This is often your first choice. Please consider your values, aspirations, pleasures, and concerns. 
We are asking about your perception of your life over the LAST TWO WEEKS. 
 
V.1) How would you rate your quality of life? 
(    ) Very poor        (     ) Poor         (    ) Neither poor nor good      (    ) Good        (     ) Very good 
 
V.2) How satisfied are you with your health? 
(  ) Very dissatisfied   (   ) Dissatisfied  (  ) Neither satisfied nor dissatisfied  (  ) Satisfied   (   ) Very satisfied 
 
V. 3) How satisfied are you with your ability to perform daily activities? 
(  ) Very dissatisfied   (   ) Dissatisfied  (  ) Neither satisfied nor dissatisfied  (  ) Satisfied   (   ) Very satisfied 
 
V.4) How satisfied are you with yourself? 
(  ) Very dissatisfied   (   ) Dissatisfied  (  ) Neither satisfied nor dissatisfied  (  ) Satisfied   (   ) Very satisfied 
 
V.5) How satisfied are you with your personal relationships? (friends, relatives, acquaintances) 
(  ) Very dissatisfied   (   ) Dissatisfied  (  ) Neither satisfied nor dissatisfied  (  ) Satisfied   (   ) Very satisfied 
 
V.6) How satisfied are you with your living conditions? 
(  ) Very dissatisfied   (   ) Dissatisfied  (  ) Neither satisfied nor dissatisfied  (  ) Satisfied   (   ) Very satisfied 
 
V.7) Do you have enough energy for your daily life? 
(    ) None        (    ) Very little      (    ) Moderate    (    ) A lot      (    ) Extremely 
 
V.8) Do you have enough money to meet your needs? 
(    ) None        (    ) Very little      (    ) Moderate    (    ) A lot      (    ) Extremely