Ideal Exercise Prescription for the Treatment of Hyperlipidemia

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Abstract

Dyslipidemia and cardiovascular disease are an ever-increasing problem in the United States, the severity and importance increasing with the rising prevalence of metabolic syndrome diagnoses. The rising cost of healthcare presents a need for less expensive treatment options for dyslipidemia and hypercholesteremia, one of which is physical activity. The purpose of this review was to outline the ideal type, intensity, and frequency of aerobic exercise and resistance training that can improve lipid levels by clinically significant amounts. A total of 19 articles were gathered the scientific databases available to the author. It was found that both moderate intensity aerobic and resistance training were most beneficial, although high intensity aerobic interval training should be the preferred aerobic modality when the patient is physically capable of sustaining that level of effort. A combined exercise protocol prescribed at the ideal intensities for 3-4 days per week, was found to significantly improve both low-density lipoprotein (LDL) and high-density lipoprotein levels (HDL).

Keywords: hyperlipidemia, hypercholesterolemia, resistance training, aerobic training, physical exercise, lipid levels, cholesterol

Ideal Exercise Prescription for the Treatment of Hyperlipidemia

Cardiovascular disease (CVD) and physical activity are becoming two increasingly discussed topics as more and more Americans realize the importance of maintaining their cardiovascular health and increasing their physical activity. This is not a problem unique to the United States despite our predilection towards unhealthy food and sedentary lifestyles. Cardiovascular disease was recently determined to be the leading cause of mortality and morbidity internationally (Catapano at al., 2011; Martin et al., 2013). In the United States coronary heart disease, found in roughly 6% of Americans, is the number one cause of death according to the Center for Disease Control (2011). Cholesterol and lipid levels are an important risk factor and predictor of outcomes with CVD and nearly 40% of Americans have high total cholesterol levels (>200 mg/dL) (American Heart Association, 2017). It is not just the total cholesterol levels that have risen to extremely problematic levels: 1 in 3 Americans also have high low-density lipoprotein (LDL) levels, and 18.7% have low high-density lipoprotein (HDL) levels (AHA, 2017). This disease state is not just concerning for adults as the prevalence of metabolic syndrome, a related condition, has been increasing in pediatric populations (Miranda, DeFronzo, Califf, & Guyton, 2005). These statistics clearly outline a significant health issue that is often exacerbated by physical inactivity.

Our increasingly sedentary culture has led to nearly one third of Americans not engaging in leisure time physical activity (AHA, 2017). A lack of activity and poor nutrition greatly affect CVD risk factors, which is why increasing physical can improve health outcomes over the long-term. One study showed that reducing periods of physical inactivity could reduce the risk of coronary heart disease (CHD) by 6% and increase life expectancy by an average of 0.68 years (Lee et al., 2012). Depending on the type of exercise and experience level of the patient, physical activity can be an accessible and cheap option to reduce health risks related to CVD and improve cholesterol levels. Exercise can be a useful therapy option in the treatment of high cholesterol, using endurance training, resistance training, or a combination of both. The purpose of this paper will be to discuss the ideal frequency, intensity, and time prescriptions for each exercise type while highlighting the role each exercise plays in the modifications of lipid levels and control of hypercholesterolemia.

Cholesterol problems, or dyslipidemia, is a principal factor in metabolic syndrome which is defined as high triglycerides, low HDL, and high LDL levels (Miranda et al., 2005). The elevated triglyceride levels play a significant role in the process that leads to insulin resistance and diabetes mellitus, worsening the symptoms of metabolic symptoms which increases the patient’s risk of mortality (Miranda et al., 2005). Metabolic syndrome is often used to describe a multitude of health problems that can often be partly controlled with improved treatment of dyslipidemia as recent American College of Cardiology (ACC) and AHA guidelines suggest (Eckel et al., 2014). These guidelines focus primarily on blood pressure and lipid modification improvements for improving health outcomes, with the goal of reducing mortality in CVD patients (Eckel et al., 2014).

The current standard and preferred medication are statins and have been shown safe even when used to decrease LDL levels beyond the current acceptable guidelines (Cholesterol Treatment Trialists’, 2010). The CTT Collaboration suggested continuing to lower LDL levels past recommended levels may be beneficial and no harmful despite the subclinical lipid levels (CTT, 2010).  Despite statins’ ability to lower lipids, the possibility of side effects suggests increasing exercise as a co-therapy while minimizing statin dosing may prove beneficial to the patient’s quality of daily living. Statin and exercise co-therapy, using long-term moderate intensity activity, has been shown to counteract common statin adverse reactions such as increased risk of diabetes, elevated liver enzymes, and myopathy (Gui et al., 2017).

Physical activity is useful as a solo therapy as well, a 25-year cohort study following 62 men improved lipid levels and CVD profiles after averaging >2050 kcal/week of leisure-time physical activity (LTPA) (Kwasniewski et al., 2016). Positive changes were seen in LDL, HDL, and triglyceride (TG) levels within the stable high LTPA group (>2050 kcal/week), indicating long-term consistent exercise is beneficial for improving health outcomes related to dyslipidemia (Kwasniewski et al., 2016). Non-significant reductions were found in the groups engaging in stable low-moderate (<2050 kcal/week) and very high (>3840 kcal/week) indicating an ideal range of physical activity may need to be prescribed in order incur the intended clinical lipid panel improvements (Kwasniewski et al., 2016). Sarzynski and colleagues (2015) propose the mechanism behind these benefits is an increase in lipoprotein lipase (LPL) and hepatic lipase (HL) due to increasing oxygen and energy demands related to an increase in physical activity, leading improved lipid panels and less clinically severe dyslipidemia. Based on this evidence, there is likely a preferred exercise prescription that would prove most beneficial in improving lipid profiles by clinically significant amounts.

Method

A total of 19 articles were included in this literature review. PubMed, Google Scholar, and the U.S. Army Medical Department Center and School Stimson Library were used to obtained articles online. Some articles attained required an interlibrary loan with the assistance of the Stimson Library staff. Commonly used search terms included: hyperlipidemia, hypercholesterolemia, resistance training, aerobic training, physical exercise, lipid levels, and cholesterol. Studies older than eight years old were excluded except for landmark research, background information, and general statistics. An effort was made to include both healthy and unhealthy individuals to improve the external validity of the results.

Review of Literature

Aerobic Training

Aerobic training, or endurance training, is one of the most accessible types of exercise and refers to common activities such as walking, running, and cycling. Oftentimes no equipment is needed to engage in aerobic activity, making this the most accessible and more commonly performed type of exercise. Its use in preventing cardiovascular related death is well documented and there is a strong foundation of research discussing its ability to control lipid levels as well.

High intensity aerobic training.

The American College of Sports Medicine (ACSM) describes high intensity exercise as >60% maximum heart rate (HRmax) (ACSM, 2013). The average American is not likely to engage in these types of activities at a higher intensity unless they have prior experience or already routinely engage in physical activity. Higher intensities have been previously shown to improve HDL levels, increasing HDL concentration and particle size, twenty-four hours after training and lasting for 15 days of detraining (Sarzynski et al., 2015). A study by Almenning et al. (2015) separated thirty-one females into high-intensity interval training (HIIT), strength training, and control groups for 10 weeks. Each exercise group performed their selected physical activity modality three times per week, while being monitored by an exercise physiologist for at least one training session per week and maintained their normal diet throughout the intervention (Almenning et al., 2015). The first two HIIT sessions each week consisted of four minutes at 90-95% HRmax separated by three minutes at 70% HRmax for four iterations while the third session consisted of ten one-minute intervals at maximal intensity separated by one minute of rest or active recovery (Almenning et al., 2015). HDL levels increased significantly (0.2 nmol/L) in the HITT group compared to the other groups (Almenning et al., 2015). Even though aerobic training is commonly associated with improvements in LDL levels, this study provides evidence that short-term, intense aerobic exercise may also have a positive effect on HDLs. The design of the HIIT intervention also provides evidence that variations in training programs may allow patients to constantly vary their exercise prescriptions to prevent burn-out and maintain interest for longer periods of time.

Not all evidence supports high intensity aerobic exercise for the improvement in HDL levels. After walking two times a day for 30 minutes at anaerobic threshold, a group of obese patients significantly decreased their LDL but saw no change in HDL after 4 weeks (Yamaguchi, Saiki, Endo, Miyashita, & Shirai, 2011). This data contradicts other studies but four weeks may not be enough time to see a significant improvement in the overall lipid profile of obese patients.

Moderate intensity aerobic training.

Moderate intensity aerobic training is currently considered to be exercise at 40-60% HRmax, although resources vary, and some sources may consider moderate intensity to range up to or around 75% HRmax (ACSM, 2013). A majority of the research supports moderate intensity aerobic training for the improvement of lipid levels and due to the heart rate range it is also one of the more common exercise modalities due to the accessibility of endurance training and associated discomfort prior to and after performing highly intense exercise. The proposed mechanism by which lipid levels improve is a hypotriacylglycerolemic effects 12-24 hours after a single bout of prolonged moderate intensity endurance exercise (Sarzynski et al., 2015).

One study found significant changes in LDL (-9.5%) and HDL (12%) after a three day per week program (30 minutes at 65% VO2max) for 6 weeks (Farias, Santos-Lozano, Urra, & Cristi-Montero, 2015). All the subjects were diagnosed with type 2 diabetes mellitus (DM) and were receiving no pharmacologic therapy (Farias et al., 2015). Moderate intensity AT is not just effective in patients previously diagnosed with metabolic disease but in obese adult populations as well. Korshoj et al. (2016) studied 116 overweight females (average BMI = 26.7%) and found that 30 minutes of supervised AT twice per week at >60% VO2max significantly decreased both LDL (0.88 mmol/L) and the LDL/HDL ratio (0.59).

The growing problem with pediatric obesity in the United States raises concern for dyslipidemia among younger patients, fortunately current research has shown moderate intensity AT to be beneficial for these patients as well (Miranda et al., 2005). Thirty-two obese adolescents (between 11 and 17 years old) engaged in AT 3 times per week (50 minutes per session) for 20 weeks (Monteiro et al., 2015). The aerobic modalities consisted of walking and running, while the intensity began at the bottom of the moderate intensity spectrum and progressively increased to between 65% and 85% VO2peak depending on the individual subjects (Monteiro et al., 2015). The results showed significant improvements in triglycerides (-32 mg/dL) and HDL (+3.1 mg/dL), along with nonsignificant LDL changes (-26.1 mg/dL) (Monteiro et al., 2015). The initial intensity was moderate but progressively increased at regular intervals to ensure effort did not decrease as physical adaptations were made to the training modality. A systematic review analyzing the relationship between physical activity, detraining, and lipid profiles in an obese pediatric population found an average of 65 minutes of physical activity 2-5 days per weeks for 12 to 48 weeks would significantly improve HDL levels (García-Hermoso, Carmona-López, Saavedra, & Escalante, 2014). More importantly, after a period of detraining, the HDL remained elevated which the authors proposed was due to an increase in healthy habits due from long-term interventions (García-Hermoso et al., 2014). This is further evidence that physical activity, in this case AT, can have positive effects lasting through the cessation of exercise programs. These studies provide some evidence that moderate intensity AT may help improve lipid profiles in younger obese populations that are at a higher risk of developing cardiovascular-related diseases as they grow older (Monteiro et al., 2015).

Another review determined aerobic exercise at 70-80% of HRmax led to an overall increase in HDL (4.6%) and decrease in LDL levels (-5%) (Mann, Beedie, & Jimenez, 2014). This study also considered exercise duration and volume, discovering that volume may be more important than intensity when attempting to improve a patient’s lipid profiles (Mann et al., 2014). This is useful data for treating patients resistant to beginning and maintaining aerobic exercise programs, as they could pursue less intense and more enjoyable activities resulting in healthy habits forming after long-term interventions.

Perhaps most importantly, intense interval training at ventilatory threshold has been shown to decrease LDL in patients with coronary artery disease who are already taking lipid-lowering medications (Tambarus et al., 2015). These subjects performed aerobic training three times per week for 16 weeks at a moderate intensity based on their ventilatory anaerobic threshold (VAT), each session lasted 30-40 minutes not including warm-up and cool-down time. (Tambarus et al., 2015). These patients already have multiple cardiovascular risk factors present and could benefit the most from high intensity aerobic training improving their lipid profile and reducing mortality risk.

Low intensity aerobic training.

Low intensity AT is generally defined as exercise at less than 40% HRmax (ACSM, 2013). One systematic review of 33 studies found that light intensity physical activity (LIPA) had no significant effects on total cholesterol, LDL, HDL or cardiovascular risk factors in adults over 18 years old (Batacan, Duncan, Dalbo, Tucker, & Fenning, 2015). This data is evidence that lighter activity may lack the intensity needed to induce change in cholesterol levels, especially when performed for comparable durations to the previously mentioned high and moderate intensity AT programs.

Based on the data previously presented, moderate intensity is likely the best prescription for the elderly, obese, pediatric, and inexperienced patient populations. Clinically significant improvements in lipid panels may not be seen for up to 2 months and patients need to perform their chosen aerobic exercise modality three times per week at an intensity of at least 60% HRmax for 45-60 minutes per training session.

Resistance Training

Resistance training, or weight training, is commonly used to describe what is not considered aerobic or endurance training even though they are often performed concurrently. Due to the knowledge and equipment required, patients who are overweight or obese may feel overwhelmed and discouraged but there are still others who prefer a gym or machines to running and walking. It is important to consider personal preferences when prescribing the appropriate exercise for a patient, and fortunately evidence exists supporting resistance training as an adequate training modality for improving lipid profiles and reducing cardiovascular risk factors.

High intensity resistance training.

A study by Oliveira et al. (2015) followed twenty-two postmenopausal women with previously controlled hyperlipidemia through a 12-week progressive resistance program, performing exercises at hard to somewhat hard rating of perceived exertion. These ratings correspond to a 13 to 15 on the Borg Rating of Perceived Exertion (RPE) scale, meaning the subjects were challenged by the activity but had to push themselves to continue with the resistance training (CDC, 2015). The exercise program consisted of performing three sets for each exercise with the repetitions starting at 12 then decreasing by two every 4 weeks, while increasing the weight accordingly to maintain a score of 13-15 on the RPE scale (Oliveira et al., 2015). Both total cholesterol and LDL significantly decreased at the end of the intervention, with medium effect sizes (Oliveira et al., 2015). Also of note an important cardiovascular risk factor, the total cholesterol divided by HDL ratio, decreased significantly from 3.91 to 3.6 along with the overall improvement the patient’s lipid profiles (Oliveira et al., 2015). This is important evidence to consider, as patients with controlled dyslipidemia still stand to benefit from a high intensity resistance training program.

Another study compared a high intensity progressive resistance training group to an active control group (three 30-minute walking sessions per week) while monitored lipid profile changes (James et al., 2016). The resistance training group performed 60 minutes of resistance training three times a week, each exercise consisting of 3 sets of at least 8 repetitions and increasing the weight once 10 repetitions could be performed (James et al., 2016). The resistance training group only saw a significant decrease in LDL (0.2 mM) compared to the control group, providing evidence that long-term resistance training programs improve lipid levels in the older populations commonly affected by dyslipidemia and cardiovascular disease (James et al., 2016). Both previously discussed high intensity resistance training programs used progressive training programs, if difficulty is not maintained throughout the intervention it is possible that the lipid effects may not be as pronounced so some monitoring of effort may be required.

Moderate intensity resistance training.

A study by Lira et al. (2010) examined 31 healthy, untrained males after performing low, moderate, and high intensity resistance training; monitoring the effects each intensity had on lipid levels after an acute bout of exercise. The subjects performing 4 sets of 20 at 50% one repetition maximum (1-RM) had greater reductions in LDL at 24 hours post-exercise than the group performing resistance training at 110% 1-RM (Lira et al., 2010). Given the importance of LDL when considering cardiovascular risk factors, it is important to prevent patients from over exerting themselves and reaching excessive intensities while strength training when the primarily goal is to reduce LDL. Further supporting moderate intensity resistance training, HDL levels also significantly increased in both the 50% and 75% 1-RM groups when compared to the 110% group at 48 hours post-exercise (Lira et al., 2010). The short-term benefits are of moderate intensity resistance training are significant, providing evidence that patients may benefit from just one or two sessions per week when performed at the correct intensity.

Along with the acute improvements in lipid levels, moderate intensity resistance training also offers substantial benefits due to effects of resistance training helping maintain improved lipid levels after a period of detraining (Farias et al., 2015). After a 6-week training program and subsequent 6-week detraining period, a moderate intensity resistance training group maintained reduced LDL and increased HDL (Farias et al., 2015). The strength training was performed at 65% 1-RM, a manageable program even for unexperienced subjects who are new to or uncomfortable utilizing standard weightlifting equipment (Farias et al., 2015). The detraining effects allows for interruptions in exercise programming, whether it be due to schedule conflicts, sickness, or injury, giving the provider flexibility to prescribe physical activity the patient is more likely to adhere to while also pausing physical activity when patient health and safety dictate a period of recovery.

As previously discussed with aerobic exercise, some evidence suggests intensity may not be the most significant factor when prescribing physical activity to treat dyslipidemia. Mann et al. (2014) found that resistance training provided the greatest benefits to lipid profiles when performed with weight equal to 75-85% 1-RM (or moderate-to-high intensity) but that like aerobic physical activity, volume was more effective at improving lipid levels than exercise intensity (Mann et al., 2014). Taking these results into account, prescribed weight may need to be decreased or exercises performed more often when necessary to maintain or improve the efficacy of moderate intensity resistance training on lipid levels.

Low intensity resistance training.

Low intensity resistance exercise is performed at less than 40% VO2max, under 40% of the patients 1-RM, or with an increased number of repetitions and lighter weight with longer rest periods (ACSM, 2013). It usually requires less equipment, being performed with smaller dumbbells, resistance bands, or even just bodyweight. This increases the accessibility by allowing lower intensity resistance training to be performed almost anywhere with much less experience than would be required to engage in heavy or intense weightlifting. These factors make low intensity resistance training ideal for older populations, including those with increased cardiovascular risk factors and dyslipidemia.

Ribeiro et al. (2015) looked at the difference in lipid profile changes between two groups, depending on if they had prior resistance training experience, after they had undergone an 8-week intervention. Sixty-five women over age 60 underwent eight supervised exercises three times per week with repetitions starting at 8 and progressively increasing to 15 over the course of the intervention (Ribeiro et al., 2015). An addition to the exercise protocol, concentric and eccentric phases of each exercise were altered. Each subject maintained constant movement velocity while emphasizing eccentric motion to achieve a concentric to eccentric ratio of 1:2 (Ribeiro et al., 2015). Both groups saw significant improvements in their triglycerides, HDL, and LDL levels; the greatest improvements being the decreases in LDL, -25.4% for the advanced group and -34% for the novice group (Ribeiro et al., 2015). This research emphasizes that prior training adaptations may not reduce intended lipid panel benefits. Patients who are already exercise at higher intensities may need a change in exercise prescription, lowering weight increasing repetitions, and increasing rest periods.

A change in intensity should not be the only focus when something as simple as slowing down the exercise movement can also positively affect lipid levels (Hamasaki et al., 2015). Hamasaki et al. (2015) took 26 obese subjects through 12 weeks of low intensity resistance training at 50% 1-RM, performing three sets of 8-10 repetitions every other day. The exercise protocol placed significant emphasis on the movement itself (a vertical half-squat), using 3 to 5 second eccentric and concentric motions with a 1 second paused contraction at the midpoint of each movement (Hamasaki et al., 2015). A significant increase in HDL (+0.4 mg/dL) was seen at the end of the trial, providing further evidence that resistance training, even done slowly and at low intensities, may help improve HDL levels (Hamasaki et al., 2015). The patients involved were also type 2 diabetes mellitus patients, with 17 taking medications to reduce cholesterol during the intervention, more evidence supporting resistance training as an option for treating patients with dyslipidemia secondary to metabolic syndrome (Hamasaki et al., 2015).

Based on the current available resistance training research available to the author, the most beneficial intensity of resistance training appears to be moderate level exercises at 50-75% 1-RM. An emphasis placed on the eccentric motion may improve the effects on lipid levels. As not all patients may want to engage in resistance training, it is important to consider the effects of resistance training combined with aerobic exercise.

Combined Exercise Programs

With all the evidence supporting aerobic exercise and resistance training individually it should come as no surprise that combined exercise programs are effective as well. A previously mentioned study monitoring obese adolescents compared an aerobic exercise program to a combined exercise program, both lasting 20 weeks (Monteiro et al., 2015). The combined exercise protocol was performed three times per week with the first 60 minutes devoted to resistance training in the form of circuit training, progressively increasing every four weeks of the intervention from 55% to 75% 1-RM (Monteiro et al., 2015). The circuit training was followed by 30 minutes of the previously described aerobic training protocol. Workload was matched between study groups by assessing the volume and intensity of each session to improve the validity of the exercise protocol comparison (Monteiro et al., 2015). The concurrent training group saw greater decreases in LDL (-33.91 mg/dL) than the aerobic exercise group (-26.06 mg/dL) along with significantly decreased TG levels (-26.28 mg/dL) and increased HDL (+5.49 mg/dL) (Monteiro et al., 2015). Combined exercise protocols also allow for more variation in training programs, which may improve patient adherence and lead to greater long-term benefits. With properly prescribed intensity and duration, combined exercise likely provides the best options for most patients to counteract dyslipidemia and improve cardiovascular risk factors.

No current research was found contradicting the efficacy of combined exercise protocols but this may be due to terms and search criteria used find relevant articles. It is possible combined exercise may be inferior to a program that relies heavily on moderate intensity aerobic exercise as it can be highly beneficial when completed alone. The ideal intensity, duration, and repetition scheme should still be considered to avoid a vague physical activity prescription and nonsignificant changes in patient lipid panels.

Discussion

Despite busy schedules and ever-changing daily activities, individuals may not need to exercise on a strict, regular schedule to maintain the benefits of exercise. The improvements in lipid levels with remain for up to six weeks, increasing the importance of timely follow-up appointments and periodic reassurance despite the occasional lapse in a patient’s usual exercise schedule (Garcia-Hermoso et al., 2014). These physiological changes are largely due to the energy requirements of exercise and the body’s ability to adapt and become more efficient with energy sources. Nonstrenuous physical work leads to an increased removal of lipoproteins (decreased TGs/LDL-C) by lipoprotein lipase within expanded capillary circulation throughout muscle and fat in both patients with and without coronary heart disease (Aronov, Bubnova, Perova, Orehkov, & Bobryshev, 2017). Though in contradiction, higher lipid levels may be linked to an adaptive response to provide energy-rich fuel for larger muscle groups recruited during strenuous physical activity suggesting inappropriate exercise regimes at less than ideal intensities may actual be detrimental to the cardiovascular health of a patient battling dyslipidemia (Aronov et al., 2017).

As both aerobic and resistance training create healthy physiological responses alone and as combined training modalities, it is reasonable to conclude that all patients intending to improve lipid levels should engage in each type of activity assuming they have no physical limitations (Monteiro et al., 2015). Patients should perform the prescribed ideal exercise programs regardless of whether they are currently receiving pharmacological treatment or other non-pharmacological treatments (Tambarus et al., 2015).

Moderate intensity aerobic activity, performed three days per week at 40-60% HRmax, is ideal for elderly, pediatric, and obese populations when no contraindications are present. High intensity aerobic training should not be ruled out but be substituted as the patients exercise tolerance improves to reach more clinically significant improvements in both LDL and HDL. If utilized, high intensity aerobic exercise should be performed at over 60% HRmax and performed three times a week as well but sessions may only need to last 20-30 minutes if training at anaerobic or ventilatory thresholds (Almenning et al., 2015; Tambarus et al., 2015).

Moderate intensity resistance training should be preferred over high intensity resistance training when assigning exercise protocols for lipid management. The ideal resistance training routine should consist of 45-60 minutes with three sets of eight repetitions per exercise at 50-75% 1-RM. An emphasis should be placed on slow eccentric motion during each movement to maximize the lipid profile benefits seen with resistance training (Hamasaki et al., 2015). The resistance training can be performed concurrently with the aerobic training or on separate days, totally at least 2-3 days per week.

Training volume should also be taken into consideration with training intensity, as it may be more important than intensity (Mann et al., 2014). This means that patients should be instructed to complete all prescribed exercise even if they lack the energy or motivation to maintain the ideal intensities. Exercises and workouts could also be broken up throughout the day, performing multiple short but high intensity activities throughout the day to meet volume and intensity goals. Patients with prior exercise experience should also be persuaded to improve their current exercise regimes, altering them to fit the ideal intensity, frequency, and volume needed for lipid panel improvements. As discussed, subjects with previous training experience still stand to benefit from clinically significant improvements in TG, HDL, and LDL (Ribeiro et al., 2015).

Physical activity, as with most of the currently available treatment options, does not come without its contraindications. Safety is an important concern with all physical activity, especially in populations who have little experience or training. A lack of experience in an untrained individual who is unable to manage the intensity of their exercise can be dangerous, as vigorous exercise increases the risk of primary cardiac arrest (Sharma, Merghani, & Mont, 2015). These events can be prevented with proper supervision by trained exercise professionals. Perhaps in situations where that is not feasible, community programs providing information and instruction may be more financially accessible in certain populations.

Limitations

This literature review was limited to articles available within the databases accessible to the author, although articles were obtained whenever possible through interlibrary loans. As with many exercise programs, results will vary by patient and not all patients will prefer to engage in the same activities. These differences can be accounted for with a thorough patient history and by building a provider-patient relationship that allows for an exercise prescription to be built around the patient’s available resources, time constraints, interests, and experience level.

Conclusion

Aerobic and resistance training should be performed by all patients being treated for dyslipidemia unless contraindications to physical exertion exist. Even the elderly, obese, and pediatric population will benefit from an exercise program consisting mainly of moderate intensity exercise. A wide variety of exercise modalities may be implemented based on the patient’s previous experience and comfort level. Future research is needed to investigate the superiority of one type of aerobic exercise over another, if running is more beneficial than cycling or if indoor versus outdoor environments make a significant different in lipid panels.

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