Exercise intervention and health checks for middle-aged men with elevated cardiovascular risk: A randomized controlled trial

Full Te ms & Condi ions o access and use can be ound a h p://www. and online.com/ac ion/jou nalIn o ma ion?jou nalCode=ip i20 Download by: [Tampe e Uni e si y] Da e: 24 No embe 2016, A : 05:07 Scandina ian Jou nal o P ima y Heal h Ca e ISSN: 0281-3432 (P in ) 1502-7724 (Online) Jou nal homepage: h p://www. and online.com/loi/ip i20 Exe cise in e en ion and heal h checks o middle-aged men wi h ele a ed ca dio ascula isk: A andomized con olled ial Helena Lii a, Elina Engbe g, Jenni Leppä uo i, S e lana F om, Hannu Kau iainen, Juha Lii a, Taina Remes-Lyly, Heikki Tikkanen & Kaisu Pi kälä To ci e his a icle: Helena Lii a, Elina Engbe g, Jenni Leppä uo i, S e lana F om, Hannu Kau iainen, Juha Lii a, Taina Remes-Lyly, Heikki Tikkanen & Kaisu Pi kälä (2014) Exe cise in e en ion and heal h checks o middle-aged men wi h ele a ed ca dio ascula isk: A andomized con olled ial, Scandina ian Jou nal o P ima y Heal h Ca e, 32:4, 156-162, DOI: 10.3109/02813432.2014.984967 To link o his a icle: h p://dx.doi.o g/10.3109/02813432.2014.984967 © 2014 The Au ho (s) Published online: 01 Dec 2014. Submi you a icle o his jou nal A icle iews: 483 View ela ed a icles View C ossma k da a Ci ing a icles: 1 View ci ing a icles Scandina ian Jou nal o P ima y Heal h Ca e, 2014; 32: 156–162 ISSN 0281-3432 p in /ISSN 1502-7724 online © 2014 The Au ho (s) DOI: 10.3109/02813432.2014.984967 ORIGINAL ARTICLE Exe cise in e en ion and heal h checks o middle-aged men wi h ele a ed ca dio ascula isk: A andomized con olled ial HELENA LIIRA 1,4 , ELINA ENGBERG 2,3 , JENNI LEPP Ä VUORI 2,3 , SVETLANA FROM 4 , HANNU KAUTIAINEN 5 , JUHA LIIRA 6 , TAINA REMES-LYLY 7 , HEIKKI TIKKANEN 2,3 & KAISU PITK Ä L Ä 4 1 Depa men o Gene al P ac ice, School o Medicine, Uni e si y o Tampe e, 2 Depa men o Spo s and Exe cise Medicine, Ins i u e o Clinical Medicine, Uni e si y o Helsinki, 3 Founda ion o Spo s and Exe cise Medicine, Clinic o Spo s and Exe cise Medicine, Helsinki, 4 Uni o P ima y Heal h Ca e, Helsinki Uni e si y Cen al Hospi al and Depa men o Gene al P ac ice, Uni e si y o Helsinki, 5 Medca e Founda ion, Ä ä nekoski, 6 Finnish Ins i u e o Occupa ional Heal h, Helsinki, and 7 Ki kkonummi Heal h Cen e Abs ac Objec i e. To s udy he e ec s o a heal h check by a nu se alone o combined wi h an exe cise in e en ion in middle-aged men a inc eased ca dio ascula isk. Design. A andomized con olled ial. Se ing and in e en ion. P ima y ca e in Ki k- konummi municipali y wi h 36 000 inhabi an s. A heal h check by a nu se alone o combined wi h an exe cise in e en ion o con ols wi h no in e en ion was compa ed. Subjec s. A o al o 168 men aged 35 o 45 yea s wi h a leas wo ca dio- ascula isk ac o s and physical ac i i y (PA) equency ⬍ 3 imes a week. Main ou come measu es. Me abolic synd ome (Me S) as de i ned by In e na ional Diabe es Fede a ion/Ame ican Hea Associa ion and sel - epo ed PA equency. Resul s. O e all, ocusing on heal h inc eased physical ac i i y equency in middle-aged men. A e one yea , 19% had inc eased PA o ⱖ 3 imes a week (95% CI 12 – 26). All s udy g oups inc eased PA o ⱖ 3 imes: 26% o men in he exe cise in e en- ion g oup, 15% o men in he heal h check g oup, and 16% o con ols. The di e ences be ween he g oups we e no s a is ically signi i can . The in e en ion did no ha e any meaning ul impac on Me S o o he ca dio ascula ou comes a one-yea ollow up. Conclusions. Physical ac i i y inc eased in all s udy g oups o middle-aged men in his heal h-p omo ion ial. The in e en ions had no e ec on me abolic synd ome o o he ca dio ascula ou comes in he pa icipan s. The ial inc eased awa eness and collabo a ion in physical ac i i y p omo ion among municipal heal h ca e and exe cise se ices. Key Wo ds: Ca dio ascula isk , exe cise in e en ion , Finland , gene al p ac ice , heal h check , me abolic synd ome wi h die a y changes, i dec eases he incidence o ype 2 diabe es melli us in high- isk g oups [3], imp o es he Me S in gene al [4], and educes HbA1c le els in pa ien s wi h ype 2 diabe es [5]. The challenge is ha people do no adhe e o PA ecom- menda ions. The main easons o his in he middle- aged include economic ac o s, lack o ime, and low mo i a ion [6]. Al hough he e ec i eness o such in e en ions on mo bidi y may now be ques ionable [7], he e was a end in Finland o conduc heal h checks o 40-yea -old men o imp o e hei li es yle habi s. Also in Ki kkonummi municipali y, he heal h ca e In oduc ion Middle-aged men s a o p esen symp oms o me - abolic synd ome (Me S), which makes hem a ele- an a ge o heal h p omo ion. In Finland, he No h Ka elia p ojec ocused mos ly on nu i ion and se es as a model o an e ec i e heal h-p omo- ion in e en ion o educe ca dio ascula isk [1]. Nowadays, a seden a y li es yle has become p e a- len and i appea s ha inc easing physical ac i i y (PA) may be one o he mos e ec i e means o con- ol ca dio ascula isk. The posi i e e ec s o PA a e well s udied: i p o- mo es weigh loss [2], especially when combined Co espondence: Helena Lii a, Kuninkaan ie 4, 02400 Ki kkonummi, Finland. E-mail: [email p o ec ed] This is an Open Access a icle dis ibu ed unde he e ms o he C ea i e Commons A ibu ion-Non-Comme cial License (h p://c ea i ecommons.o g/licenses/by-nc/3.0) (Recei ed 9 Ap il 2014 ; accep ed 10 Oc obe 2014 ) Heal h checks and exe cise in e en ion o men wi h ca dio ascula isk 157 policy-make s wan ed o commence a p og amme o heal h checks. Howe e , in addi ion o heal h checks we we e able o s a a andomized con olled ial s udying he e ec i eness o heal h checks alone o in combina ion wi h an exe cise in e en ion. Because an indi idual app oach may no be su - i cien o li es yle changes, we added a g oup-based exe cise in e en ion o he ial. This was especially impo an as Ki kkonummi is a commu e own in he Helsinki a ea whe e mos inhabi an s mo e o wo k in he capi al egion and as a esul o his men end up lacking hei na u al g oups o pee s o exe - cise. The e o e, as one o he communi y a ge s wi h his ial we aimed o es ablish g oups o men exe cis- ing oge he . We also wan ed o c ea e coope a ion be ween he heal h cen e and o he municipal ac i - i ies, such as adul educa ion and exe cise se ices in heal h p omo ion. Al hough he e is e idence o he e ec s o exe - cise plus die in indi iduals al eady p esen ing wi h impai ed glucose ole ance [3] and o he clinical mani es a ions [4,5], he e is s ill a need o s udies on exe cise alone in p ima y heal h ca e a ge ed a isk g oups. Ou aim was o a ge he isk g oup o middle-aged men wi h ca dio ascula isk ac o s wi h wo in e en ions: heal h checks and an exe cise in e en ion, and o s udy he e ec s in a andomized con olled ial. In his pape , we p esen he i ndings o he ial wi h ega d o i s main ou comes: me a- bolic synd ome and physical ac i i y. Ma e ial and me hods Gene al design We planned a h ee-a med one-cen e andomized con olled ial (see Figu e 1). The me hods ha e been desc ibed in de ail ea lie [8]. Men we e ec ui ed by h ee me hods: by in i a ion le e s o 40-yea -olds, by mass media and local campaigning, and by a ge ed ec ui ing in he heal h se ices. A e sc eening and andomiza ion, he i s s udy a m ecei ed a 1 ½ -hou heal h check in e en ion by a public heal h nu se. The second in e en ion a m ecei ed, in addi ion o he heal h check, a guided g oup exe cise in e en ion o 12 weeks. The hi d g oup se ed as a con ol g oup, and men in his g oup had he oppo uni y o pa icipa e in he heal h checks and exe cise in e en ions a e one yea . Pa icipan s Inclusion c i e ia we e p ede i ned as ollows: men aged 35 o 45 wi h a leas wo ca dio ascula isk ac o s. These included BMI 27 – 34 kg/m 2 , wais ci - cum e ence ⬎ 94 cm, as ing glucose ⬎ 6.1 mmol/l, o al plasma choles e ol ⬎ 5.0 mmol/l, LDL-choles- e ol ⬎ 3.0 mmol/l, iglyce ides ⬎ 2.0 mmol/l, sys- olic blood p essu e ⬎ 140 mmHg, dias olic blood p essu e ⬎ 90 mmHg and cu en ly ei he smoking o on choles e ol-lowe ing o blood p essu e-lowe - ing medica ion. Exclusion c i e ia we e as ollows: BMI o e 34 (o any o he physical ba ie p e en ing pa icipa- ion in he exe cise in e en ion) o ac i e exe cise (exe cising o a leas 30 minu es h ee imes a week o mo e) o ha ing an immedia e heal h p oblem equi ing ea men o a se e e isk ac o , o exam- ple, ecen ly diagnosed o uncon olled ype I diabe- es, o symp oma ic co ona y a e y disease. Randomiza ion Once he men had consen ed o pa icipa e in he s udy and he baseline measu emen s we e ca ied ou , hey we e andomly alloca ed o one o he h ee s udy g oups. A andomiza ion lis based on andom num- be s was made and ans e ed o sequen ially num- be ed, sealed en elopes. The s udy coo dina o (SF) opened he en elopes in numbe ed o de and in o med pa icipan s o hei s udy a m and p ocedu es. S udy in e en ions Heal h check in e en ion by a nu se . Public heal h nu ses used s anda d p ac ices in hei heal h-p o- mo ion in e en ion. P io o he onse o he ial, hey a ended a aining session a anged by he Finnish Hea Associa ion. In hei in e en ions, he nu ses used he ype 2 diabe es disease isk assessmen o m (Finnish Diabe es Associa ion) [9], and he ca dio ascula isk assessmen cha ( he Finnish Hea Associa ion). The in e en ion I is known ha p omo ion o physical ac i i y in p ima y ca e o seden a y adul s leads o a small o medium imp o emen in sel - epo ed physi- cal ac i i y a 12 mon hs. A 19% inc ease was obse ed a one yea in • o e all sel - epo ed physical ac i i y in mid- dle-aged men who pa icipa ed in a heal h- p omo ion ial. The change in physical ac i i y did no ha e • an e ec on he heal h ou comes a one-yea ollow-up. The ial had communi y e ec s: g oups o • men con inued exe cising oge he and he ial inc eased collabo a ion be ween heal h and exe cise se ices in he municipali y. 158 H. Lii a e al. included assessmen s o indi idual isks, die a y habi s, PA, and a mo i a ional alk abou hese hab- i s. The in e en ion las ed up o 90 minu es and did no include a ollow-up. Exe cise in e en ion. In addi ion o he heal h checks, he second in e en ion g oup was also in i ed o a g oup exe cise in e en ion. The size o hese g oups a ied om 10 o 20 people. The exe cise in e en- ion g oup me once a week and was guided by a physical educa ion counsello and consis ed o a i- ous ypes o basic physical aining. The exe cise ses- sions las ed 60 minu es each. Du ing he 12 weekly mee ings se e al sa e exe cise ac i i ies o a leas mode a e in ensi y we e in oduced, such as No dic walking, i ness ci cle, olleyball, swimming, ci cui aining, gym, boxing, zumba, e c. In addi ion o he s udy in e en ions, all g oups ecei ed, i necessa y, s anda d ea men a Ki kkon- ummi Heal h Cen e, a municipal public p ima y ca e uni . I a pa icipan showed any need o medical ea men , o his medica ions equi ed medical a en- ion, he was e e ed o a p ima y ca e physician. Ou come measu es The ou comes we e measu ed a e h ee and 12 mon hs o he andomiza ion. The blood es s we e aken a mon hs 0, 3, and 12. O he ou comes we e measu ed by In e ne su eys and, i he pa icipan did no espond, by elephone su eys. We had wo p ima y ou come measu es. Fi s , Me S as de i ned by he In e na ional Diabe es Fede a ion/Ame ican Hea Associa ion [10], i.e. 436 eligible o labo a o y es ing and isk assessmen A = Heal h check by a nu se n = 60 168 men ga e consen and we e andomized B = Exe cise in e en ion and heal hcheck n = 54 C = Con ols n = 54 665 men sc eened Excluded: 39 wi h BMI >34 190 exe cised a leas 3 imes e week 3 mon h ollow up n = 47 3 mon h ollow up n = 32 3 mon h ollow up n = 46 12 mon h ollow up n = 42 12 mon h ollow up n = 46 12 mon h ollow up n = 43 Figu e 1. Pa icipan l ow diag am. Heal h checks and exe cise in e en ion o men wi h ca dio ascula isk 159 checking whe he h ee o mo e o he ollowing c i- e ia we e ul i lled: (i) sys olic blood p essu e ⱖ 130 o dias olic blood p essu e ⱖ 85 o speci i c medica- ion; (ii) iglyce ides ⱖ 1.7 mmol/L o speci i c medica ion; (iii) HDL choles e ol ⬍ 1.0 mmol/L o speci i c medica ion; (i ) as ing plasma glucose ⱖ 5.6 mmol/L o speci i c medica ion; o ( ) wais ci cum e ence ⬎ 94 cm. We chose me abolic syn- d ome as ou main ou come measu e as we expec ed ha in his g oup o men wi h ele a ed ca dio ascu- la isk i could be modi i ed by ou in e en ions. The second p ima y ou come measu e was sel - epo ed PA assessed by asking how many imes pe week a pa icipan pe o med any exe cise ha induced swea ing and go he pe son a leas sligh ly ou o b ea h, i.e. was a leas o mode a e in ensi y, o a leas 30 minu es. S a is ical analyses The esul s a e exp essed as p opo ions o means and s anda d de ia ions (SD). S a is ical compa i- sons be ween he g oups wi h con inuous a iables in baseline cha ac e is ics we e pe o med using analysis o a iance o he K uskall-Wallis es and wi h a chi-squa ed es o Fishe ’ s exac es o dicho omous a iables. The di e ences be ween g oups in PA and Me S we e es ed by using boo - s ap echniques. Boo s apping is a e-sampling me hod, in which no assump ions on dis ibu ion a e made [11]. The α -le el was se a 0.05. All s a is ical analyses we e pe o med using STATA ( o Windows), e sion 10 (S a a Co p, College S a- ion, TX, USA). Resul s Th ee age coho s we e in i ed o he s udy, he 1969 bo n (n ⫽ 313 and 122 esponded), he 1970 bo n (n ⫽ 330 and 110 esponded), and he 1971 bo n (n ⫽ 303 and 88 esponded). O e all, 320 o 946 in i ed men (34%) esponded and pa icipa ed in he sc eening. An addi ional 345 men became in e es ed in he ial ia he mass media, campaigning, o a - ge ed in i a ions. Be ween 2009 and 2011, a o al o 665 men aged be ween 35 and 45 yea s esponded o he sc eening ques ionnai e o he ial. The pa - icipan l ow diag am is p esen ed in Figu e 1. A e labo a o y es ing and isk assessmen , al oge he 168 men consen ed and we e andomized in o he ial. The baseline cha ac e is ics o he men a e p e- sen ed in Table I. Physical ac i i y O e all, he men in he ial inc eased hei PA e- quency. Since men who exe cised a leas h ee imes pe week we e excluded om he ial, none o he pa icipan s exe cised h ee imes pe week a baseline. All s udy g oups inc eased hei PA (Figu e 2), and o all pa icipan s, 19% (95% CI 12 – 26) con inued Table I. Baseline pa icipan cha ac e is ics: mean (and s anda d de ia ion). All (n ⫽ 168) Heal h check (n ⫽ 60) Exe cise in e en ion (n ⫽ 54) Con ols (n ⫽ 54) P 1 Mean age, yea s (SD) 40.3 (2.9) 40.2 (2.5) 40.4 (2.8) 40.3 (3.5) 0.95 (NS) Weigh , kg (SD) 88.4 (11.9) 89.3 (12.9) 89.6 (11.1) 86.2 (11.4) 0.26 (NS) Heigh , cm (SD) 180.8 (6.4) 181.3 (6.6) 180.5 (6.3) 180.7 (6.2) 0.79 (NS) Wais ci cum e ence, cm (SD) 99 (13.4) 99 (11.6) 101 (18.0) 98 (10.2) 0.55 (NS) Sys olic blood p essu e, mmHg (SD) 134 (12.9) 132 (14.3) 135 (10.2) 136 (13.9) 0.28 (NS) Dias olic blood p essu e, mmHg (SD) 84 (9.0) 82 (9.5) 86 (7.6) 84 (9.7) 0.09 (NS) RR medica ion (%) 8 3 11 9 0.27 (NS) Glucose, mmol/l (SD) 5.7 (0.7) 5.8 (0.9) 5.7 (0.6) 5.6 (0.4) 0.67 (NS) Choles e ol, mmol/l (SD) 5.4 (0.8) 5.5 (0.8) 5.3 (0.8) 5.2 (0.8) 0.05 (NS) LDL, mmol/l (SD) 3.6 (0.7) 3.7 (0.7) 3.5 (0.7) 3.5 (0.7) 0.10 (NS) HDL, mmol/l (SD) 1.4 (0.4) 1.3 (0.4) 1.4 (0.4) 1.4 (0.3) 0.90 (NS) T iglyce ides, mmol/l (SD) 1.4 (0.7) 1.6 (0.9) 1.4 (0.7) 1.2 (0.5) 0.01 ( * ) Me abolic synd ome, n (%) 45 (7) 59 (13) 42 (13) 35 (13) 0.03 ( * ) F equency o physical ac i i y (a leas mode a e in ensi y, ⱖ 30 minu es), n (%) 2 Some imes o ne e 1 – 2 imes/week 58 (35) 110 (65) 21 (35) 39 (65) 21 (31) 33 (69) 16 (40) 38 (60) 0.07 (NS) No es: 1 S a is ical compa isons be ween he g oups we e pe o med using analysis o a iance o K uskall – Wallis es o con inuous a iables and chi-squa ed es o Fishe ’ s exac es o ca ego ical a iables. 2 The men who exe cised ⱖ 3 imes/week we e excluded om he ial and he e o e no one exe cised his much a baseline. 160 H. Lii a e al. exe cising a leas h ee imes a week a 12 mon hs. In he exe cise in e en ion g oup, 26% (95% CI 11 – 40) o men pu sued exe cising a leas h ee imes a week, in he heal h check g oup 16% (95% CI 5 – 27) and in he con ol g oup 17% (95% CI 5 – 29); howe e he di e ences be ween he g oups we e no s a is ically signi i can (Figu e 2). Me abolic synd ome A baseline, 45% o men ul i lled he c i e ia o Me S. Al hough he e was a end owa ds a dec eased p opo ion o men wi h Me S a h ee mon hs, a e 12 mon hs he p e alence o Me S had e u ned o he o iginal le el o abo e (Figu e 3). The e we e no di e ences be ween he in e en ion g oups and he con ol g oup in he p e alence o Me S. O he ou comes The ca dio ascula ou comes a e p esen ed in Table II. The in e en ions had no s a is ically sig- ni i can e ec s on hese ou comes a h ee mon hs o a 12 mon hs. Discussion Ou p agma ic ial o an exe cise in e en ion and heal h checks in a municipal heal h cen e was able o change he exe cise habi s o middle-aged men in all s udy g oups. We ec ui ed men wi h a leas wo ca dio ascula isk ac o s and low le els o PA. A e one yea , 19% o hese seden a y men had inc eased hei PA equency o a leas h ee imes a week. The e we e no di e ences be ween he s udy g oups in PA. Ou esul s a e simila o p e ious s udies on heal h p omo ion in p ima y ca e. A sys ema ic e iew published in 2012 [12] obse ed small e ec s wi h physical ac i i y p omo ion o pa ien s ec ui ed in p ima y ca e. I p o ided an es ima ion o a numbe needed o ea (NNT) o 12, which means ha 12 pa ien s need o be a ge ed wi h physical ac i i y p omo ion o one o become ac i e. This can be compa ed wi h smoking cessa- ion ad ice, whe e NNTs o 50 o 120 ha e been epo ed [13]. Al hough men inc eased he equency o exe cise, we ound no e ec s on heal h ou comes, me abolic synd ome, o indi idual ca dio ascula ou comes. Fo subs an ial heal h bene i s, adul s should do a leas 150 minu es a week o mode a e in ensi y, o 75 min- u es a week o igo ous-in ensi y ae obic physical ac i i y, o an equi alen combina ion o hese [14,15]. Ou ou come measu e, sel - epo ed physical ac i i y, is somewha c ude and does no ake in o accoun he in ensi y o he exe cise o he po en ial exe cise du - ing wo king hou s. Howe e , in a p agma ic p ima y heal h ca e ial i was he mos easible me hod. Time, mon hs 312 Physical ac i i y ≥3 imes pe week, % 0 6 12 18 24 30 36 42 48 54 60 Heal h Exe cise Con ol p=0.51 p=0.42 Key: Heal h = heal h check. Exe cise = exe cise in e en ion and heal h check. Figu e 2. Pe cen age o men who pe o med physical ac i i y a leas h ee imes a week a h ee and 12 mon hs in s udy g oups. Time, mon hs 03 12 Pe cen age o Me S 0 10 20 30 40 50 60 70 80 90 100 p=0.013 p=0.19 p=0.33 Heal h Exe cise Con ol Key: Me S = me abolic synd ome. Heal h = heal h check. Exe cise = exe cise in e en ion and heal h check. Figu e 3. Pe cen age o men wi h 95% con i dence in e als wi h me abolic synd ome a h ee and 12 mon hs in s udy g oups. Heal h checks and exe cise in e en ion o men wi h ca dio ascula isk 161 The changes in exe cise habi s did no ha e e ec s on he p e alence o me abolic synd ome in he pa icipan s. Ei he he change in ac i i y was no la ge enough, he ollow-up was no long enough o obse e he e ec s, o o he li es yle changes such as die ing would ha e been equi ed. I also appea s ha me abolic synd ome is di i cul o al e and may no be an op imal ou come measu e. The choice o he ou come measu es mus be conside ed as a lim- i a ion o his ial. Randomized con olled ials a e no commonly conduc ed in p ima y ca e in Finland. This e o augh us se e al lessons. Using mass media and local campaigning was e ec i e o ec ui men bu i also con amina ed he ial as he p ojec was e y isible in he local newspape and e en s, which led o he con ol men also ecei ing some o he in e en ion. The weakness o ou s udy is ha i lacks powe . I was designed o 300 men, and we we e able o ec ui and andomize only 168 men. Al hough he ial ecei ed much a en ion in he communi y and men eage ly ook pa in he sc eening su ey, i was di i cul o mo i a e hem o a end o labo a o y es ing and o pa icipa e in he ollow-up. Middle-aged men li e busy li es wi h wo k and amilies and i is challenging o hem o commi hemsel es o a weekly in e en ion. Acco ding o he g oup counsello s, he pa icipa ion a es in he exe cise g oups a ied be ween 50% and 80%. Pa icipan s in he con ol g oup we e in i ed o comple e an online ques ionnai e wi h heal h- and li es yle- ela ed ques ions a baseline and a h ee and 12 mon hs. Fu he mo e, hey we e p omised heal h counselling and g oup exe cise aining a e he 12-mon h s udy pe iod. The ques ionnai es, keeping in con ac wi h he s udy coo dina o , and u u e heal h counselling and exe cise aining may ha e mo i a ed hem o inc ease hei PA. Ou esul s a e consis en wi h p e ious p ima y ca e s udies epo ing inc eases in PA le els also among he con ol g oup. In a Du ch s udy, a ailo ed PA in e en ion inc eased PA le els bu no mo e han in he con ol g oup [16]. I appea ed ha he physical ac i i y measu emen s independen ly a ec ed pa icipan s ’ beha iou [17]. The communi y a ge s in ou s udy we e suc- cess ul. Some men in he exe cise in e en ion g oups con inued exe cising oge he a e he ial, which was one o ou communi y aims. In addi ion, he ial also inc eased collabo a ion be ween he heal h and exe cise se ices in he municipali y. An exe cise counsello s a ed consul a ions a he heal h cen e, and physicians lea n o be e e e hei pa ien s o he municipal exe cise se ices. Since amily medi- cine is no only o indi iduals bu also o communi- Table II. Ca dio ascula ou comes h ee mon hs and 12 mon hs a e he in e en ion: Mean (and s anda d de ia ion). 1. All Heal h check Exe cise in e en ion Con ols Weigh , kg 3 m 12 m 87.3 (11.8) 88.3 (11.8) 90.0 (12.8) 89.6 (11.3) 87.9 (12.1) 89.9 (10.9) 84.7 (10.3) 85.5 (13.0) Sys olic blood p essu e, mmHg (SD) 3 m 12 m 135 (13.0) 136 (11.9) 131 (8.0) 135 (11.8) 138 (14.1) 139 (11.7) 136 (14.8) 134 (12.2) Dias olic blood p essu e, mmHg (SD) 3 m 12 m 83 (8.7) 85 (9.4) 81 (8.3) 83 (10.2) 86 (8.6) 87 (8.2) 80 (9.1) 83 (9.7) Glucose, mmol/l (SD) 3 m 12 m 5.6 (0.6) 5.7 (0.6) 5.5 (0.5) 5.6 (0.6) 5.6 (0.8) 5.7 (0.6) 5.6 (0.5) 5.7 (0.6) Choles e ol, mmol/l (SD) 3 m 12 m 5.2 (0.8) 5.4 (0.9) 5.4 (0.8) 5.5 (0.8) 5.1 (0.9) 5.3 (0.9) 5.1 (0.8) 5.2 (0.8) LDL, mmol/l (SD) 3 m 12 m 3.5 (0.7) 3.5 (0.7) 3.6 (0.7) 3.7 (0.7) 3.4 (0.8) 3.5 (0.8) 3.4 (0.7) 3.4 (0.7) HDL, mmol/l (SD) 3 m 12 m 1.4 (0.3) 1.4 (0.4) 1.3 (0.3) 1.4 (0.3) 1.4 (0.3) 1.4 (0.4) 1.4 (0.3) 1.5 (0.4) T iglyce ides, mmol/l (SD) 3 m 12 m 1.3 (0.6) 1.4 (0.7) 1.4 (0.7) 1.5 (0.8) 1.2 (0.5) 1.4 (0.7) 1.1 (0.4) 1.2 (0.5) No e: 1 Di e ences a e s a is ically non-signi i can . 162 H. Lii a e al. ies, i is impo an o pu he ocus on communi y consequences o ials [18]. In conclusion, ou ial led o small changes in he physical ac i i y o middle-aged men bu we obse ed no changes in ca dio ascula heal h. We we e, howe e , able o inc ease awa eness and col- labo a ion in he municipali y on physical ac i i y heal h p omo ion. E hics app o al The ial was app o ed by he municipal au ho i ies and by he Coo dina ing E hics Commi ee a Helsinki Uni e si y Hospi al on 8 June, 2009 ( e : 4/13/03/00/09). The s udy was egis e ed a Con olled T ials (h p://www.con olled- ials.com). T ial numbe : ISRCTN80672011. Acknowledgemen s The au ho s would like o hank Ms Ma ia Te ä ä inen o help wi h he s udy ma e ial, and he public heal h nu ses ha pe o med he heal h checks as well as he employees a he municipal adul educa ion and exe cise se ices o excellen collabo a ion. Decla a ion o in e es The au ho s epo no con l ic s o in e es . 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