Relationship Of A Community Physical Activity Program With The Number Of Antihypertensive Drugs Used By Elderly Women With Arterial Hypertension: A Cross-Sectional Study

Background: Physical activity is an important tool to manage systemic arterial hypertension. However, less is known about the relationship of physical activity with the number of antihypertensive drugs used by older adults. The aim of this study was to compare the number of antihypertensive drugs used by older female adults (aged ≥ 60 years) with a low level of physical activity with the number used by those with a high level of physical activity, and to verify how many participants used more than two antihypertensive drugs. The habitual level of physical activity was evaluated by the Baecke questionnaire Methods: Twenty-eight physically active older women with systemic arterial hypertension who participated in a physical activity program for community-dwelling older female adults were divided into two groups: participants who presented lower habitual physical activity levels were placed in group 1 and participants that presented higher habitual physical activity levels were placed in group 2, according to the Baecke questionnaire. In addition, the number of antihypertensive drugs used by participants was collected. Results: The number of prescribed antihypertensive tablets was 2.0 (median) for both groups investigated. There was no signicant difference between groups regarding the number of antihypertensive tablets prescribed (p>0.05). There was no statistical difference in proportion of participants from the lower physical activity group used more than two antihypertensive drugs. Conclusions: The level of habitual physical activity did not affect the number of antihypertensive tablets used by hypertensive elderly women. DATS: acquisition of data, analysis, interpretation of data and revising article critically. MSA: acquisition of data, analysis, interpretation of data and revising article critically. PTN: analysis, interpretation of data and revising article critically. BK: analysis, interpretation of data and revising article critically.

participants from the lower physical activity group used more than two antihypertensive drugs.
Conclusions: The level of habitual physical activity did not affect the number of antihypertensive tablets used by hypertensive elderly women.

Background
Aging of the population and the increased prevalence of chronic noncommunicable diseases among older adults are major challenges facing society and the medical community [1]. Among these diseases, systemic arterial hypertension is a signi cant cause and consequence of disability among older adults [2,3].
Systemic arterial hypertension is a multifactorial clinical condition characterized by elevated and sustained blood pressure levels. It is often associated with functional and/or structural changes in target organs (e.g. heart, brain, kidneys and blood vessels) and metabolic changes, with a consequent increase in the risk of cardiovascular events [3,4].
According to the High Blood Pressure Clinical Practice Guideline, 46% of the population has systemic arterial hypertension. In addition, the prevalence increases dramatically with increasing age and is higher in black people than in Caucasians, Asians and Hispanics [5]. Furthermore, the prevalence of systemic arterial hypertension is lower in women than in men up to the fth decade, but it is higher at the end of life in women than in men [5]. For these reasons, the study of systemic arterial hypertension in older women is an area of growing interest.
The most frequently used treatment for systemic arterial hypertension is antihypertensive medication [6,7]. However, in the last decades alternative therapies such as physical activity have been gaining notoriety for the important bene cial effects on blood pressure of patients with systemic arterial hypertension [8][9][10]. Indeed, a plethora of studies showed that physical activity may be a potential nonpharmacological treatment for the improvement of blood pressure in patients with hypertension [11]. Because of these effects, some authors have suggested that exercise may reduce or even replace pharmacological treatment. In this sense, Maruf et al. [12] investigated the effects of aerobic exercise combined with antihypertensive drugs on blood pressure and the number of antihypertensive drugs used by individuals with hypertension. These authors found that the combination of aerobic exercise and antihypertensive drugs reduces the number of antihypertensive drugs needed to achieve blood pressure control and enhances blood pressure control in individuals with hypertension on two antihypertensive drugs. In another study, Dimeo et al. [13] showed that exercise is able to decrease blood pressure even in participants with low responsiveness to medical treatment, and concluded that exercise should be included in the therapeutic approach to resistant hypertension. Reid, Maher, and Jennings [14], showed that 71% of patients submitted to lifestyle management (including physical activity) who had been well controlled on antihypertensive medication were able to remain normotensive and free of drug therapy for 9 months.
From the above, the role of physical activity in the control of blood pressure in individuals with systemic arterial hypertension is indubitable. For this reason, there are many governmental initiatives that aim to encourage the participation of the population in physical activity programs [15,16]. These initiatives are community physical activity programs characterized by outdoor activities that take place in public spaces, such as squares, beaches and parks. In Brazil, the main concern about these community physical activity programs is the lack of individualization of exercise prescription, in some cases lack of specialized professionals (coaches and/or physical education professionals) to guide and supervise participants, and adequate exercise facilities. Thus, it is reasonable to assume that factors relating to physical training, such as intensity, weekly frequency and volume, are not strictly controlled. As a consequence, the health bene ts may not be gained [17]. Speci cally, in the case of patients with systemic arterial hypertension, it is expected, in addition to a decrease in blood pressure, a decrease in the amount of antihypertensive drugs used [7,12].
Given that a myriad of studies showed bene cial effects of physical activity on the blood pressure of individuals with systemic arterial hypertension, physical activity may complement the blood pressurelowering effects of antihypertensive drugs [12,18], thereby reducing the number and/or dose of drugs required [7,12]. This matter is very important because a number of daily antihypertensive drugs tablets intake greater than two has been associated with no adherence to drug therapy [19]. Considering that drugs cost money and may produce negative side effects [20], it is very important to investigate strategies that will lead to a reduction in the daily antihypertensive drugs tablets intake.
Therefore, the aim of the present study was to compare the number of antihypertensive drugs taken by women who have a low level of physical activity with the number of antihypertensive drugs taken by those with a high level of activity. We also wanted to establish how many participants in one group took more than two antihypertensive drugs compared with those participants from the other group. We hypothesized that the higher the habitual physical activity levels the lower the number of antihypertensive drugs used and that these participants would use two or less antihypertensive drugs. It is noteworthy that investigating community physical activity programs has great ecological validity because they re ect real situations and scenarios.

Methods
Participants A cross-sectional study was performed comprising 28 female older participants (a convenience sample out of a total of 280 people) who were recruited using advertisements placed in a physical activity program for community-dwelling older adults (located in the city of Serra, Espírito Santo, Brazil) and consisted of women using antihypertensive drugs. The inclusion criteria used were: being physically active (participated in a physical activity program for community-dwelling older adults); to present arterial hypertension; to use regularly at least one antihypertensive drug prescribed by physicians; and aged ≥ 60 years. Sedentary and male older adults were excluded from the sample.
After a clear explanation of the experimental procedures, including the risks and bene ts of participation, written consent was obtained. The age and anthropometrical characteristics of the participants are presented in Table 1. Ethics approval for all experimental procedures was granted by the Federal University of Espírito Santo Human Research Ethics Committee and conformed to the principles outlined in the Declaration of Helsinki.

Study design
Participants answered a questionnaire about the use of antihypertensive drugs and habitual physical activity levels using the Baecke Habitual Physical Activity Questionnaire [21]. Because of the low educational level of the sample, an interview was used to ll out the questions. The participants were divided into two groups according to the questionnaire results. To this end, we used the median values of total score for habitual physical activity provided by the Baecke questionnaire. Thus, participants who presented lower habitual physical activity levels (values below median) were placed in group 1 and those that presented higher (values above median) were placed in group 2.
Physical activity program for community-dwelling older adults The physical activity program for community-dwelling older adults provides health-promotion actions by encouraging physical activity and healthy eating, with a view to disease prevention. Group classes are offered, 2-3 times per week, with an orientation to aerobic exercise (running and walking), localized gymnastics and stretching, among others. Each class lasted 45-50 minutes.
Antihypertensive drugs use questionnaire The questionnaire comprised questions intended to capture information about the number of antihypertensive drugs used. It is worth noting that the number of antihypertensive drugs was counted regardless of whether it was a full or half-dose.

Baecke Habitual Physical Activity Questionnaire
The habitual level of physical activity was evaluated by the Baecke questionnaire [21]. This questionnaire consists of 16 questions involving three habitual physical activity scores relating to the previous 12 months: occupational physical activity (eight questions); leisure time physical activity (four questions); and leisure and locomotion sport activities (four questions). As the participants were retired or housewives, we evaluated only leisure time physical activity and leisure and locomotion sport activities for the purposes of the present study. The total score for habitual physical activity was obtained by summing leisure time physical activity and leisure and locomotion sport activities. The higher the score achieved, the higher the level of habitual physical activity.

Statistical analyses
As the habitual physical activity level and number of antihypertensive drugs used by participants were not normally distributed according to the Shapiro-Wilk normality test, the data were expressed as medians (Quartile 1 Quartile 3) and the Mann-Whitney test was used to compare variables between the groups [group 1 (lower habitual physical activity) vs. group 2 (higher habitual physical activity)]. Fisher's exact test was used to check for an association between the level of habitual physical activity (group 1 and group 2) and the number of antihypertensive drugs consumed (≤2 and >2). Cramer's V was used to express effect size in these analyses in order to test the strength for any association or practical signi cance from the Fisher's exact test analysis. It could be interpreted as follows: effect size of 0.1 is small, effect size of 0.3 is medium, and an effect size of 0.5 is large [22]. The SPSS statistical package, version 23.0 (IBM Corp., Armonk, NY) was used for statistical analysis, and a signi cance level of 0.05 was set for all statistical tests.

Results
Antihypertensive drug used by participants were diuretics (n= 13), calcium-channel blockers (n=6), βblockers (n=11), angiotensin-converting enzyme inhibitors (n=5), angiotensin II type 1 blockers (n=11) and α-2 adrenergic agonists (n=2). The sum of the number of antihypertensive drugs does not result in the total number of participants since there were participants who used more than one drug. Table 2 shows the habitual physical activity evaluated by the Baecke questionnaire according to the median [lower (group 1) vs. higher (group 2) habitual physical activity] of the questionnaire score. The Mann-Whitney test revealed signi cant differences between groups for subscales and total score. Table 3 shows the participants' consumption of antihypertensive drugs [lower (group 1) vs. higher (group 2) habitual physical activity]. The Mann-Whitney test revealed no signi cant differences. Table 4 shows the association of participants who used more than two antihypertensive drugs between groups. The Fisher's exact test revealed no signi cant association between variables. However, the effect size expressed by Cramer's V was 0.316, indicating that there is a medium to large effect.

Discussion
The main aim of the current study was to verify whether the number of antihypertensive drugs intake is different between a sample of two groups of female older adults with different habitual physical activity levels (lower vs. higher). We found that there were no signi cant differences in the number of antihypertensive drugs consumed in a sample categorized according to habitual physical activity provided by the Baecke questionnaire. Despite of there was no statistical difference in proportion of participants from the lower physical activity group used more than two antihypertensive drugs, the effect size expressed by Cramer's V was medium to large, suggesting that a higher proportion of participants from the more physically active group consumed two or less antihypertensive tablets.
Previously, several studies have been conducted to assess the effectiveness of physical activity to manage systemic arterial hypertension [23,24]. Overall, these studies showed the bene cial effects of physical activity by using protocols that are controlled, standardized and structured. The existing exercise recommendations for hypertension advocate that with regards to frequency, aerobic exercise should be undertaken on most (preferably all) days of the week and resistance exercise on two to three days per week [24]. With regards to intensity, the recommendation is for moderate intensity aerobic exercise (i.e., 40 to 60% of maximal oxygen uptake or heart rate reserve; 11-13 rating of perceived exertion on the 6-20 Borg Scale and moderate intensity dynamic resistance exercise (60-80% of one repetition maximum) [24]. In terms of time, the duration of exercise should total 150 min or more per week [24]. Finally, progression should be gradual, avoiding large increases in any exercise components (frequency, intensity and time).
From the above, the lack of difference in the number of antihypertensive drugs intake between groups (lower vs. higher habitual physical activity) found in the current study could probably be attributed to characteristics of the physical activity program for community-dwelling older adults. Brie y, this program is characterized by a lack of standardization with regards to physical activity intensity, session duration and weekly frequency. According to Dimeo et al. [13], in daily life, physical activity in arterial hypertension is usually not monitored by a sophisticated method such as lactate concentration. Therefore, the recommendation of training intensity has to be kept more practical. Accordingly, it is reasonable to assume that physical activity performed by participants did not follow the guidelines of exercise prescription for managing systemic arterial hypertension. However, the older women that we studied were part of a public health program that seeks to promote and educate for health and quality of life and to change negative health habits, which in our view is a strong point of the program.
Another aspect that can be considered to explain the results obtained by the current study is that -in Brazil, at least -physicians are not involved with concepts related to exercise and sports science.
According to the Centers for Disease Control and Prevention [CDC] [25], only 19% of physicians counsel patients about physical activity. Probably, these results can be attributed because physicians are not interested in learning about exercise science due to time pressures. As a result, it is reasonable to assume that physicians could attribute the clinical improvements of a patient to pharmacological treatment rather than physical activity/engagement, and for this reason did not decrease the prescribed number of drugs. Corroborating this assertion, it has already been demonstrated that only a few patients receive exercise counselling from physicians for managing blood pressure to improve health outcomes [26].
A daily administration of more than two antihypertensive drugs has been associated with nonadherence to drug therapy [19]. Individuals with systemic arterial hypertension who either discontinue medication or are nonadherent to the prescribed drug therapy are at risk of developing cardiovascular complications [20]. In the current study, 28.6% (six participants in group 1 and two in group 2) used more than two antihypertensive drugs. Although there was no signi cant association of participants who used more than two antihypertensives drugs between groups, the number of participants in group 2 (higher levels of habitual physical activity) who ingested more than two drugs was one third of that of group 1 (lower levels of habitual physical activity), consequently the proportion of participants who used two or less antihypertensive tablets is higher in Group 2. The effect size of this analysis expressed by Cramer's V was medium to large. This result has clinical signi cance, because it highlights that although the physical activity program for community-dwelling older adults did not strictly follow current recommendations for exercise to reduce arterial hypertension, Group 2 showed an important effect, since the number of participants who used more than two antihypertensive drugs was lower; this is probably because the intensity and volume of exercise performed by Group 2 were higher. Furthermore, this result suggests that the need to prescribe a third antihypertensive drug would be minimized in these individuals, which suggests that exercise in conjunction with antihypertensive drug therapy improves blood pressure control and may even lead to fewer antihypertensive drugs prescribed. In practical terms, primary health-care professionals, aware of these results, could recommend that patients with systemic arterial hypertension increase the amount of physical activity in order to decrease the number of antihypertension drugs ingested.

Limitations of study
A number of limitations of the study must be mentioned. First, this study was cross-sectional and we were therefore unable to assess the responsiveness of physical exercise participation over time. Second, the cross-sectional data made it di cult to assess the direction of causality. Therefore, future longitudinal studies are warranted. Third, we did not measure blood pressure values; therefore, we did not know the severity of arterial hypertension. Fourth, we did not assess the dose of antihypertensive drugs; it is possible that the dose prescribed could have been decreased, however the amount of ingested tablets remained the same. Fifth, the current study used a relatively small, convenience sample of female older adults. Consequently, generalizations should be made with caution. Nevertheless, we believe that these limitations do not prevent conclusions being drawn from the study, for the reason that investigations into this kind of community physical activity program have considerable ecological validity because they re ect real situations and scenarios.

Conclusion
In conclusion, the ndings show that the number of ingested antihypertensive tablets is not different between groups constituted by female older adults with different levels of habitual physical activity (lower vs. higher) engaged in a public health physical activity program. In addition, although there was no statistical association, participants with higher habitual physical activity presented a lower proportion of participants that ingested more than two antihypertensive drugs and this result has clinical signi cance.

Declarations
Ethics, consent and permissions: All subjects were informed of the intent and experimental procedures and written informed consent was obtained from each participant before any data were collected. All procedures involved in this study were approved by the Federal University of Espírito Santo Ethics Committee (protocol number [CAAE]: 63228215.1.3001.5505) and followed the principles outlined in the Declaration of Helsinki.

Consent for publication: Not applicable
Competing interests: The authors declare that they have no competing interests. Authors' contributions: CABL: conception and design of the study, acquisition of data, analysis, interpretation of data, drafting the article and revising it critically. RGS: conception and design of the study, analysis, interpretation of data, drafting the article and revising it critically. ABG: acquisition of data, analysis, interpretation of data and revising article critically. DATS: acquisition of data, analysis, interpretation of data and revising article critically. MSA: acquisition of data, analysis, interpretation of data and revising article critically. PTN: analysis, interpretation of data and revising article critically. BK: analysis, interpretation of data and revising article critically.

Supplementary Files
This is a list of supplementary les associated with this preprint. Click to download.   Quartile 3]. atotal score for habitual physical activity was obtained by summing physical exercise in leisure and leisure and locomotion activity scores.  Data are presented as relative (absolute) frequencies.