1. An Evaluation of the National Exercise
Referral Scheme and its Benefits to
Cardiovascular Health
Henry David Rahman Tank
BSc Sport & Exercise Science

2. Abstract
Introduction: In 2002, it was estimated that 16.7million people across the globe die every
year due to CVDs, accounting for 1/3rd of all deaths worldwide (World Health Organisation,
2004). Despite this overwhelming statistic there is still a distinct lack of Cardiac
Rehabilitation (CR) programs that have been implemented and funded. Aims: The aims of
this study were [1] To investigate the levels of participation throughout a moderate
intensity, 16-week exercise regime, and [2] to analyse the health benefits to those who
remain on it. Methodology: This study measured anthropometric data (body mass index,
waist circumference, body mass) and haemodynamic variables (heart rate, systolic blood
pressure, diastolic blood pressure) before and after the physical activity regime. Results: Of
those referred to the scheme by general practitioners, only 53% remained active after 4
weeks and only 36% actually completed it. For those patients that completed the scheme, it
elicited mean reductions to all variables: Body Mass -2.0kg (SD± 20.28), Heart Rate -2.9bpm
(SD± 10.74), Waist Circumference -2.8cm (SD± 14.10), Body Mass Index -0.8 (SD± 6.38),
Systolic Blood Pressure -7.3mmHg (SD± 16.5), Diastolic Blood Pressure -4.9mmHg (SD±
11.33). Statistical Analysis: The data was analyzed using a paired samples t-test, all mean
reductions to parameters were statistically significant (P<0.5). Conclusion: The scheme’s
ability to significantly ameliorate all health parameters greatly evidenced its antipathogenic
and antihypertensive properties; hypothesized earlier in this study, these properties related
to reducing the risk of cardiovascular disease, Type II Diabetes Mellitus, stroke, metabolic
syndrome and even certain cancers (Agarwal, 2009).

3. Table of Contents
i. Abbreviations........................................................................... 4
ii. Keywords.................................................................................. 5
iii. Acknowledgements............................................................ 5
1.0 Introduction ........................................................................................................................ 6
1.1 Introduction & Literature Review..……............……...…………..............……............. 6
2.0 Methodology..................................................................................................................... 15
2.1 Methodology Introduction............................................................................................. 15
2.2 Ethics....................................................................................................................................... 15
2.3 Anthropometrics.................................................................................................................15
2.4 Regime Structure………………………...…...………………………..............…………....... 15
2.5 Participant Catchment..................................................................................................... 16
2.6 Experimental Design...............................................…...............................................…… 16
2.6.1 Measures of Adherence............................................... 16
2.6.2 Physiological Parameters........................................... 17
2.7 Statistical Analysis…………………………………….…………................………………..... 17
3.0 Results.................................................................................................................................... 18
3.1-3.6 Measures of Adherence & Physiological Data.…….....…..….......................... 18
3.7 Anthropometric and Haemodynamic Data............................................................. .19
3.8 Antihypertensive Properties of the National Exercise Referral Scheme.... 19
3.9 Obesity Related Hypertension........................................................................................20
4.0 Discussion............................................................................................................................ 21
4.1 Summary of Results.……………………………………………………………..…………..... 21
4.2 Pathogenesis of the Metabolic Syndrome and Cardiovascular Disease….. 22
4.3 Antipathogenic Effects of the National Exercise Referral Scheme…............ 25
4.4 Scheme Prognostics…………………………..……………………..……………………....... 28
4.5 The Detrimental Impact of Other Pathologies…………………..…………………..30
4.6 Conclusion............................................................................................................................ 31
4.7 Limitations & Recommendations............................................................................... 32
References..................................................................................34

4. i. Abbreviations
AT1 ………..………………………………………………………………………….. Angiotensin Receptors
BMI ………………………………………………………….…………………………………. Body Mass Index
CAD ..……………………………………………………………………………….. Coronary Artery Disease
CR ..……………………………………………………………………………………… Cardiac Rehabilitation
CV ………………………………………………………………………………………………….. Cardiovascular
CVD ……………………………………………………………………………………. Cardiovascular Disease
DBP ………………………………………………………………………………….. Diastolic Blood Pressure
FFA ………………………………………………………………………………………………. Free Fatty Acids
HDL ……………………………………………………………………………….. High Density Lipoproteins
HR ………………………………………………………………………………………………………… Heart Rate
LDL …………………………………………………………………………………… Low Density Lipoprotein
MetS …………………………………………………………………………………….. Metabolic Syndrome
NERS …………………………………………………………………. National Exercise Referral Scheme
RAAS …………………………………………………………. Renin Angiotensin-Aldosterone System
RVLM ………………………………………………………………………. Rostral Ventrolateral Medulla
SBP ……………………………………………………………………………………. Systolic Blood Pressure
SD ……………………………………………………………………………………………. Standard Deviation
SNS …………………………………………………………………………… Sympathetic Nervous System
TG ………………………………………………………………………………………………………. Triglyceride
WC ……………………………………………………………………………………….. Waist Circumference

5. iia. Keywords
Sympathoexcitation Cardiovascular
Renin-angiotensin aldosterone system Antihypertensive
Rostral Ventrolateral Medulla Obesity
Hypertension Adherence
Adrenergic Haemodynamic
Diabetes Mellitus Epidemiology
Atheromatous Sedentary
Pathogenesis Participation
iib. Acknowledgements
Firstly, I sincerely thank my family and friends who have encouraged and supported
me throughout this degree, also to Cat Lodge who ensured I was consistently focused.
I am eternally grateful to my mother, Kate Brady, who has been the sole driving force
throughout my undergraduate studies and has instilled a work ethic and mental fortitude
that I will indefinitely carry forward into my postgraduate life.
Many thanks also to Daniel Harries, Daniel Thorne, Scott Morris, Phillip Matthews
and Kayleigh Tonge-Jones, all of whom significantly contributed to the inner-workings of
this thesis and greatly facilitated its implementation in Blaenau Gwent.
I am extremely appreciative of the direction and insight that was provided by Pip
Laugharne, whose relentless passion and enthusiasm for the subject has inspired and
guided me throughout all aspects of my degree, in particular that of this research-based
thesis track.

6. 1.0- Introduction & Literature Review
The twenty-first century has seen an unprecedented obesity epidemic; bringing with
it an overabundance of health issues, cardiovascular diseases (CVDs) and concerns with
psychological wellbeing. In 2002, it was estimated that 16.7million people across the globe
die every year due to CVDs, accounting for 1/3rd of all deaths worldwide (World Health
Organisation, 2004). Despite this overwhelming statistic there is still a distinct lack of
Cardiac Rehabilitation (CR) programs that have been implemented and funded.
The approach of all existing CR schemes can vary in many ways; from the exact
conditions they seek to prevent, to the methodology and rationale that they involve.
Regarding protocol differentiation, CR programs can involve methods of future prevention
via the use of direct medication or conversely physical activity based regimes. One such
programme involving the latter is the National Exercise Referral Scheme, funded by the
Welsh Assembly Government. Ranked approximately 8th in the world for deaths per year
from heart disease (World Health Organisation, 2003), it is evident that Wales, like other
communities, must take an active approach to tackle factors leading to death by coronary
heart disease, which alone accounts for approximately 19% of all Welsh mortalities (NHS
Wales, 2010).
The scheme comprises a General Practitioner’s referral for patients with previous or
ongoing cardiac conditions. It involves the completion of a carefully monitored, 16-week
exercise regime, with the objective of introducing long-lasting lifestyle changes as well as
generating physiological improvements. This research project sought to assess and quantify
the level at which the scheme facilitates it’s participants towards cardiovascular recovery,
and in particular that of haemodynamic health.
Optimal adaptation to exercise training requires the development of, and adherence
to, an exercise prescription (Ehrman et al, 2009). It must first be understood that in order
for a patient to fully acquire any improvements to their health, a certain level of adherence
must take place. Effectively, to benefit from physical activity, one must first engage in
physical activity. The two main aims of this study were:
 To investigate the levels of participation throughout the regime
 To analyse the health benefits to those who remain on it.

7. A similar evaluation of the scheme conducted in 2010 (Murphy et al, 2010) concluded, “In
sub-group analysis, there were statistically significantly greater effects on all outcomes
among those who completed the 16-week programme”. Assessing 2,160 patients, this study
discovered that the greatest occurrence of withdrawals from the scheme was between entry
to the scheme and the 4 week mark. With only 58% still partaking by this point, a further
14% withdrew over the following 12 weeks. The report administered by the Welsh
Assembly Government focused predominantly on variables pertaining to socio-economic
stability, cost effectiveness and programme reach and adherence; however, even for the
44% that completed the regime, no research was conducted as to whether it actually
benefitted their health.
Upon updating the adherence-based statistics, this study combined them with
analysis of physiological variables in order to accurately assess the scheme’s proficiency in
cardiac rehabilitation. Although no literature is available as yet to support the theorized
physiological benefits of the NERS, there is a wealth of knowledge available to substantiate
its possible importance in our society’s efforts to quash this fast-growing epidemic.
In a meta-analysis report conducted by Agarwal (2012), it stated that, by 2030, the
American Heart Association predict a 9.9% increase in the prevalence of CVDs, a 25%
increase in the prevalence of strokes or heart failures and a consequent rise in the cost of
healthcare to $818 billion. Agarwal’s report stated that, of the 58 million deaths worldwide
in 2005, those caused by cardiovascular diseases equated to almost a third, three times
greater than that of infectious diseases such as malaria, HIV/AIDs and tuberculosis
combined (World Health Organisation, 2004). Given that a vast majority of infectious
diseases are extremely costly and some currently incurable, it is astounding that
supplementation of CR programs is not a worldwide perogative in order to oppose the 25
million CVD-related deaths predicted for 2020.
Be it a maladaptive mind-set likened to geographical inertia, whereby persons
believe the disasters of the world will not affect them, or be it a lack of concrete information
to justify their need to exercise; our global population struggles to see the importance of
minimizing such an ominous yet preventable epidemic which, is not only facilitated by
ignorance, but vastly exacerbated by it.

8. The known benefits of exercise are far-reaching and simultaneously easy,
inexpensive and effective. Hippocrates (460-377 BC) once stated that “In order to remain
healthy, the entire day should be devoted entirely to ways of increasing one’s strength and
staying healthy, and the best way to do this is through physical exercise”; the timescale of
such an archaic yet innovative finding has certainly waned, but it’s stature and significance
in modern society should not.
Agarwal’s report provides substantial foundation to the notion that regular exercise
has been shown to not only reduce cardiovascular risk factors and chances of morbidity, but
to alleviate the detriment of type 2 diabetes, some cancers, depression, metabolic syndrome,
obesity and falls. Regarding the latter, a new initiative of the NERS seeks to lessen the
occurrence of falls and offset the psychological impairment affiliated with dementia, done so
via the implementation of coordination based, low intensity exercise. This falls prevention
course receives further support from Agarwal’s summaries; stating that range of motion and
stretching exercises reduce sympathetic activity and improve several cardiovascular risk
factor parameters. With the Charity’s proposed expansion follows the need for external
subsidization from philanthropic programs; Agarwal proceeded to suggest that
governmental or corporate funding to employers integrating such regimes can help to
decrease the anticipated burden of CVDs on future populations.
The possible role of the National Exercise Referral Scheme in modern society is
proving more fundamentally important by the year; however, employing a seemingly
minute exercise regime to combat the overwhelming tyranny of cardiovascular disease can,
from an external perspective, appear wholesomely futile. However, recent ecological
approaches to increase participation place the creation of supportive environments on par
with personal skill development and reorientation of health services (King, 1994). The
importance of exercise as a simple method to prevent and counteract CVDs is well known,
so too are the improvements to socio-economic factors and psychological wellbeing induced
by the NERS. Between these two facts lies an area of ambiguity in which, as of yet, there is
no concrete evidence to suggest that government funded exercise regimes have a formative
impact on the cardiovascular health of its participants.

9. Entitled “An Evaluation of the National Exercise Referral Scheme and its Benefits to
Cardiovascular Health”, this two-pronged research project studied the effectiveness of a
government-funded physical activity regime on reducing cardiovascular risk factors in post
CVD patients; comprising a physiological analysis and adherence-based study.
The aims of the aforementioned scheme are to, over a course of four months,
improve both the mental and physical wellbeing of its patients, as well as to encourage
physical activity for life. Collection and analysis of haemodynamic measures such as blood
pressure (BP) and heart rate (HR) were conducted, enabling an accurate comparison to be
made regarding the patient’s initial cardiovascular fitness and its possible modulations
throughout. According to Mora (et al 2007) such changes in a person’s physiology are both
favourable and more frequent following an increase in physical activity or the initiation of a
structured exercise regime.
Alongside these two variables a further three were measured throughout: body mass,
waist circumference and BMI. Although conceding its limitations, the National Heart, Lung
and Blood Institute (2013) reported that the higher a person’s BMI, the higher their risk of
heart disease, hypertension and certain cancers.
The assessment of weight management aimed to provide conclusion over the
scheme’s possible antihypertensive effects and subsequent improvements to cardiovascular
fitness. Hagberg et al (1990) discovered that during a moderate-intensity exercise regime,
for every two pounds of weight a patient lost there was a 2-mmHG decrease in blood
pressure. Despite uncertainty about their independent effects on mortality, overweight or
obese people are at a greater risk of developing hypertension, diabetes, or having a stroke
(National Institutes of Health Development Panel, 1985). This research project seeks to
further solidify the hypothesis that weight loss, via a structured exercise programme, can
better a patient’s prognosis, paying particular concern to the cardiovascular disease risk
factors.
Concurrent with the conclusions previously formulated by the works of Hagberg (et
al, 1990), research conducted by Judith (et al, 2003) also found evidence of possible
antihypertensive mechanisms that were attributed to weight loss. Additionally, the findings
were similar to that of Agarwal in its cognizance of the CVD epidemic’s projected worsening,
discussing how in Western societies the prevalence of obesity is likely to increase the
burden of hypertension and its consequent cardiovascular mortalities.

10. Encompassing 25 parallel trials published between 1966 and 2002, this meta-
analysis (Judith et al, 2003) examined correlations between weight loss and blood pressure
reductions, although it did not provide conclusive evidence to the physiology behind it’s
relation, it provided a definitive link between correlative reductions in the two factors and
proposed plausible ideas as to how they intertwined. One such theory being the over-
activation of the renin-angiotensin aldosterone system (RAAS); apparently common in
obese patients (Thethi et al, 2012), this could lead to excessive amounts of the strong
vasoconstrictors Angiotensin II and vasopressin left circulating in the blood stream and thus
expedite hypertension.
A random-effects model was used to account for heterogeneity among trials; an
average weight loss of -5.1kg by means of energy restriction, increased physical activity or
both, reduced blood pressure accordingly. The mean total reduction in systolic blood
pressure (SBP) was -4.44mmHg and -3.74mmHg for diastolic blood pressure (DBP);
expressed per kilogramme of weight loss the reductions in SBP were -1.05mmHg and -
0.92mmHg in DBP.
Reference was made to a similar meta-analysis conducted in 1988 (Staessen et al,
2000), which found that, per kilogramme of weight loss, there was a -2.4mmHg reduction in
SBP, and a -1.5mmHg reduction in DBP. Comprising of thousands of data points, this report
strongly evidenced a correlation between weight loss and reductions in blood pressure,
92% of the studies involved displayed positive modulations to blood pressure in accordance
with weight loss. The Evaluation of the National Exercise Referral Scheme sought to
duplicate the findings of Judith et al (2003) and the other studies prior; these being that
physical exercise indefinitely benefits cardiovascular health, in particular the possible effect
of weight loss on blood pressure.
The role of physical activity in the mediation of cardiovascular disease risk factors is
noticeable across a range of prominent, well-known physiological variables; however,
delving deeper into its effects on the body at a macromolecular level depicts a series of
mechanisms far more intricate than measurements such as weight or arteriovenous blood
pressure. For example, changes to lipid profiles within the human body are often precursors
of the changes to more easily measured physiological variables such as blood pressure, yet
due to the intrusive nature of their measurement techniques the impact of their variations
often goes unnoticed.

11. Durstine et al (2001) conducted a cross-sectional study to analyse the blood lipid and
lipoprotein adaptations to regular, moderate intensity exercise. The balance of intravenous
lipoproteins can greatly affect a person’s cardiovascular risk factors as well as their
susceptibility to other, similar diseases such as atherosclerosis. Circulating cholesterol and
triglycerides are insoluble in blood and so are encapsulated by lipoproteins; high density
lipoproteins (HDLs), which are smaller in size, consist predominantly of protein and
cholesterol, arguably more beneficial than their larger, lipid-filled counterparts referred to
as low density lipoproteins (LDLs)(Porth, 2011).
HDLs are often referred to as ‘good cholesterol’ most notably due to their
transportation of cholesterol from peripheral, atheromatous plaques to the liver for
excretion. As such, there is an inverse relation between HDL levels and the development of
atherosclerosis (Ridker & Libby, 2008). Conversely, the role of LDLs can be one of detriment
to the human vasculature: endogenous triglycerides (TG) synthesized in the liver are
transported by LDLs to fat and muscle cells, excessive levels of circulating LDLs encourage
their extraction from vessels by scavenging endothelial cells, this is believed to be
associated with the development of atherosclerosis (Guyton & Hall, 2011).
In his analysis, Durstine concluded that exercise eliciting over 1200kcal of
expenditure was associated with 2-8mg/dl increases in HDL levels and reductions in TG
levels of 8-20mg/dl. Additionally, although less commonly reported, reductions in LDL
concentrations also occur as a result of similar exercise regimes, these reductions continue
to be the primary target for cholesterol lowering therapy, particularly in people at risk of
coronary artery disease (CAD) or cardiovascular disease.
These favourable modifications, also prevalent in other studies (Denke & Pasternak,
2001), greatly support the preceding literature and their positive inclination towards
exercise as a preventative method for cardiovascular disease; although such measurements
were unattainable during this NERS evaluation, it was hoped that the implemented exercise
regime would incur similar, desired physiological changes to that of Durstine’s report.
With the general consensus depicting a possible affirmation of the hypothesized
benefits of the NERS, its potential for success provides hope to the cardiovascular health of
future populations.

12. Regarding the diversity of health benefits achievable via completion of the NERS, the
possible opposition and diminishment of Metabolic Syndrome was attentively hypothesized
in this study. The World Health Organisation defines The Metabolic Syndrome as:
Type II Diabetes, impaired glucose tolerance or normal glucose tolerance with insulin
resistance, together with two or more of the following:
- Abdominal obesity and/or BMI >30kg/m²
- Elevated Blood Pressure (greater than 130/85mmHg or active treatment of
hypertension)
- Low HDL concentrations (< 1.0mg/dl for men, and <1.2mg/dl for women)
- High Triglyceride concentrations (>1.7mmol/L)
- Microalbuminurea (excessive loss of protein in the urine)
Categorized as part of a cascade of conditions and disorders, major adverse
consequences of metabolic syndrome can be the development of cardiovascular disease and
atherosclerosis. Consolidated by its nature and in conjunction with obesity or insulin
resistance, it usually precedes the development of Type II Diabetes (Guyton & Hall, 2011).
Susceptibility to the accruement of metabolic syndrome and consequent diabetes is most
sensitive between the ages of 50 and 60 and thus is referred to as adult-onset diabetes. In
the process of ageing the anatomical and physiological changes to several visceral systems
can lead to functional disability and increased risk of premature death (Harbraouck et al,
1999). Although irreversible on a grander scale, this inevitable senescence is augmented by
physical inactivity and thus can be supplemented with exercise prescription (Ehrman et al,
2009).
The majority of patients enrolled on the National Exercise Regime not only fall into the
approximated age category, but also satisfy the above criteria for Metabolic Syndrome. With
the NERS aiming predominantly to combat obesity and hypertension, its subsequent success
would theoretically eliminate two of the five criteria pertaining to metabolic syndrome. The
results obtained by Judith (et al, 2001) and Staessen (et al, 2000) suggested a strong
possibility of this occurrence. Furthermore, the reported, favourable changes to lipid
profiles as a result of exercise (Durstine et al, 2001) substantiated the possibility of reduced
triglyceride concentrations and increased HDL concentrations as consequence to regular,
moderate intensity exercise. Further epidemiological evidence also supports the role of
exercise in the primary prevention or delay of Type II Diabetes (Xiao et al, 1997).

13. Adopting a theoretical perspective, metabolic syndrome can be regarded as an operative
template for the transition between the accumulation of smaller, less aggressive disorders,
and the development of more severe conditions, diseases or risk factor parameters.
The National Exercise Referral Scheme aims to facilitate cardiovascular health
replenishment and seeks to lessen risk factors associated with the development of
cardiovascular disease. Application of the above transitional model supports the hypothesis
that regular, moderate intensity exercise can induce an abundance of health benefits related
to the aforementioned conditions. Considered as method of CVD and MS prevention, this
study aims to further elucidate the scheme’s ability to reduce their associated risk factors,
and consequent contraction of type II diabetes and cardiovascular disease; the findings of
Judith (et al, 2001) and Durstine (et al, 2001) support the theorized combatting of metabolic
syndrome and CVD prerequisites such as obesity, hypertension, low LDL concentrations and
high TG levels.
If left to accumulate however, these parameters are considered to conjunctively
represent metabolic syndrome, if untended to there is a possibility for worsening of health
in the development of diabetes or cardiovascular disease. The previously stated benefits of
exercise concluded by Agarwal (2012) lend suggestion to the possible treatment of MS
through exercise and a reduced risk of CVD as consequence; stating that regular exercise can
not only reduce CVD-risk factors but accordingly alleviate the detriment of type II diabetes
and metabolic syndrome.
There is a dearth of information available that is applicable to this physiological theory,
supporting the hypothesis that exercise can reduce such risk factors in the early stages of
this chronological pathway, or conversely combat their developments in the later stages
once accrued. The findings exhibited in the preceding literature aid aims and aspirations of
this study in its attempt to solidify the benefits of the NERS across a range of health
variables and risk factor parameters. This study sought to definitively conclude that the
implementation of a monitored, 16-week exercise regime can: reduce CVD and MS risk
factors, actively counter metabolic syndrome, and finally lessen the detriment of a plethora
of subsequent conditions such as cardiovascular disease, diabetes and atherosclerosis. Thus,
the following working hypotheses were postulated:
H1 =Participation levels would decrease throughout the scheme and it would elicit
favourable reductions to all health parameters.
H0 =Participation levels would remain constant throughout the scheme and it would
elicit unfavourable increases to all health parameters

14. 2.0 - Methodology
2.1 - Methodology Introduction
This section of the study denotes the methods, protocols and equipment used during its
research and data collection components, and subsequently that of the statistical analysis
conducted upon said data. This two-pronged research project investigated both the levels of
adherence on the National Exercise Referral Scheme and the physiological benefits attained
by those who completed it.
2.2 - Ethical Issues
Prior to research, all patients completed a series of forms to assess their eligibility and
safety to proceed, such as a Physical Activity Readiness Questionnaire and an EQ-5D
Questionnaire (see Appendices). Additionally a Participant Information Sheet was issued in
order to fully explain the safety precautions, protocols and rationale of the study. A HESAS
Ethics Undergraduate Research Form was approved and signed by a member of the Faculty
of Life Sciences and Education Undergraduate Research Committee to verify that the study
was ethically appropriate.
2.3 - Anthropometrics
During an initial consultation various anthropometric measures were recorded, all
measurements were conducted three times and an average attained for each: Height (cm),
Weight (kg), Waist Circumference and also BMI using the following equation:
BMI =
Weight (kg)
Height² (m)
2.4 - Regime Structure
Following referral of patients and completion of an Initial Consultation an exercise schedule
was implemented; participants were to complete 2 hours of moderate intensity exercise
each week consisting of two 60-minute exercise classes. This involved choice of either a
Gentle Exercise Class or a Gym-based Exercise class. Participants are lead by a NERS
exercise Coordinator through various warm-up and stretching movements before
commencing the above circuits. All movements are of low to moderate intensity and are
attentively monitored by the exercise professional throughout. Following the circuits a
gentle warm-down session is conducted.

15. 2.5 - Participant Catchment
40 elderly, ambulatory men and women (aged 50-85 years) with a mean body weight of
96kg (SD± 20.28) were recruited for this study. All were at risk of, or had a medical history
involving cardiovascular disease, diabetes, strokes, certain cancers or general concerns
surrounding obesity (see NERS Inclusion Criteria in Appendix). A General Practitioner
referred all participants in this study to the NERS.
2.6.1 Experimental Design - Measures of Adherence
This section of the study investigated the number of participants who remained on the
NERS at each of its consultatory stages: Initial Referral, First Consultation, Introductory
Session, Consultations at weeks 4, 8, 12 and 16 upon scheme completion followed by a 12
Month Lifestyle Meeting. It assessed the figures of those initially referred that completed the
scheme and those who did not.
2.6.2 - Experimental Design: Physiological Measures
The measurement of physiological variables constituted the main analytical hub of this
study; during each consultatory stage six health parameters were measured three times and
an average attained. Systolic and diastolic blood pressure (mmHg) were measured using an
automatic blood pressure monitor (OMRON M3 HEM-CR24, Healthcare Co, Ltd, Kyoto,
Japan, made in Vietnam: P Intelli Sense) two cuff sizes were used: Standard Adult Cuff (22-
32cm) and a Large Adult Cuff (32-42cm). Body Mass (kg) and BMI were measured using
Marsden electronic scales (Model MPPS-250 by Marsden/The Weighing Company: Made in
China by Charder Electronic Co, Ltd). Height (cm) was measured using Seca Measurement
Systems and Waist Circumference was measured using a standard orlistat (Manufactured by
Xenical), done so midway between the uppermost boarder of the iliac crest and the lower
boarder of the costal margin. For overweight or obese patients whose skeletal landmarks
were not easily located, the tape was aligned with the patient’s belly button.
2.7 - Statistical Analysis
Upon satisfying the assumptions of normality and homogeneity of variance, a paired
samples t-test was conducted using SPSS Statistics v.22 (IBM, Armonk, NY, USA). Results
were compared before and after scheme completion to determine whether any changes
were statistically significant.

16. 3.0 – Results
3.1-3.6 - Measures of Adherence & Physiological Data
The figures below (figure 3.1 – 3.6) depict the changes to each variable before and after
scheme completion with relation to the participation levels during each consultatory stage.

17. 3.7 – Anthropometric & Haemodynamic Data
3.8 - Antihypertensive Properties of NERS
Figure 3.8 was formulated to highlight the prevalence of favourable blood pressure
reductions. It depicts the percentage of patients who experienced favourable changes to all,
some or none of the variables; also illustrated is the percentage of patients whose
unfavourable changes were attributed to blood pressure.

18. 3.9 Obesity-Related Hypertension
To further elucidate the possible interaction between obesity and hypertension in the
metabolic syndrome, figure 3.7 (below) was devised to depict the relationship between the
Systolic Blood Pressure and Body Weight values of NERS patients. This interaction, as
discussed by Judith (et al, 2003), is prevalent in the metabolic syndrome and plausibly
revolves around over -activation of the renin-angiotensin aldosterone system and
sympathoexcitation.

19. 4.0 - Discussion
4.1- Summary of Results
The findings of this study have further elucidated the possible benefits to health
achieved via the implementation of an exercise regime; all reductions to variables were
statistically significant and the scheme’s ability to restore its patients’ health was evidenced
substantially, with particular reinforcement made to it’s previously theorized
antihypertensive properties. These findings conclusively satisfied the following working
hypothesis:
H1 =Participation levels would decrease throughout the scheme and it would
elicit favourable reductions to all health parameters.
The analytical perspectives of this two-pronged study focused firstly upon the
evaluation of adherence throughout the scheme and secondly upon the benefits to health
achieved by those who remained on it. The adherence-based statistics showed that, of those
referred to the scheme by general practitioners, only 53% remained active after 4 weeks
and only 36% actually completed it. Although drastic reductions in participation were
exhibited, analysis of physiological and anthropometric data showed that, for the 36% who
completed the scheme, the following modulations to health were incurred:
1. Body weight: –2.0kg (SD± 20.28 / P = 0.00109†)
2. Waist Circumference: -2.8cm (SD± 14.10 / P= 0.00008†)
3. Heart Rate: -2.9bpm (SD± 10.74 / P= 0.01399†)
4. Body Mass Index: -0.8 (SD± 6.38/ P= P= 0.00185†)
5. Systolic Blood Pressure: -7.3mmHg (SD± 16.5 / P= 0.00003†)
6. Diastolic Blood pressure: -4.9mmHg (SD± 11.33 / P= 0.0008†)

20. 4.2 - Pathogenesis of Metabolic Syndrome and Cardiovascular Disease
The pathogenesis of metabolic syndrome, cardiovascular disease, and type II
diabetes mellitus encompasses a vast network of elaborate physiological inter-
relationships; these highly integrated mechanisms, which are concomitant with positive
energy balance and a sedentary lifestyle, are not only inter-dependent but are often up-
regulatory of one another (Kishi & Hirooka, 2013).
The purpose of using simple anthropometry in the identification of those at
increased health risk is to identify those with CVD risk factors (Janssen et al, 2004). In
addition to anthropometrics, the other variables measured in this study focused
predominantly on internal physiological changes to provide a broader yet more meticulous
insight as to the changes to health that occurred. Although not definitive predictors of
cardiovascular risk, all epidemiological studies that sought to answer questions about BMI,
heart rate and all-cause morbidity, reported that increases to either are greatly associated
with a higher risk of all-cause morbidity and CV events (Perret-Guillame, 2009).
The metabolic syndrome is predominantly characterized by impaired glucose
tolerance, elevated blood pressure and visceral obesity; patients who satisfy these criteria
are three times more susceptible to cardiovascular-related death than healthier
counterparts; as such metabolic syndrome is rapidly becoming a global concern (Kishi &
Hirooka, 2013).
The schema overleaf (figure 4.2.1) was devised to depict the pathogenesis of more
severe conditions through the accruement of earlier risk factor parameters such as
hypertension and abdominal obesity. As previously discussed, depending on the type and
severity of worsening to these parameters, they can be collectively known as metabolic
syndrome.
It must first be understood that the processes depicted in the schema are more often
accumulative as a result of poor diet or lack of exercise; as changes to certain measures
amass, so too does the risk of developing cardiovascular disease or other conditions.

21. Figure 4.2.1 depicts the process of health degeneration across a temporal baseline from
normal health to the development of cardiovascular disease and other pathological
conditions
Figure 4.2.1 – Schema todepict the pathogenesis of cardiovasculardisease. Ref; 1: Kishi& Hirooka, 2013. 2: Canale et al, 2013. 3: Janssen et al,
2004. 4: Perret-Guillame et al, 2009. 5:National Heart, Lung and Blood Institute, 2013. 6: National Institute of HealthDevelopment Panel,
1985. 7: Guyton & Hall, 2010. 8: Ford, 2005.
With regards to the schema, those classified as obese, hypertensive or somewhat diabetic
exhibit a rightward shift toward metabolic syndrome (Stage 1). Concordant with a
continued absence of lifestyle modifications or nutritional interventions is a possible,
further shift toward cardiovascular disease through the damaging accumulation of later risk
factor parameters (Stage 2). Consequential perseverance of these aggressive comorbidities
can, if unopposed, ultimately lead to the contraction of cardiovascular disease, type II
diabetes mellitus, atherosclerosis and even certain cancers (Poirier et al, 2006).
The underpinning physiological concepts to which these quantifiable, pathogenic
changes are attributed, pertain predominantly to the over-activation of the sympathetic
nervous system (SNS) (Kishi & Hirooka, 2013). Thermogenesis and blood pressure are both
under adrenergic control (Canale et al, 2013), thus in the pathogenesis of hypertension,
metabolic syndrome, and CVD, underlying SNS activation is critically involved; additionally,
previous studies have suggested that this activation is notably interactive with insulin
resistance and stimulation of the renin-angiotensin aldosterone system (RAAS) (Grassi et al,
1981). In accordance to hypertension, central obesity demonstrates augmented sympathetic
outflow when compared to non-central adiposity even in the absence of elevated blood
pressure, which, if also present, further augments the sympathetic nervous system (Kishi &
Hirooka, 2013).

22. A schema formulated by Kishi & Hirooka (2013) illustrated the pathogenesis of
hypertension and subsequent obesity in the metabolic syndrome; although conceptual it
depicted the mechanisms plausibly involved. Over-activation of the RAAS, which frequently
occurs in obesity (Thethi et al, 2012), can result in heightened levels of the vasoconstrictor
angiotensin II left circulating in the blood stream; as such the pathogenesis of obesity-
related hypertension in the metabolic syndrome is considered to be substantially involved
in the development of cardiovascular disease.
Sympathoexcitation associated with the renin-angiotensin aldosterone system in MS
elicits a considerable degree of oxidative stress on the rostral ventrolateral medulla (RVLM)
and thus is considered neurogenic. This stress, induced by the coupling of angiotension-1
receptors (AT1) and their ligand angiotensin II, markedly potentiates sympathetic neural
discharge; resultantly this increases intravenous insulin levels and elevates blood pressure
accordingly. Moreover, RAAS-induced secretion of renin increases water and electrolyte
retention in the kidneys; osmotic distension of interstitial fluid and surrounding cells
constricts the intrarenal vasculature and increases blood pressure (Guyton & Hall, 2011).
SNS activation is partly aimed at β-adrenergic thermogenesis to promote negative
energy balance, decreased fat storage and weight loss, however; its normal activation of
brown adipose tissue and other baseline mechanisms do not occur in obese patients (Kishi
& Hirooka, 2013). Additionally, its subsequent activation of the RAAS is of considerable
detriment to intra-physiological mechanisms, expediting lipolytic production of non-
esterified free fatty acids (FFAs) and increasing insulin resistance.
4.2- Antipathogenic Effects of the National Exercise Referral Scheme
It is ubiquitously known that regular exercise benefits health, but with regard to the
alleviation of CV-risk factor parameters during the later stages of pathogenesis, the exact
exercise intensity that yields the greatest benefit is relatively unknown (Tjønna, 2007). The
National Exercise Referral Scheme aims to regenerate the health of its patients or
significantly ameliorate a multiplicity of risk factor parameters. The hopes and aims of this
study were to quantitatively evidence the scheme’s capacity to reduce the risk of
cardiovascular disease, theoretically eliminate the metabolic syndrome or even guide it’s
patients back to normal health.

23. Applying the findings of this study to the previously devised theoretical schema (figure
4.3.1) enabled its orientation to be modified in favour of the antipathogenic effects of the
National Exercise Referral Scheme. Figure 5.1 depicts the pathogenic pathway of
cardiovascular disease and it’s subsequent reversal following the implementation of an
exercise programme
Figure 4.3.1 – Antipathogenic effects of the National Exercise Referral Scheme. Ref; 1: Agarwal, 2012. 2:Tjønna, 2007. 3: Perret-Guillame,
2009. 4: Janssen et al, 2004. 5: Esleret al, 2006. 6: Judith et al, 2003. 7: Durstine et al, 2001. 8: Denke & Pasternak, 2001. 9: Xiao et al, 1997.
Typographical Daggerdenotes statistical significance.
Figure 4.3.1 depicts the possible antipathogenic effects of regular, moderate intensity
exercise with regards to cardiovascular disease, type II diabetes mellitus, atherosclerosis,
metabolic syndrome and even certain cancers (Agarwal, 2012). Although comprised
primarily of the data collected in this NERS evaluation, supplementary information is
exhibited where other, comparable studies have elicited applicably similar or additional
modulations to these health parameters.
The physiological interconnectedness of these parameters, as discussed, appears to
principally revolve around sympathoexcitation, adrenergic overdrive and over-activation of
the renin-angiotensin aldosterone system; previous studies have stated that moderate
intensity exercise incorporating stretching and range of motion movement patterns can
reduce sympathetic activity and improve several other CVD risk factors (Agarwal, 2012).
This knowledge, compiled with that of the Gentle Exercise Class’ steady, mobility-based
approach (see Methodology), provides ample explanation to the positive modulations
incurred by this scheme.

24. As a central feature contributing to the mortality and morbidity associated with metabolic
syndrome (Canale et al, 2013), weight management was monitored attentively throughout
the scheme. The mean reductions to weight (-2.0kg ± 20.28) were of favourable orientation
and, with several patients shedding an excess of 10kg and one even 16.2kg, were not
conclusively demonstrative of the scheme’s potential. Plausibly interactive with obesity,
alterations to blood pressure scores were equally scrutinized.
Regular exercise reduces blood pressure, its sympathetic inhibition, preferentially
involving that of renal sympathetic outflow, is well placed to achieve an antihypertensive
effect (Esler et al, 2006). The scheme incurred a significant mean SBP decrease of 7.3mmHg
(±16.5), and mean DBP decrease of 4.9mmHg (±11.33). In addition to the mean values, 40%
of patients who were initially considered to be hypertensive reduced either DBP or SBP to
normotensive thresholds; furthermore 8% of patients reduced both DBP and SBP to
normotensive values. An increase in blood pressure of 10mmHg is associated with a 20%
increase in the risk of cardiovascular-related death (Perret-Guillame, 2009); consequently,
for the 43% of participants who exhibited a 10mmHg SBP reduction, their risk of CV-related
death was reduced by one fifth.
Of the three variables measured in this study pertaining to the metabolic syndrome,
waist circumference also exhibited significantly favourable modulations in addition to the
variables prior. It has been established that abdominal obesity, assessed by waist
circumference, effectively predicts obesity-related health risk (World Health Organization,
1998); thus favourable reductions in the former would subsequently lessen the detriment of
the latter. Mean reductions to waist circumference of 2.9cm (±14.1) were exhibited
following completion of the scheme; 77.5% of the population reduced their WC with three
patients showing reductions of 10cm or more and one eliciting an 18cm decrease. Of the
22.5% who did not reduce their WC, only two patients showed increases of a greater margin
than that of the group’s mean reduction.
The metabolic syndrome encompasses a constellation of risk factors, two of which
being abdominal obesity and hypertension; however, due to the invasive techniques
required to assess the remaining criteria, the metabolic syndrome could not be accurately
diagnosed within this study. Conversely, of the 88% who originally satisfied one criterion or
more, analysis was conducted as to whether these fulfillments remained, or if reductions to
these prerequisites below MS baselines occurred. Of this population, 49% experienced
positive changes to one or more of the parameters associated with MetS, subsequently
reducing their risk of metabolic syndrome and cardiovascular disease (Agarwal, 2012).

25. In accordance with these changes, it is hoped that the remaining criteria and their
underpinning intra-physiological mechanisms underwent antipathogenic alterations.
Previous studies have detailed that in addition to reducing BP and WC, exercise, particularly
regimes of longevity, can elicit significant reductions to triglyceride concentrations
(Durstine et al, 2002), increase HDL concentrations, abolish microalbuminurea and thus
partly or fully reverse the metabolic syndrome (Tjønna, 2007). Conclusively it is hoped that,
although currently immeasurable under NERS data collection protocol, such desired
physiological changes also befell the patients of the National Exercise Referral Scheme.
The metabolic syndrome does not incorporate changes associated with body mass
index or heart rate, however they are widely acknowledged as independent risk factors for
cardiovascular disease and other pathological conditions (Janssen et al, 2004. Perret-
Guillame, 2009).
Interventions designed to reduce BMI would likely obtain maximal benefits in
reducing the incidence or prevalence of CVD risk factors (Janssen et al, 2004).
Implementation of the NERS’ exercise regime reduced the population’s mean BMI scores by
0.8kg/m2 (±6.38). With knowledge of its association to all-cause cardiovascular morbidity,
these reductions to body mass index and their subsequent implications were considered to
be in some way anti-pathogenic.
Due to the risks associated with an accelerated heart rate being not only statistically
significant, but also clinically relevant (Perret-Guillame, 2009), patient’s heart rates were
carefully monitored throughout this analytical study. Regarding the study population, the
implemented exercise regime induced a mean heart rate reduction of 2.9bpm (±6.38).
Moreover, 18% of participants exhibited a heart rate reduction of 10bpm or more, which,
congruent with a 10mmHg blood pressure decrease, is associated with lessening the risk of
cardiovascular-related death by 20% (Perret-Guillame, 2009).
4.4 - Scheme Prognostics
The south wales valleys suffer from a number of socio economic problems (David et
al, 2003), when juxtaposed with the expeditious increase in CVD mortalities it is evident
that an influx of health and lifestyle interventions must be deliberated and endorsed.
Further fortification of such schemes could likely impose a multitude of benefits across not
only health and wellbeing platforms but also those of socio economic orientation.

26. Regular physical activity substantially aids mood improvement, personal capacity for
work and recreation, and also enhances motivational climate (Ntoumanis et al, 1999). The
socially inclusive approach of this exercise scheme bares testament to the breadth and
variety of benefits than can be achieved by partaking; providing a medium in which
community adhesion can grow and prosper, the opportunities it provides to socially interact
with like-minded individuals could, although not necessarily quantifiable, provide hope to
these at-risk societies.
The influence of these interactive environments can also alleviate the detriment of
neurological and psychological conditions such as anxiety and depression which, upon
assessment of other, similar exercise referral schemes, have proved to be significantly
reduced via the implementation of a physical activity regime (Pavey, 2011. Murphy et al,
2010). Additionally, when compared to anti-depressant pharmaceuticals, the
implementation of a 16-week exercise regime has proved equally as effective at reducing
depression levels (Blumenthal et al, 1999). Also evidencing positive modulations to
haemodynamic variables, many of these other exercise referral based studies have stated
that, if maintained over time, adherence to these physical activity regimes could bring about
population-level benefits in health.
The current literature available to substantiate the benefits of exercise is indeed
diverse and plethoric; for example, those with good muscoskeletal flexibility, which is highly
attainable through physical activity, will significantly reduce the risk of lower back injury
(Cady et al, 1979). This beneficial adaptation however can extend beyond the confines of
chiropractics and also positively transcend into day-to-day life, such as substantially
improving safety whilst driving (West Virginia University, 1988).
Summating the antipathogenic findings of this study with the neuropsychological
(Pavey, T. 2011. Murphy et al, 2010. Blumenthal et al, 1999), cardiovascular (Agarwal
2010), and economic (Agarwal, 2010) benefits evidenced in similar exercise schemes,
provides substantial support to the hypothesised future impact of exercise referral schemes
across a range of parameters. In addition, other reported improvements to muscoskeletal
mechanisms (Cady et al, 1979), oncological concerns (Sternfeld, 1992) and respiratory
pathologies (Ries et al, 1995), bare testament to the heterogeneity of potential
improvements to health incurred by regular, moderate intensity exercise.

27. 4.5 - The Detrimental Impact of Other Pathologies
In 2005 there were 58 million deaths worldwide, those attributed to cardiovascular
disease equated to almost a third (World Health Organization, 2004). As the most common
cause of death from cancer, lung cancer claimed the lives of 1.18 million people out of 1.35
million initially diagnosed in 2005 (American Cancer Society, 2005). Equally as fatal,
Leukemia claimed 222,000 lives of the 300,000 diagnosed in 2005; this poor patient
prognosis is partly attributed to the complex and often unattainable treatment
administrations that are required. Although having a large bearing on global deaths, cancer,
even when combined with deaths attributed to all infectious diseases, did not equal that of
cardiovascular morbidities.
The ratio of malaria diagnoses and subsequent mortalities is substantially lower
than that of its cancerous counterparts, yet each year Malaria claims the lives of
approximately 584,000 people of 198 million who are diagnosed. Once again a vast majority
of these deaths are attributed to the inaccessibility of costly health interventions such as
insecticide-treated mosquito nets or artemisinin-based therapies (World Health
Organization, 2004).
Emerging from this statistical juxtaposition is a distinct and concerning trend; it
revolves principally around the inaccessibility of certain medical interventions and thus the
limited ability to mitigate the detriment of various pathologies. With knowledge that
cardiovascular disease accounts for 1/3 of global deaths each year, it is staggering that the
well known, far-reaching and simultaneously easy, inexpensive and effective (Agarwal,
2012) methods of prevention such as exercise are not given the respect or funding that they
require and as consequence 16.7 million lives are claimed by it each year.

28. 4.6 - Conclusion
The National Exercise Referral Scheme, as quantitatively and qualitatively evidenced
in this study, is definitively beneficial to the health and wellbeing of its patients. The
implemented exercise regime elicited favourable reductions to diastolic and systolic blood
pressure, body weight, body mass index, heart rate and waist circumference. The scheme’s
ability to ameliorate these health parameters greatly evidenced its antipathogenic and
antihypertensive properties; hypothesized earlier in this study, these properties related to
reducing the risk of cardiovascular disease, Type II Diabetes Mellitus, stroke, metabolic
syndrome and even certain cancers (Agarwal, 2009).
The findings of this study have definitively elucidated the National Exercise Referral
Scheme’s ability to reduce the risk of the metabolic syndrome and cardiovascular disease. In
addition, the scheme elicited favourable reductions to all parameters, and due to the
reduction of CVD risk, reduced accordingly was the risk of developing atherosclerosis and
subsequent injurious consequences to visceral systems throughout the body (Guyton & Hall,
2011). The ill-omened tyranny of cardiovascular disease currently claims more lives each
year than any other disease, pathological condition, accident, war or natural disaster (World
Health Organisation, 2004); however, increasing knowledge of its effective preventative
methods equips today’s societies with a dexterous arsenal of techniques and practices that
can aid overcoming it, now added to this arsenal are the recently affirmed and scientifically
proven benefits of the National Exercise Referral Scheme.

29. 4.7 - Limitations & Recommendations
Although proving conclusively beneficial to its participants, this study conceded
various limitations and measures that, if counteracted in a future study, could further
substantiate the data set and authenticate the antipathogenic conclusions.
Firstly, in comparison to the vast volume of patients that the National Exercise
Referral Scheme treats the data set examined was relatively deficient. The time frame within
which the study was conducted ran parallel to two terms during a University academic year;
increasing the study’s longevity would proportionately heighten the quantity of current or
new patients that could eligibly partake. Moreover, increased frequency of data collection
would present much more information to be included in means, trends and graphical
representations. As such, the study’s elicited conclusions would provide a more meticulous
insight into the health benefits achievable by the NERS regime and represent them more
reliably.
Similar to an increased data set, the addition of further variables and measures might
also strengthen the findings; to give example, incorporating an exercising heart rate via the
implementation of HR monitors would more effectively elucidate the hearts capability and
functionality within an active, exercising medium. Furthermore, depending on ethical issues
or accessibility of equipment, the utilization of blood sampling could provide insight into the
modulations to lipid profiles throughout the regime; similar to Agarwal’s (2012) findings it
could proficiently assess a patient’s susceptibility to conditions such as atherosclerosis.
The NERS database management protocols, although effective, were considered a
partial limitation. Although a separate database was created for the duration of this study,
the implementation of new NERS modes and protocols could expedite the processes of data
collection, storage and retrieval - subsequently enhancing the efficiency and confidentiality
of data storage at the National Exercise Referral Scheme.
As highlighted in this study, one key limitation of the exercise regime was the patient
adherence and participation levels throughout the scheme with only 53% of the population
still active by week 4. Upon discussion with the patients involved, it became definitively
apparent that the limitations to participation significantly focused upon transport and
accessibility, which, to those with disability or impairment, often revolves around the
goodwill and availability of family and friends (Oliver et al, 1988). To ameliorate current
outreach and accessibility strategies within the scheme could perhaps breadthen the
scheme’s catchment and increase the volume of patients journeying from initial consultation
through to completion.

30. However, the plausible methods of which to increase the prevalence and success of this
scheme would likely have a significant financial impact on this charitable organization.
Furthermore, due to the current economic decline of rural Welsh areas (David et al), the
required injection of capital to these rehabilitative schemes is not one that is necessarily
feasible.
In conclusion, the limitations of this study involved the implementation of further
measures in which to strengthen the orientation and depth of the current findings.
Regarding those limitations pertaining to the National Exercise Referral Scheme itself, they
appear to revolve predominantly around financial, societal and socio-economic issues as
opposed to the actual rehabilitative protocols currently in place that have proved
substantially beneficial to the health of it’s patients.

31. Agarwal, S. (2012). Cardiovascular Benefits of Exercise. International Journal of General
Medicine. 5, 451-455.
Blumenthal, J Babyak, M Moore, K Craighead, W Herman, S Khatri, P Wangh, R Napolitano, M
Forman, L Appelbaum, M Doraiswang, M Krishnan, K. (1999). Effects of Exercise Training on
Elder Adults with Major Depression. Archive of International Medicine. 2349-2356.
Cady, L Bischoff, D O'Connell, E Thomas, P Allan, H. (1979). Strength and Fitness and
Subsequent Back Injuries in Firefighters. Journal of Occupational Medicine. 21, 269-272.
Canale, M Di Villahermosa, S Martino, G Rovella, V Noce, A De Lorenzo, A Di Daniele, N. 2013.
Obesity-Related Metabolic Syndrome: Mechanisms of Sympathetic Overactivity.
International Journal of Endocrinology, 1-12.
David, R. (2003) The Socio-Economic Characteristics of the South Wales Valleys in a Broader
Context: A report for the Welsh Assembly Government.
Denke, M Pasternak, R. (2001). Defining and Treating the Metabolic Syndrome: A Primer
From the Adult Treatment Panel III. Cardiac Med. 3, 251-253.
Durstine, J Grandjean, P Davis, P Ferguson, M Alderson, N DuBose, K. (2001). Blood lipid and
lipoprotein adaptations to exercise: a quantitative analysis. Sports Medicine. 31 (15), 1033-
1062
Ehrman, J Gordon, P Visich, P Keteyian, S (2009). Clinical Exercise Physiology. 9th ed. USA:
Human Kinetics.
Esler, M Straznicky, N Eikelis, N Masuo, K Lambert, G Lambert, E. (2006). Mechanisms of
Sympathetic Activation in Obesity-Related Hypertension. American Heart Association:
Hypertension.
Guyton, A Hall, J (2011). Guyton and Hall: Textbook of Medical Physiology. 12th ed.
Philadelphia: Saunders Elsevier.
Hagberg, J.M et al (1990). Exercise, Fitness, and Health: A consensus of Current Knowledge -
Exercise, Fitness, and Hypertension.
Harbraouck, L Stevens, J Dellinger, A Batabyal, P Crosby, E Vallura, B Kresnow, M Huero, J.
(1999). Surveillance for Injuries and Violence Among Older Adults. MMWR. 48, 27-50.
http://www.nhlbi.nih.gov/health/educational/wecan/portion/documents/BACKGROUND1
.pdf (Last accessed: 20th April 2015).
Janssen, I Katzmarzyk, P Ross, R. (2004). Waist Circumference and not Body Mass Index
Explains Obesity Related Health Risk . American Journal of Clinical Nutrition. (3), 379-384.
Judith, E Neter, B Stam, F Frans, J Diederick, E Grobbee, J Geleijnse, J. (2003). Influence of
Weight Reduction on Blood Pressure. American Heart Association: Hypertension.
King, A. (1994). Community and Public Health Approaches to the Promotion of Physical
Activity. Med Sci Sports Ex. 26 (c), 1405-1412.
Mora S, et al (2007). Physical activity and reduced risk of cardiovascular events: potential
mediating mechanisms pg 2110–pg2118.
Mora, S, Cook, N, Buring, J Ridker, P, Lee, I. 2007. Physical activity and reduced risk of
cardiovascular events: potential mediating mechanisms. Circulation, 116, 2110–2118.

32. Kishi, T Hirooka, Y. (2013). Sympathoexcitation Associated with Renin-Angiotensin System
in Metabolic Syndrome. International Journal of Hypertension
Libby, P Ridker, P Hansson, G. 2009. Inflammation in atherosclerosis: From
Pathophysiology to Practice. Journal of the American College of Cardiology, 54, 2129–2138.
Mora S, et al (2007). Physical activity and reduced risk of cardiovascular events: potential
mediating mechanisms pg 2110–pg2118.
Mora, S, Cook, N, Buring, J Ridker, P, Lee, I. 2007. Physical activity and reduced risk of
cardiovascular events: potential mediating mechanisms. Circulation, 116, 2110–2118.
Murphy et al (2010). The evalaution of the National Exercise Referral Scheme in Wales.
Cardiff Institute of Society and Health, School of Social Sciences, Cardiff University, Cardiff,
Wales.
National Heart, Lung, and Blood Institute (2013). Assessing your weight and health risk.
http://www.nhlbi.nih.gov/health/public/heart/obesity/lose_wt/risk.htm.
National Institutes of Health Development (1985). Health Implications of Obesity: Annals of
Internal Medicine pg1073-pg1077.
NHS Wales (2010). An Evaluation of Cardiac Disease.
Ntoumanis, N Biddle, S. (1999). A Review of Motivational Climate in Physical Activity.
Journal of Sports Science. 17, 643-655.
Pavey, T.G., 2011. Effect of exercise referral schemes in primary care on physical activity
and improving health outcomes: systematic review and meta-analysis. BMJ. 343.
Perret Guillame, C Joly, L Benetos, A. (2009). Heart Rate as a Risk Factor for Cardiovascular
Disease. Prog Cardiovasc Dis. (1), 6-10.
Poirier, P Giles, T Bray, G Yuling, H Stern, J Pi-Sunyer, F Eckel, R. 2006. Obesity and
Cardiovascular Disease: Pathophysiology, Evaluation and Effect of Weight Loss. Circulation.
113, 898-918.
Porth, C. 2011. Essentials of pathophysiology: concepts of altered health states. 3rd Edition.
Philadelphia: Lippincott Williams & Wilkins, 407-408.
Ries, A Kaplan, R Limberg, T Prewitt, L. (1995). Effects of Pulmonary Rehabilitation on
Physiological and Psychosocial Outcomes in Patients with Chronic Obstructive Pulmonary
Disease. Ann Intern Med. 122, 823-832.
Staessen, J Fagard, R Amery, A. 1988. The relationship between body weight and blood
pressure. Journal of Human Hypertension. 2, 207–217.
Sternfield, B. (1992). Cancer and the protective Effect of Physical Activity: The
Epidemiological Evidence. Med Sci Sports Exerc. 24, 1195-1209.
Thethi, T Kamiyama, M Kobori, H, 2012. The link between the renin-angiotensin-
aldosterone system and renal injury in obesity and the metabolic syndrome. Current
Hypertension Reports. 14, 160-169.
Tjonna, A Lee, S Rognmo, O Stolen, T Bye, A Haram, P Loennechen, J Al-share, Q Skogvoll, E
Slordahl, S Kemi, O Najjar, J Wisloff, O. (2008). Aerobic interval training vs. continuous
moderate exercise as a treatment for the metabolic syndrome - “A Pilot Study”. American
Heart Association: Circulation. 118 (4), 346-354.

33. Tjonna, A Lee, S Rognmo, O Stolen, T Bye, A Haram, P Loennechen, J Al-share, Q Skogvoll, E
Slordahl, S Kemi, O Najjar, J Wisloff, O. (2008). Aerobic interval training vs. continuous
moderate exercise as a treatment for the metabolic syndrome - “A Pilot Study”. American
Heart Association: Circulation. 118 (4), 346-354.
West Virginia University, Department of Safety and Health Studies and Department of
Sports and Exercise Studies. (1988). Physical Fitness and the Ageing Driver: Phase I. AAA
Foundation of Road Safety
World Health Organisation (2003). World Health Report.
World Health Organisation (2004). Atlas of Heart Disease and Stroke.
World Health Organization, 2000. Obesity: preventing and managing the global epidemic.
Report of a WHO consultation on obesity. Geneva: World Health Organization.
World Health Organization, 2015. World Malaria Report 2014 Summary. (Online Resource)
Available at:
http://apps.who.int/iris/bitstream/10665/160458/1/WHO_HTM_GMP_2015.2_eng.pdf?ua
=1&ua=1 (Last accessed: 20th April 2015).
Xiao, J Pun, X Li, G Hu, Y Wang, J Yung, W Hu, Z Lin, J Cao, H Liu, P Jiang, X Jiang, Y Wang, J
Zhang, H Zhang, H. (1997). Effects of Diet and Exercise in Preventing NIDDM in People With
Impaired Glucose Tolerance. Diabetes Care. 20, 573-544