Walking for hypertension

Summary of findings 1. Walking compared to no intervention (overall) for control of blood pressure

Outcomes	*Anticipated absolute effects^ (95% CI)**		№ of participants (studies)	Certainty of the evidence (GRADE)	Comments
Walking compared to no intervention (overall) for hypertension
Patient or population: adults with or without hypertension Setting: general population Intervention: walking Comparison: no intervention (overall)
Outcomes	Effect with no intervention mmHg	Effect with Walking mmHg	№ of participants (studies)	Certainty of the evidence (GRADE)	Comments
Systolic blood pressure	The mean systolic blood pressure was ‐1.30	MD 4.11 lower (5.22 lower to 3.01 lower)	5060 (73 RCTs)	⊕⊕⊕⊝ MODERATE ^{1 2}	Walking interventions probably reduce systolic blood pressure.
Diastolic blood pressure	The mean diastolic blood pressure was ‐0.73	MD 1.79 lower (2.51 lower to 1.07 lower)	4711 (69 RCTs)	⊕⊕⊝⊝ LOW ^{2 3}	Walking interventions may reduce diastolic blood pressure.
Heart rate [beats/min]	The mean heart rate [beats/min] was ‐0.41 beats/min	MD 2.76 beats/min lower (4.57 lower to 0.95 lower)	1747 (26 RCTs)	⊕⊕⊝⊝ LOW ^{2 4}	Walking interventions may reduce heart rate.
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: Confidence interval; DBP: diastolic blood pressure; MD: mean difference; RCT: randomised controlled trial; SBP: systolic blood pressure.
GRADE Working Group grades of evidence High certainty: we are very confident that the true effect lies close to that of the estimate of the effect. Moderate certainty: we are moderately confident in the effect estimate; the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. Low certainty: our confidence in the effect estimate is limited; the true effect may be substantially different from the estimate of the effect. Very low certainty: we have very little confidence in the effect estimate; the true effect is likely to be substantially different from the estimate of effect.
¹ Not downgraded one level for risk of bias even though more than half of included studies failed to report details of randomisation and allocation concealment. This is because a sensitivity analysis based on trials judged as being at low risk of bias also showed a statistically significant reduction of SBP: Weighted Mean Difference= ‐4.31, 95% CI: ‐7.99 to ‐0.63, P = 0.02, I² = 0%, n = 235. ² Downgraded one level for inconsistency on the basis of statistically significant heterogeneity. ³ Downgraded one level for risk of bias; More than half of the included studies failed to report details of randomisation and allocation concealment. The sensitivity analysis based on trials judged as being at low risk of bias failed to show a statistically significant reduction of DBP: Weighted Mean Difference = ‐0.47, 95% CI: ‐2.54 to 1.61, P = 0.66, I² = 18%, n = 235. ⁴ Downgraded one level for risk of bias; More than half of included studies failed to report details of randomisation and allocation concealment and there is no data for further sensitivity analysis.

Summary of findings 2. Walking compared to no intervention by age for control of blood pressure

Outcomes	*Anticipated absolute effects^ (95% CI)**		№ of participants (studies)	Certainty of the evidence (GRADE)	Comments

Patient or population: adults with or without hypertension Setting: general population Intervention: walking Comparison: no intervention, by age
Outcomes	Effect with no intervention mmHg	Effect with Walking mmHg	№ of participants (studies)	Certainty of the evidence (GRADE)	Comments
SBP age <=40	The mean SBP was 1.71	MD 4.41 lower (6.17 lower to 2.65 lower)	491 (14 RCTs)	⊕⊕⊕⊝ MODERATE ¹	Walking interventions probably reduce systolic blood pressure in adults aged equal to or less than 40 years.
SBP age 41‐60	The mean SBP was ‐1.88	MD 3.79 lower (5.64 lower to 1.94 lower)	1959 (35 RCTs)	⊕⊕⊝⊝ LOW ^{1 2}	Walking interventions may reduce systolic blood pressure in adults aged 41 to 60 years.
SBP age >60	The mean SBP was ‐2.21	MD 4.30 lower (6.17 lower to 2.44 lower)	2610 (24 RCTs)	⊕⊕⊝⊝ LOW ^{1 2}	Walking interventions may reduce systolic blood pressure in adults aged over 60 years.
DBP age <=40	The mean DBP was ‐0.24	MD 3.01 lower (4.44 lower to 1.58 lower)	491 (14 RCTs)	⊕⊕⊕⊝ MODERATE ¹	Walking interventions probably reduce diastolic blood pressure in adults aged equal to or less than 40 years.
DBP age 41‐60	The mean DBP by age 41‐60 was ‐0.87	MD 1.74 lower (2.95 lower to 0.52 lower)	1730 (32 RCTs)	⊕⊕⊝⊝ LOW ^{1 2}	Walking interventions may reduce diastolic blood pressure in adults aged 41 to 60 years.
DBP age >60	The mean DBP was ‐0.86	MD 1.33 lower (2.40 lower to 0.26 lower)	2490 (23 RCTs)	⊕⊕⊝⊝ LOW ^{1 2}	Walking interventions may reduce diastolic blood pressure in adults aged over 60 years.
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: Confidence interval; DBP: diastolic blood pressure; MD: mean difference; RCT: randomised controlled trial; SBP: systolic blood pressure.
GRADE Working Group grades of evidence High certainty: we are very confident that the true effect lies close to that of the estimate of the effect. Moderate certainty: we are moderately confident in the effect estimate; the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. Low certainty: our confidence in the effect estimate is limited; the true effect may be substantially different from the estimate of the effect. Very low certainty: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect
¹ Downgraded one level for risk of bias; the majority of included studies failed to report details of randomisation and allocation concealment. ² Downgraded one level for inconsistency; there was statistically significant heterogeneity.

Summary of findings 3. Walking compared to no intervention by sex for control of blood pressure

Outcomes	Effect with no intervention mmHg	Effect with Walking mmHg		№ of participants (studies)	Certainty of the evidence (GRADE)	Comments

Patient or population: adults with or without hypertension Setting: general population Intervention: walking Comparison: no intervention, by sex
Outcomes	*Anticipated absolute effects^ (95% CI)**			№ of participants (studies)	Certainty of the evidence (GRADE)	Comments
SBP in males	The mean SBP was ‐1.22	MD 4.64 lower (8.69 lower to 0.59 lower)	‐	203 (6 RCTs)	⊕⊕⊝⊝ LOW ^{1 2}	Walking interventions may lower systolic blood pressure in male adults.
SBP in females	The mean SBP was ‐0.48	MD 5.65 lower (7.89 lower to 3.41 lower)	‐	1149 (22 RCTs)	⊕⊕⊝⊝ LOW ^{2 3}	Walking interventions may reduce systolic blood pressure in female adults.
DBP in males	The mean DBP was ‐1.81	MD 2.54 lower (4.84 lower to 0.24 lower)	‐	203 (6 RCTs)	⊕⊕⊕⊝ MODERATE ²	Walking interventions probably reduce diastolic blood pressure in male adults.
DBP in females	The mean DBP was 0.53	MD 2.69 lower (4.16 lower to 1.23 lower)	‐	1000 (20 RCTs)	⊕⊕⊝⊝ LOW ^{2 3}	Walking interventions may reduce diastolic blood pressure in female adults.
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: Confidence interval;
GRADE Working Group grades of evidence High certainty: We are very confident that the true effect lies close to that of the estimate of the effect Moderate certainty: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different Low certainty: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect Very low certainty: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect
¹ Large 95% confidence intervals. ² Downgraded one level for risk of bias; the majority of included studies failed to report details of randomisation and allocation concealment. ³ Downgraded one level for inconsistency; there was statistically significant heterogeneity.

Background

Description of the condition

Hypertension is responsible for approximately nine million deaths worldwide each year (Lim 2012) and an estimated 1.13 billion people globally have hypertension, with two‐thirds living in low‐ and middle‐income countries (WHO 2019). The premature death and disability caused by hypertension can have a considerable financial toll on families, health services, and national finances (WHO 2013). Hypertension is also a risk factor for various health problems, such as myocardial infarction, heart failure, chronic kidney disease, stroke, peripheral artery disease, and atrial fibrillation (Qamar 2018). Epidemiologic studies show that cardiovascular disease (CVD) events, such as coronary heart disease, stroke, and heart failure, are associated with elevated blood pressure levels (Amici 2009; Pini 2008; Rodriguez 2014). Observational studies document a progressive increase in heart disease risk as blood pressure rises above 115/75 mmHg ( Lawes 2008; Lewington 2002). A recent meta‐analysis of prospective cohort studies demonstrates that even just a stage I hypertension (systolic blood pressure (SBP) 130 to 139 mmHg or diastolic blood pressure (DBP) 80 to 89 mmHg) is associated with those CVD events and its morbidity and mortality (Han 2019).

Lowering blood pressure to standard targets has been found to be effective in reducing the risks of coronary artery disease and stroke (Lewington 2002; Staessen 2001; Vargas‐Urocoechea 2019), and effective control of stage 1 hypertension was found to prevent more than 10% of CVD (Han 2019). The report to the Eighth Joint National Committee for Detection, Evaluation, and Treatment of High Blood Pressure (JNC‐8) recommends that individuals achieve a target SBP <140 mmHg and DBP lower than 90 mmHg (James 2014; Lawes 2008; Lewington 2002). SBP is suggested as a better predictor of adverse health events than DBP (Ettehad 2016; Haider 2003).

Hypertension control through pharmacological treatment has led to substantial benefits in the primary prevention of morbidity and mortality from cardiovascular diseases (Ettehad 2016; Law 2009; Li 2019; Musini 2019; Blood Pressure Lowering Treatment Trialists 2000; Blood Pressure Lowering Treatment Trialists 2008; Wright 2018). Given some of the drawbacks to the pharmacological treatment of hypertension, such as discontinuation of the drug treatment due to potential adverse effects and the level of adherence with prescribed medication, non‐pharmacological interventions play an important role in controlling hypertension (Bonilla Ocampo 2018; Hagberg 2000).

There are several non‐modifiable risk factors for hypertension including a family history of hypertension, age over 65 years and co‐existing diseases (e.g. kidney disease and diabetes), but modifiable risk factors for hypertension include use of tobacco and consumption of alcohol, high fat diet, excessive salt consumption, physical inactivity and obesity (WHO 2002; WHO 2019). These modifiable risk factors for hypertension are related to lifestyle.

As hypertension is associated with lifestyle factors, all of the current guidelines highlight the role of non‐pharmacological interventions in hypertension management (James 2014; Whelton 2002; WHO 2003; Williams 2004). When most people with hypertension fall into the categories of high‐normal to stage 1 blood pressure elevations, which are lower than the level at which physicians often begin to prescribe antihypertensive medications (Wang 2004), lifestyle modifications maybe even more important than pharmacological treatment to control blood pressure.

Description of the intervention

Lifestyle physical activity interventions have been recommended as a way of lowering blood pressure and reducing the risk of heart disease (James 2014; Williams 2004). Some randomised controlled trials have provided evidence of the benefits of physical activity on reduction in SBP (Duru 2010; Murphy 2006), however, other studies found no such benefits (Elley 2003; Lawton 2008; Liira 2014). These contradictory data could result from methodological differences in the type of physical activity used in the intervention (frequency, duration, intensity, mode of supervision), target population, or overall study design. In addition, many people may find it difficult to fit physical exercise into their daily lives. Walking is one of the easiest forms of low‐cost physical activity and one which many people can do.

How the intervention might work

Evidence from randomised and non‐randomised trials suggests that walking may lead to improvements in SBP and DBP (Kelley 2001; Lee 2006). Walking, as an everyday activity for most people, is likely to be the most relevant low‐to‐moderate‐intensity activity, and brisk walking is a common and feasible form of sustainable dynamic aerobic exercise (Mabire 2017; Tschentscher 2013). For adults aged 18 and over, walking is the most popular physical activity (Afonso 2001; Australian Bureau of Statistics 2003; National Institutes of Health 1996), and the most common leisure activity among both men and women (Australian Bureau of Statistics 2003; Crespo 1996; Office for National Statistics 2003).

Why it is important to do this review

Results from previous studies examining the effect of walking interventions on blood pressure have been inconsistent. A meta‐analysis of walking programs for blood pressure management found beneficial effects either from various study designs (Kelley 2001); limited in a specific population, such as inactive adults (Oja 2018) or those with type 2 diabetes (Cai 2014); complex interventions, such as combining walking, jogging and/or running (Nieman 2013, Shabaaninia 2017, Sijie 2012); or compared a walking intervention with participants in the control group who also received an intervention, such as active pedometer‐based walking intervention (Vetrovsky 2018) or lifestyle modification, such as health education (Zhang (張舒) 2012) or salt reduction (Subramanian 2011). More evidence from randomised controlled trials in the general population and investigation of the effect of walking alone on blood pressure is needed. The purpose of this review is to examine whether walking is effective in controlling blood pressure.

Objectives

To determine the effect of walking as a physical activity intervention on blood pressure and heart rate.

Methods

Criteria for considering studies for this review

Types of studies

We included individually‐randomised parallel group controlled trials. We excluded cluster‐randomised studies due to the risk of contamination and we did not include cross‐over trials due to possible carry‐over effects of the intervention.

Types of participants

Both hypertensive and normotensive adults aged 16 years and over.

Types of interventions

Walking interventions including community, laboratory‐based (e.g. treadmill), or non‐stair and non‐uphill treadmill walking were included. Mixed interventions of walking with other modes of physical activity, such as jogging, or other forms of lifestyle modification, such as dietary salt reduction, were excluded.

The comparison was non‐exercising and non‐intervention controls.

Types of outcome measures

All outcome measures of: systolic blood pressure (SBP), diastolic blood pressure (DBP) and heart rate (HR) as continuous data.

Primary outcomes

Systolic blood pressure (SBP) (continuous): measured by any standard devices, such as electronic or traditional mercury sphygmomanometer, or 24 hours ambulatory blood pressure measurement in millimetres of mercury (mmHg) pressure units.

Secondary outcomes

Diastolic blood pressure (DBP) (continuous): measured by any standard devices, such as electronic or traditional mercury sphygmomanometer, or 24 hours ambulatory blood pressure measurement in mmHg.
Heart rate (HR) (continuous): measured by any standard devices in beats per minute (bpm).

Search methods for identification of studies

Electronic searches

The Cochrane Hypertension Information Specialist conducted systematic searches in the following databases for randomised controlled trials without language, publication year, or publication status restrictions:

Cochrane Hypertension Specialised Register via the Cochrane Register of Studies (CRS‐Web) (searched 8 March 2020);
Cochrane Central Register of Controlled Trials (CENTRAL) via the Cochrane Register of Studies (CRS‐Web) (2020, Issue 2);
MEDLINE Ovid (from 1946 onwards), MEDLINE Ovid Epub Ahead of Print, and MEDLINE Ovid In‐Process & Other Non‐Indexed Citations (searched 7 March 2020);
Embase Ovid (searched 7 March 2020);
CINAHL EBSCO (searched 9 March 2020);
SPORTDiscus EBSCO (searched 11 March 2020);
PsycINFO EBSCO (searched 9 March 2020);
Physiotherapy Evidence Database (PEDro) (searched 11 March 2020);
ClinicalTrials.gov (www.clinicaltrials.gov) (searched 11 March 2020);
World Health Organization International Clinical Trials Registry Platform (https://apps.who.int/trialsearch) (searched 11 March 2020).

Databases were searched from the date of inception. The Information Specialist modelled subject strategies for databases on the search strategy designed for MEDLINE. Where appropriate, they were combined with subject strategy adaptations of the sensitivity‐ and precision maximising search strategy designed by Cochrane for identifying randomised controlled (as described in Chapter 4 of the Cochrane Handbook for Systematic Reviews of Interventions Version 6 (Lefebrve 2019). We present the search strategies for major databases in Appendix 1.

The review authors also searched the following databases from the date of inception:

Index to Taiwan Periodical Literature System (searched 18 May 2020);
National Digital Library of Theses and Dissertations in Taiwan (searched 18 May 2020);
China National Knowledge Infrastructure (CNKI)‐Journals, Theses & Dissertations (searched 18 May 2020);
Wanfang Medical Online (searched 18 May 2020).

Searching other resources

The Cochrane Hypertension Information Specialist searched the Hypertension Specialised Register segment (which includes searches of MEDLINE and Epistemonikos for systematic reviews) to retrieve existing systematic reviews relevant to this systematic review, so that we could scan their reference lists for additional trials. The Specialised Register also includes searches of CAB Abstracts & Global Health, CINAHL, ProQuest Dissertations & Theses and Web of Knowledge.

We checked the bibliographies of included studies and any relevant systematic reviews identified for further references to relevant trials. Where necessary, we contacted authors of key papers and abstracts to request additional information about their trials. We did not perform a separate search for adverse effects of interventions used for the treatment of hypertension. We considered adverse effects described in the included studies only.

Data collection and analysis

Selection of studies

All titles and abstracts identified through the searches were scanned by two review authors (LLL and HHL) independently for eligibility of inclusion. Abstracts that did not meet all the inclusion criteria were rejected. Any discrepancies were discussed and resolved by a third review author (CM). Full‐text articles for all included titles and abstracts were then retrieved and assessed by two review authors (LLL and HHL) to determine whether they met the inclusion criteria. Uncertainties concerning the appropriateness of studies for inclusion in the review were discussed and resolved through consultation with a third review author (CM). We have produced a PRISMA flow chart (Figure 1) showing how we selected our studies for inclusion in the review.

Figure 1

Data extraction and management

A data extraction form was used to extract data on population, study methods, intervention, and outcomes. Two review authors independently extracted data (CM and LLL; EC and YW) and then compared the data. Any discrepancies were identified and resolved via discussion. We extracted data on study aim, inclusion and exclusion criteria, description of the intervention and control, and outcomes of interest. Special care was taken to avoid the inclusion of multiple reports pertaining to the same individuals, for example in trials reporting outcomes over multiple time periods. Where data were not available in the published trial reports, we contacted authors requesting missing information, and studies were excluded when data were not available.

Assessment of risk of bias in included studies

Using the Cochrane 'Risk of bias' tool (RoB1), two review authors (CM and LLL; EC and YW) independently assessed each study by examining randomisation procedure; allocation concealment; blinding of participants, intervention providers, and outcome assessors; incomplete outcome and losses to follow‐up. Discrepancies were resolved by discussion between the two review authors and, if needed, by consulting a third review author.

Measures of treatment effect

The mean blood pressure and heart rate differences from baseline to follow‐up in the intervention and control groups were compared and pooled using the weighted mean difference (WMD) approach (see Cochrane Collaboration: http://www.epi.bris.ac.uk/cochrane/stats3.html). The appropriateness of conducting meta‐analysis was checked by assessing clinical, methodological, and statistical homogeneity. Where insufficient information about the variance has been provided in trial reports, we calculated variances and took the correlation of baseline and final blood pressure measurements (Follmann 1992) into account. We contacted trial authors to collect the data insufficiently reported in the original trial, such as systolic or diastolic blood pressure readings at either baseline or follow‐up, and trials were excluded when the requested data were not available.

Unit of analysis issues

The unit of analysis was each participant. For studies with more than two arms, we included only arms that met the inclusion criteria of the review.

Dealing with missing data

We addressed the issue of missing data by requesting information from the original study authors. Where such attempts were unsuccessful and data could not be obtained, or estimates had to be derived by making further assumptions, the robustness of the overall findings was assessed through sensitivity analyses.

Assessment of heterogeneity

We used forest plots, Chi² tests, and I²to test for heterogeneity between the results of the studies in the review. We regarded a level of heterogeneity above 50% as substantial or high, as explained in the Cochrane Handbook for Systematic Reviews of Interventions, Section 9.5.2 (Higgins 2011). Where significant heterogeneity existed, explanations were sought for the sources of heterogeneity such as differences in the design or methodological characteristics.

Assessment of reporting biases

The possibility of publication bias was examined using funnel plots. If there was evidence that publication bias did exist, the trim‐and‐fill method (Duval 2000; Peters 2007) was used. This method estimates and adjusts for the numbers and outcomes of studies estimated as being missing and provides a sensitivity analysis to assess the robustness of the results to the likely degree of publication bias in the literature.

Data synthesis

We checked the appropriateness of conducting meta‐analysis by assessing for clinical and design homogeneity and presented the pooled results of SBP and DBP, and heart rate as mean differences (MDs) between groups and 95% Confidence Intervals (CIs). Random‐effects models were used to take account of statistical heterogeneity between combinable studies. We used Cochrane Review Manager 5.4 (RevMan 2014 [Computer program]) for data synthesis.

Subgroup analysis and investigation of heterogeneity

Subgroup analyses according to age and sex were carried out among the studies with sufficient information. Pooled results for SBP and DBP and heart rate were presented as MDs between groups and 95% CIs. Statistical heterogeneity was quantified by I². Random‐effects models were used to allow for statistical heterogeneity present between studies.

Sensitivity analysis

We performed sensitivity analyses to assess the effect of walking on blood pressure in studies we assessed at low risk of overall bias. We also performed a sensitivity analysis for studies assessed at low risk of attrition bias.

Summary of findings and assessment of the certainty of the evidence

We used the GRADE approach (Grading of Recommendations, Assessment, Development and Evaluation) (Guyatt 2011) to assess the certainty of the evidence for each estimate of intervention effect (Schünemann 2019a; Schünemann 2019b). We rated the certainty of the evidence by assessing the 'Risk of bias' evaluation, indirectness of evidence, inconsistency (considering I² and P value), imprecision of effect estimates (95%CI or small size of effect), and potential publication bias. We rated the certainty of the evidence as high, moderate, low or very low. We downgraded the evidence from 'high certainty' by one level for serious limitations or by two levels for very serious study limitations. We present key findings of the review in the 'Summary of findings' tables, including a summary of the amount of data, the magnitude of the effect size and the overall certainty of the evidence.

Results

Description of studies

Results of the search, included and excluded studies are described as follows.

Results of the search

Our initial searches identified 51,195 potentially relevant papers. After the removal of duplicates and initial screening, 7565 records remained. After conducting a further assessment on the basis of title and abstract, we excluded 7166 records and obtained the full text of 399 studies. After screening the full text of these 399 studies, 73 studies remained (Figure 1). Three studies are ongoing and will be considered in updates of this review when needed (Characteristics of ongoing studies).

Included studies

Seventy‐three randomised controlled trials involving 6473 participants met our inclusion criteria and were included in the review. Of the 6473 participants randomised into the 73 trials, 5763 received the eligible intervention and 5060 were analysed. The details of the methods, participants, intervention, comparison group, and outcome measures for each of the included trials are shown in the Characteristics of included studies. Further study details are presented in Table 1. The trials were published over a 30‐year period between 1991 and 2020, with 10 published during the 1990s, 23 during the 2000s, and 40 in 2010 to 2020.

See: Summary of findings 1 Walking compared to no intervention (overall) for control of blood pressure; Summary of findings 2 Walking compared to no intervention by age for control of blood pressure; Summary of findings 3 Walking compared to no intervention by sex for control of blood pressure

Table 1. Baseline characteristics of included studies

Study ID	Participants randomised n	Country	Study population	Mean age (SD) or range	Male/total (%)	Mean baseline SBP (SD)(mmHg)	Mean baseline DBP (SD)(mmHg)	Mean baseline HR (SD)(beats/min)
Araiza 2006	30	USA	type 2 diabetes mellitus, free from advanced secondary complications of diabetes.	Range 33 to 69; IG: 49 (SD 11); CG:51 (SD 10)	NR	IG: 140.6 (SD 21.4); CG: 136.6 (SD 19.3)	IG: 80.7 (SD 12.2); CG: 77.6 (SD 8.9)	NR
Arija 2017	419	Spain	Older primary health‐care patients (attending primary health care facilities)	IG: 64.5 (SD 9.2); CG: 66.99 (SD 10.28)	84/364 (23.2%)	IG: 131.06 (SD 15.94); CG: 135.32 (SD 16.62)	IG: 76.75 (SD 9.09); CG: 75.96 (SD 9.86)	NR
Baker 2008	80	UK	Sedentary general population	Range 18 to 65; IG: 47.3 (SD9.3); CG: 51.2 (SD7.9)	16/79 (20.3%)	IG: 118.2 (SD 17.9); CG: 119.9 (SD 15.9)	IG: 75.1(SD 11.4); CG: 75.5 (SD 11.8)	IG: 68.6 (SD 7.2); CG: 67.9 (SD 8.6)
Bang 2016	60	Korea	General population (Office workers)	IG: 42.22 (SD 11.44); CG: 37.37 (SD 9.32)	3/45 (6.67%)	IG: 121.39 (SD 16.02); CG: 112.52 (SD 12.49)	IG: 79.00 (SD 9.37); CG: 72.85 (SD 9.35)	NR
Baross 2017	24	UK	Sedentary young adults	IG: 20.9 (SD 2.0); CG: 21.3 (SD 2.0)	13 (54%)	IG: 126.7 (SD 3.7); CG: 127.9 (SD 4.2)	IG: 77.7 (SD 3.0); CG: 77.0 (SD 1.8)	IG: 66.0 (SD 3.1); CG: 67.4 (SD 2.7)
Bayat 2018	120	Iran	Woman with Type 2 Diabetes	IG: 53.77 (SD 6.52); CG: 52.06 (SD 6.28)	0 (0%)	IG: 126.04 (SD 16.69), CG: 130.9 (SD 15.64)	IG: 74.9 (SD 10.85); CG: 85.0 (SD 10.0)
Bell 2010	140	Canada	Sedentary general population	Male: 49 (SD 11); Female: 50 (SD 9)	NR	IG: 124 (SD 14); CG: 125 (SD 13)	IG: 78 (SD 9); CG: 80 (SD 9)	IG: 73 (SD 9); CG: 76 (SD 11)
Braith 1994	30	USA	Normotensive elderly adults	Range 60 to 79; IG: 66 (SD 5); CG: 66 (SD 5)	NR	IG: 121 (SD 10); CG: 121 (SD 12)	IG: 72 (SD 8); CG: 74 (SD 5)	IG: 71 (SD 8); CG: 65 (SD 8)
Brandon 2006	52	USA	Obese sedentary adults	(total: 37.93; AAE: 34.0 (SD 7.2); AAC: 36.0 (SD 8.4); WE: 40.5 (SD 7.1); WC: 42.0 (SD 9.7)	0 (0%)	AAE: 110.0 (SD 11.9); AAC: 103.9 (SD 15.6); WE: 111.0 (SD 14.9); WC: 115.0 (SD 18.1)	AAE: 69.7 (SD 8.9); AAC: 63.8 (SD 14.6) WE: 67.0 (SD 10.3); WC: 68.5 (SD 10.2)	NR
Brenner 2020	48	Canada	Patients with vascular problems	IG 68.6 (SD 6.87); CG 63.7 (SD 8.47)	21/33 (63.6%)	IG: 124 (SD 15); CG: 132 (SD 14)	IG: 67 (SD 8); CG: 69 (SD 11)	IG: 63 (SD 12); CG: 66 (SD 13)
Brown 2014	94	UK	General population (Office workers)	IG1: 46.3 (SD 9.4); IG2: 39.3 (SD 10.3); CG: 40.2 (SD 11.0)	74 (78.7%)	IG1: 135.1 (SD 12.3); IG2: 128.9 (SD 15.1); CG: 133.3 (SD 10.5)	IG1: 86.0 (SD 7.6); IG2: 81.5 (SD 11.9); CG: 79.5 (SD 7.1)	IG1: 67.1 (SD 10.0); IG2: 63.6 (SD 10.1); CG: 64.6 (SD 12.5)
Chan 2018	164	Hong Kong	Hypertensive patients	IG: 63.22 (SD 11.11); CG: 65.13 (SD 10.22)	80 (48.8%)	IG: 138.15 (SD17.39); CG: 142.49 (SD19.12)	IG: 79.74 (SD 10.51); CG: 82.59 (SD 10.68)	NR
Chiang 2019	32	Taiwan	College students with obesity	IG1: 19.17 (SD 1.03); IG2: 20.64 (SD 1.80); CG: 19.36 (SD 1.12)	NR	IG1: 121.92 (SD 15.70); IG2: 121.36 (SD 11.48); CG: 127.00 (SD 17.18)	IG1: 76.92 (SD 12.06); IG2: 79.55 (SD 8.85); CG: 74.33 (SD 11.06)	IG1: 75.92 (SD 10.13) IG2: 78.3 (SD 10.02) CG: 79.78 (SD 7.85)
Coghill 2008	67	UK	Hypercholesterolaemic men	Range 45 to 65	67 (100%)	IG: 138.04 (SD 15.61); CG: 140 (SD 15.63)	IG: 89.90 (SD 9.93); CG: 88.32 (SD 9.52)	NR
Cooper 2000	90	UK	Sedentary adults with unmedicated hypertension 150‐180 mmHg	Range 25 to 63; IG: 46.2 (SD 9.4); CG: 49.4 (SD 8.9)	72 (80%)	IG: 139.8 (SD 12.7); CG: 135.7 (SD 9.3)	IG: 89.5 (SD 9.6); CG: 87.6 (SD 8.5)	NR
Dong 2007	120	China	Patients with chronic heart failure	IG: 61.7 (SD 12.3); CG: 61.9 (SD 12.1)	66 (55%)	IG: 149.10 (SD 44.50); CG: 147.2 (SD 44.1)	NR	IG: 104 (SD 25); CG: 105 (SD 21)
Dong 2012	51	China	White coat hypertension patients	Range 45 to 71; IG: 53.75 (SD 16.42); CG: 54.26 (SD 17.18)	29 (56.9%)	IG: 129.51 (SD 25.42); CG: 127.96 (SD 23.13)	IG: 82.09 (SD 17.23); CG: 83.46 (SD 18.52)	NR
Duncan 1991	102	USA	Sedentary pre‐menopausal women	Range 20 to 40	0 (0%)	IG1: 105 (SD 8); IG2: 109 (SD 9); IG3: 108 (SD 6); CG: 108 (SD 8)	IG1: 70 (SD 7); IG2: 74 (SD 8); IG3: 73 (SD 9); CG: 74 (SD 7)	NR
Dureja 2014	10	India	Young adults (post‐graduate students)	Range 19 to 25	10 (100%)	IG: 116 (SD 5.47); CG: 123 (SD 10.36)	IG: 79 (SD 8.94); CG: 82.0 (SD 11.51)	NR
Foulds 2014	90	Canada	General population	Range 20 to 65; total: 44 (SD 13)	21/58 (36.2%)	IG1: 116 (SD 16.11); IG2: 111.22 (SD 11.39); IG3: 108.28 (SD 11.58); IG4: 115.15 (SD 11.31);CG: 114.6 (SD 16.97)	IG1: 75.2 (SD 10.3); IG2: 72.3 (SD 7.14); IG3: 68.2 (SD 9.17); IG4: 74.9 (SD 11);CG: 69.2 (SD 8.6)	NR
Fritz 2013	213	Sweden	Overweight general population, & individuals with IGT or T2DM	Range 45 to 69; total: 60 (SD 5.3)	95 (44.6%)	IG1_NGT: 138 (SD 12.5); IG2_IGT: 141 (SD 14.0); IG3_T2DM: 143 (SD 13.2);CG1_NGT: 137 (SD 15.0); CG2_IGT: 141 (SD 13.0); CG3_T2DM: 144 (SD 12.6)	IG1_NGT: 85 (SD 7.9); IG2_IGT: 84 (SD 7.8); IG3_T2DM: 85 (SD 7.6);CG1_NGT: 84 (SD 8.8); CG2_IGT: 86 (SD 9.4); CG3_T2DM: 83 (SD 7.4)	NR
Geddes 2009	15	USA	Multiple sclerosis adults	IG: Range 40 to 64; CG: Range 22 to 50	3/12 (25%)	NR baseline SBP	NR baseline DBP	NR
Gilson 2007	70	UK	General population (University employees office workers)	Male: 41 (SD 11); Female: 42 (SD 11)	7 (10%)	IG1: 121.7 (SD 17.3); IG2: 119.0 (SD 7.4); CG: 121.6 (SD 9.9)	IG1: 85.6 (SD 12.1); IG2: 85.7 (SD 10); CG: 82.9 (SD 7.3)	NR
Gradidge 2018	132	South Africa	Obese women (university staff)	IG: 44.4 (SD 11.5); CG: 37.4 (SD 8.78)	0 (0%)	IG: 127 (SD 14.7); CG: 122 (SD 15.6)	NR	NR
Hamdorf 1999	49	Australia	Elderly sedentary women	Range 79 to 91; IG: 82.4 (SEM 0.66); CG: 83.1 (SEM 0.69)	0 (0%)	IG: 144.6 (SEM 4.9); CG: 149.3 (SEM 5.1)	IG: 72.6 (SEM 2.2); CG: 77.7 (SEM 2.5)	IG: 74.4 (SEM 2.1) CG: 72.7 (SEM 1.7)
Headley 2017	49	USA	Stage 3 chronic kidney disease adults	IG: 58 (SD 8.0); CG: 57.1 (SD 9.0)	30/46 (65.2%)	IG: 126.4 (SD 17.8); CG: 133.7 (SD 19.2)	IG: 79.5 (SD 10.2); CG: 79.1 (SD 10.7)	IG: 64.3 (SD 8.9); CG: 65.5 (SD 12.3)
Herzig 2014	78	Finland	Impaired fasting glucose/ glucose tolerance adults	IG: 58.1 (SD 9.9); CG: 59.5 (SD 10.8)	18/68 (26.5%)	IG: 138.5 (SD 16.4); CG: 150.4 (SD 20.2)	IG: 83.8 (SD 8.0); CG: 85.4 (SD 9.5)	NR
Higashi 1999b	27	Japan	Essential hypertensive adults	IG: 53 (SD 10); CG: 51 (SD 8)	20 (74%)	IG: 155.0 (SD 6.6); CG: 155.4 (SD 8.3)	IG: 96.0 (SD 4.9); CG: 97.6 (SD 4.3)	IG: 71.8 (SD 9.7); CG: 73.1 (SD 6.4)
Holloway 1997	102	USA	Sedentary middle‐aged	Range 20 to 50	unknown	IG1_XS: 113.6 (SD 9.8); IG2_T: 113.4 (SD 11.1); IG3_S: 116.7 (SD 10.0); CG: 114.5 (SD 12.3)	IG1_XS: 80.0 (SD 7.3); IG2_T: 81.9 (SD 9.1); IG3_S: 83.5 (SD 8.7); CG: 82.7 (SD 6.0)	IG1_XS: 76.4 (SD 9.0) IG2_T:77.0 (SD 8.8) IG3_S: 75.9 (SD 6.3) CG:78.6 (SD 10.1)
Hua 2006	47	Canada	Hypertensive adults	IG‐Male:55.8 (SD 9.5); IG‐Female: 56.3 (SD 9.6) CG‐Male: 55.9 (SD 10.2) CG‐Female:58.5 (SD 11.3)	20/40 (50%)	IG‐Male: 140 (SD 11); IG‐Female: 141 (SD 16); CG‐Male: 142 (SD 15); CG‐Female: 141 (SD 17)	IG‐Male: 92 (SD 7); IG‐Female: 87 (SD 9); CG‐Male: 91 (SD 11); CG‐Female: 88 (SD 9)	IG‐Male: 69 (SD 7); IG‐Female: 75 (SD 12); CG‐Male: 75 (SD 15); CG‐Female: 70 (SD 12)
Karstoft 2013	34	Denmark	Type 2 diabetes adults	IG_CWT: 60.8 (SD 2.2); IG_IWT: 57.5 (SD 2.4); CG: 57.1 (SD 3.0)	20/32 (62.5%)	IG_CWT: 155 (SD 5.4); IG_IWT: 138 (SD 3.3); CG: 142 (SD 4.3)	IG_CWT: 90.0 (SD 1.8); IG_IWT: 85.0 (SD 2.8); CG: 86.6 (SD 3.5)	NR
Khalid 2013	30	Egypt	Hypertensive post‐menopausal women	Range 40 to 50; IG: 52.9 (SD 2.6); CG: 52.7 (SD 2.2)	0 (0%)	IG: 148 (SD 5.6); CG: 154 (SD 6.7)
Koh 2010	43	Australia	Long‐term haemodialysis patients	IG: 52.1 (SD 13.6); CG: 51.3 (SD 14.4)	19/31 (61.3%)	IG: 143 (SD 32) CG: 145 (SD 18)	IG: 78 (SD 16); CG: 80 (SD 9)	IG: 73 (SD 9); CG: 74 (SD 10)
Kukkonen‐Harjula 1998	116	Finland	Healthy middle‐aged adults	Range 30 to 55; IG: 42.1 (SD 5.1); CG: 40.3 (SD 4.5)	55 (47.4%)	IG: 118 (SD 12)	CG: 75 (SD 11)	NR
Kurban 2011	60	Turkey	Type 2 diabetes adults	IG: 53.77 (SD 8.2); CG: 53.57 (SD 6.6)	29 (48%)	IG: 129.17 (SD 12.1); CG: 124.83 (SD 14.59)	IG: 78.83 (SD 6.78); CG: 77.88 (SD 10.53)	NR
Lee 2007	202	Taiwan	Hypertensive adults (mild / moderate)	IG: 71.3 (SD 6.4); CG: 71.3 (SD 5.7)	118 (58.4%)	IG: 152.0 (SD 10.5); CG: 152.4 (SD 11.1)	IG: 83.5 (SD 11.2); CG: 80.6 (SD 8.8)	NR
Li 2018	100	China	University teachers	IG: 42.26 (SD 8.63); CG: 42.39 (SD 8.35)	48/100 (48%) (22+26)	IG: 112.69 (SD 13.74); CG: 118.95 (SD 14.99)	NR	NR
Li 2003	48	USA	Elderly sedentary adults	Range 60 and above; IG: 72 (SD 6.4); CG: 73.3 (SD 7.3)	9/40 (22.5%)	IG: 133.64 (SD 9.68); CG: 132.17 (SD 13.62)	IG: 81.5 (SD 9.41); CG: 81.22 (SD 8.59)	NR
Lin 2000	22	Taiwan	Borderline hypertensive adolescents / students	Range 16 to 18	22 (100%)	IG1: 140 (SD 11.14); IG2: 137.75 (SD 6.69); CG: 145.67 (SD 10.33)	IG1: 92.25 (SD 3.45); IG2: 91.75 (SD 4.06); CG: 93.67 (SD 4.27)	NR
Ming 2018	64	China	Elderly patients with Coronary Heart Disease and Hypertension	IG: 63.18 (SD 5.42); CG: 62.76 (SD 5.54)	40 (62.5%)	IG: 136.79 (SD 7.03); CG: 137.32 (SD 7.44)	IG: 95.88 (SD 4.10); CG: 96.30 (SD 4.52)	IG: 83.18 (SD 8.14); CG: 83.55 (SD 8.09)
Moreau 2001	24	USA	Postmenopausal women with borderline stage 1 hypertension	IG: 53 (SE 2); CG: 55 (SE 1)	0 (0%)	IG: 142 (SE 3); CG: 142 (SE 3)	IG: 84 (SE 1); CG: 86 (SE 2)	IG: 77 (SE 3); CG: 77 (SE 3)
Murphy 1998	47	UK	Sedentary middle‐aged women	IG1: 44.8 (SD 8.4); IG2: 48.0 (SD 5.5); CG: 47.3 (SD 4.1)	0 (0%)	IG1_short bout: 125.5 (SD10.8); IG2_long bout: 124.2 (SD11.1); CG: 128.6 (SD13.3)	NR	NR
Murphy 2006	37	UK	Sedentary general population (civil servants)	IG: 41.4 (SD 7.5); CG: 40.8 (SD 10.0)	13 (35%)	IG: 120.4 (SD 19.7); CG: 116.5 (SD 1 3)	IG: 77.2 (SD 9.4); CG: 74.6 (SD 9.0)	NR
Murtagh 2005	48	UK	Sedentary general population (university staff/students)	45.7 (SD 9.4)	17 (35%)	IG1_single bout: 117.9 (SD 12.0); IG2_accumulated bout: 121.7 (SD 11.2); CG: 117.5 (SD 18.1)	IG1_single bout: 74 (SD 9.8) IG2_accumulated bout: 75.4 (SD 6.6); CG: 73.1 (SD 10.6)	NR
Nemoto 2007	246	Japan	General population adults	Range 44 to 78; 63 (SD 6)	60 (24%)	W_cnt_male: 141 (SE 2); W_cnt_female: 135 (SE 3); W_int_male: 146 (SE 2); W_int_female: 140 (SE 3); CG_male: 143 (SE 2); CG_female: 142 (SE 3)	W_cnt_male: 85 (SE 2); W_cnt_female: 81 (SE 2); W_int_male: 87 (SE 3); W_int_female; 85 (SE 2); CG_male: 84 (SE 2); CG_female: 83 (SE 2)	W_cnt_male: 81 (SE 3); W_cnt_female: 78 (SE 1); W_int_male: 75 (SE 3); W_int_female; 81 (SE 2); CG_male: 80 (SE 3); CG_female: 79 (SE 1)
Neumann 2006	25	USA	Older adults with Silent Myocardial Ischaemia	Range 56 to 83; IG: 71 (SE 2); CG: 63 (SE 2)	17 (68%)	IG: 134 (SE 3); CG: 140 (SE 6)	IG: 76 (SE 3); CG: 80 (SE 2);	IG: 71 (SE 3); CG: 71 (SE 3)
Pagonas 2014	72	Germany	Hypertensive outpatients	IG: Range 42 to 79CG: Range 43 to 77	31 (43.1%)	IG: 137.9 (SD 12.3); CG: 133.1 (SD 12.1)	IG: 78.1 (SD 8.9); CG: 73.8 (SD 6.4)	NR
Palmer 1995b	27	USA	Sedentary middle‐aged premenopausal women	Range 29 to 50; 37.4	0 (0%)	IG: 117.1 (SD 14); CG: 122.6 (SD 13.8)	IG: 80.9 (SD 10.6); CG: 77.6 (SD 11.2)	IG: 74 (SD 10.8); CG: 71 (SD 6.5)
Pernar 2017	41	Sweden	Prostate cancer patients	Range 54.5 to 81.7	41 (100%)	IG: 170; CG: 162	IG: 93; CG: 89	NR
Pospieszna 2017	39	Poland	Postmenopausal women (healthy volunteers)	Range 52 to 72; IG: 62 (SD 3.79); CG: 62 (SD 1.12)	0 (0%)	IG: 134.7 (SD 21.23); CG: 132.16 (SD 3.8)	IG: 75.8 (SD 7.06); CG: 78.58 (SD 1.96)	NR
Ready 1996	79	Canada	Sedentary postmenopausal women	Range 50 and above; 61.3 (SD 5.8)	0 (0%)	IG1_3D: 134 (SD 18); IG2_5D: 131 (SD 20); CG: 131 (SD 16)	IG1_3D: 77 (SD 11); IG2_5D: 76 (SD 9) CG: 77 (SD 10)	NR
Romero 2019	55	USA	Sedentary elderly female	Range 60 to 75	0 (0%)	IG: 143.67 (SD 21.91); CG: 146.07 (SD 24.18)	IG: 84.41 (SD 15.19); CG: 82.96 (SD 10.29)	NR
Sakuragi 2006	20	Japan	Sedentary general population (female college students)	Range 20 to 22; IG: 19.4 (SD 1.4); CG: 20.1 (SD 1.2)	0 (0%)	IG：93.324(SD17.55);CG：100.13(SD18.09)	IG：43.779(SD14.18);CG：50.054(SD11.72)	Figure 2
Salesi 2014	32	Iran	Elderly women	Range 50 to 55	0 (0%)	IG: 136.0 (SD 12.1); CG: 131.1 (SD 8.7)	IG: 83.1 (SD 10.1); CG: 80.3 (SD 3.8)	NR
Saptharishi 2009	58	India	Confirmed hypertensive / pre‐hypertensive patients	IG: 22.4 (SD 1.3); CG: 22.5 (SD 1.4)	39 (67.2%)	IG: 128.6 (SD 7.7); CG: 123.1 (SD 10.2)	IG: 87.4 (SD 4.8); CG: 82.9 (SD 7.1)	NR
Serwe 2011	60	USA	Sedentary office women	Range 18 to 50; IG1: 37.1 (SD 7.2); IG2: 38.2 (SD 7.3); CG: 36.3 (SD 8.1)	0 (0%)	IG1: 115.1 (SD 10.5); IG2: 117.7 (SD 12.1); CG: 120.9 (SD 9.2)	IG1: 73.4 (SD 8.1); IG2: 73.2 (SD 8.7); CG: 72.7 (SD 7.2)	IG1: 68.4 (SD 10.4); IG2: 65.8 (SD 6.0); CG: 72.7 (SD 9.5)
Shenoy 2010	40	India	T2DM patients	Range 40 to 70; IG: 53.15 (SD 4.4); CG: 51 (SD 5.4)	29 (73%)	IG: 122 (SD 13.8); CG: 131 (SD 12.7)	IG: 85.6 (SD 16.1); CG: 86.0 (SD 7.2)	IG: 82.7 (SD 10.6); CG: 81.0 (SD9.7)
Stanton 1996	102	New Zealand	Sedentary, essential hypertension volunteers	IG: 55.2 (SE 1.4); CG:53.8 (SE 1.5)	42/89 (47.2%)	IG: 142.9 (SE 2.5); CG: 145.3 (SE 2.6)	IG: 88.4 (SE 1.4); CG: 94.0 (SE 1.4)	NR
Stutzman 2010	25	Canada	Sedentary normal & overweight 20 weeks pregnant women	IG_normal weight: 30.4 (SD 4.2); IG_overweight: 28.8 (SD 6.9); CG_normal weight: 25.8 (SD 3.0); CG_overweight: 26.2 (SD 5.6)	0 (0%)	IG_normal weight: 111 (SD 12); IG_overweight: 114 (SD 14); CG_normal weight: 109 (SD 7); CG_overweight: 107 (SD 8)	IG_normal weight: 76 (SD 11); IG_overweight: 75 (SD 10); CG_normal weight: 74 (SD 4); CG_overweight: 72 (SD 4)	NR
Tudor‐Locke 2004	60	Canada	Sedentary overweight T2DM patients	Range 40 to 60; total: 52.7 (SD 5.2); IG: 52.8 (SD 5.7) CG: 52.5 (SD 4.8)	26/47 (55.3%)	IG: 138.2 (SD 17.2); CG: 130.1 (SD 15.9);	IG: 81.5 (SD 9.5); CG: 78.9 (SD 8.0)	IG: 76.4 (SD 11.8) CG: 77.0 (SD 9.7)
Tudor‐Locke 2020	120	USA	Sedentary overweight/obese and postmenopausal women	Range 45 to 75; IG1: 62.6 (SD 6.5); IG2: 61.7 (SD 6.2); CG: 58.4 (SD 5.8)	0 (0%)	IG1: 127.6 (SD 16.6); IG2: 125.2 (SD 12.7); CG: 122.5 (SD 13.9)	IG1: 78.7 (SD 8.0); IG2: 75.5 (SD 7.6); CG: 77.3 (SD 7.3)	NR
Tully 2005	31	UK	Sedentary middle‐aged adults	Range 50 to 65; IG: 55.52 (SD 3.99); CG: 57.75 (SD 4.64)	13 (42%)	IG: 129.94 (SD 8.61); CG: 125.78 (SD 14.02)	IG: 78.47 (SD 4.16); CG: 77.22 (SD 7.74)	NR
Tully 2007a	106	UK	Sedentary middle‐aged adults (civil servants)	Range 40 to 61; IG1_3D: 47.8 (SD 5.97); IG2_5D: 46.37 (SD 4.76); CG: 49.05 (SD 6.31)	42 (39.6%)	IG1_3‐Day: 134 (SD 15); IG2_5‐Day: 133 (SD 15); CG: 128 (SD 15)	IG1_3‐Day: 87 (SD 11); IG2_5‐Day: 87 (SD 11); CG: 83 (SD 10)	IG1_3‐Day: 69 (SD 12); IG2_5‐Day: 72 (SD 10); CG: 75 (SD 11)
Tully 2011	12	UK	Sedentary university students	21.16 (SD 6.17)	2 (16.7%)	IG: 120 (SD 15.62); CG: 131.67 (SD 11.85)	IG: 79.00 (SD 8.23); CG: 86.33 (SD 8.50)	NR
Venturelli 2011	24	Italy	Late stage Alzheimer's disease patients	Range 65 and above; IG: 83 (SD 6); CG: 85 (SD 5);	0 (0%)	IG: 132 (SD 10); CG: 133 (SD 6)	IG: 84 (SD 5); CG: 84 (SD 3)	NR
Wallis 2017	46	Australia	Severe OA patients rated as grade III or IV affecting at least one of the tibiofemoral compartments	Range 50 to 84; IG: 68 (SD 8); CG: 67 (SD 7)	26 (56.5%)	IG: 142 (SD 10); CG: 138 (SD 24)	IG: 82 (SD 10); CG: 81 (SD 11.1)	NR
Wang (王正斌) 2014	62	China	Patients with hypertension and Diabetes Mellitus	Range 40 to 70; IG: 55.8 (SD 9.3); CG: 57.4 (SD 8.9)	39 (62.9%)	IG: 143 (SD 11); CG: 141 (SD 14)	IG: 81 (SD 11); CG: 88 (SD 9)	NR
Wang 2014	53	Taiwan	Sedentary postmenopausal women	Range 45 to 70; IG: 56.9 (SD 6.2) CG: 55.1 (SD 7.8)	0 (0%)	IG: 124.6 (S D9.2); CG: 127 (SD 10.1)	IG: 76.8 (SD 8.1) CG: 79 (SD 9.4)	NR
Wang 2016	61	China	Hypertensive coal miners	Range 18 to 64; IG: 49.61 (SD 4.91); CG: 48.50 (SD 6.31)	31/48 (64.6%)	IG: 134.83 (SD 17.43); CG: 143.97 (SD 20.91)	IG: 82.39 (SD 12.94); CG: 87.63 (SD 10.48)	NR
Westhoff 2007	54	Germany	Sedentary Isolated Systolic Hypertension elderly patient	Range 60 and above; IG: 67.2 (SD 4.8); CG: 68.9 (SD 5.2)	26 (48.1%)	IG: 136.6 (SD 12.7); CG: 134.8 (SD 11)	IG: 76.3 (SD 7.3); CG: 72.8 (SD 7.2)	Figure 2
Xiao 2010	124	China	Elderly Type 2 Diabetes Mellitus patients	IG: 65.84 (SD 6.32); CG 65.82 (SD 6.39)	36/112 (32.1%)	IG: 141.82 (SD 16.23); CG 141.05 (SD 20.06)	IG: 82.91 (SD 9.94); CG 84.04 (SD 10.15)	NR
Yan 2010	418	China	Patients with Congestive Heart Failure	IG: 61.2 (SD 11.8); CG: 62.5 (SD 11.6)	261 (62.4%)	IG: 123.1 (SD 21.9); CG: 125.6 (SD 20.2)	IG: 68.6 (SD 10.8); CG: 68.5 (SD 10.6)	IG: 74.2 (SD 15.7) CG: 77.1 (SD 15.2)
Yu 2018	231	China	Elderly patients with Isolated Systolic Hypertension	IG1: 82.96 (SD 2.06); IG2: 83.01 (SD 2.09); CG: 83.44 (SD 1.99)	139/211 (65.9%)	IG1: 141.67 (SD 5.95); IG2: 140.87 (SD 6.45); CG: 141.94 (SD 5.22)	IG1: 63.2 (SD 3.59); IG2: 62.36 (SD 2.84); CG: 63.43 (SD 3.11)	NR

CG: control group; CWT: continuous walking training; IG: intervention group; IGT: impaired glucose tolerance; IWT: intermittent walking training; NGT: normal glucose tolerance; NR: not reported; OA: Osteoarthritis; SD: standard deviation; SE: standard error; T2DM: type 2 diabetes mellitus; W_cnt : moderate‐intensity continuous walking training group; W_int : high‐intensity interval walking training group

Study and participant characteristics

The mean age of participants ranged from 16 to 84 years; and there were approximately 1.5 times as many female participants as male ones (3122 versus 2075). Among the trials that reported data about sex, the majority recruited both male and female participants (n = 49 trials), 20 recruited only women and four only men. Hua 2006 and Nemoto 2007 recruited both male and female participants and provided outcome data for each. Sample sizes ranged from 10 to 396. The majority of the trials were conducted in the USA (n = 14) and the UK (n = 12); with nine in China; seven in Canada; four in Taiwan; three each in Australia, India, and Japan; two each in Finland, Germany, Iran, and Sweden; and one each in Denmark, Egypt, Iran, Italy, Korea, Poland, New Zealand, Poland, Spain, and Turkey (Table 1). Among the 73 trials included in the current review, nearly one quarter (n = 17, 23%) reported that they recruited hypertensive participants, while 15 reported that they recruited non‐hypertensive participants (21%).

Interventions and comparators

Among the trials that clearly stated the setting of their interventions (n = 71), the walking interventions were mainly carried out at home/in the community (n = 50) (such as indoor or outdoor walking, nature/city/campus walking, or daily walking), or in the laboratory with the treadmill or stepper (n = 16). There was a total of 36 trials conducting supervised walking programs among the 47 trials reported the information of supervision. The prescription of walking interventions varied widely in the 73 included trials, and included treadmill walking (n = 18), outdoor walking (n = 17), brisk walking (n = 16), and Nordic walking (n = 6). Participants in the control groups received no intervention. In order to be able to compare the length of time of each intervention, we decided to present the time of the intervention in weeks and thus when the length of the intervention was presented as months, we calculated months into weeks using the following formula: number of months*4.33 weeks. On the basis of this calculation, the intervention length ranged from four to 64 weeks, including 12 to 13 weeks in 26 trials and 24 to 26 weeks in 13 trials. Moreau 2001 conducted two outcome measures at both 12 and 24 weeks, respectively and Chan 2018 conducted three at three, six, and nine months, respectively, and we conservatively used the data obtained at the shortest intervention length, which is 12 weeks (three months). The average length of the intervention among all studies was 15 weeks. In terms of frequency and duration of walking, most trials prescribed walking three to five sessions per week and 20 to 40 minutes per session. Among the 77 walking intervention groups that clearly stated the prescription for weekly walking frequency and duration of walking per session, the walking time per week ranged widely from 10 to 845 minutes. The average walking duration per week was 153 minutes (range 150 to 180) prescribed by 22 studies. The second and third most frequently prescribed duration were a walking duration of 90 to 100 minutes per week prescribed by 13 studies and 120 to 149 minutes prescribed by 12 studies.

Among the walking groups that provided information for classifying measures of the walking intensity, 27 intervention groups used maximum heart rate (in the form of either a percentage or calculated heart rate); 24 each reported a walking intensity as VO2max (in the form of either a percentage or calculated VO2max) and walking distance per hour (e.g. 6.5km/hour), per day (e.g. 3 km/day) or per second (e.g. 1.6 to 1.8 metres/second), respectively. Fourteen studies reported the ratings of perceived exertion using the Borg Scale of Perceived Exertion (Borg 1982), and eight used the percentage of heart rate reserve. Of these, 14 walking group intensities were measured using mixed methods, such as walking distance per hour plus the percentage of the maximum heart rate. The intensity of walking varied from minor to high and the majority of the walking groups were moderate intensity (n = 62), with 13 low intensity, 11 self‐paced, and five high intensity.

Funding sources

More than one‐third of the trials included in the current review failed to report their funding sources (n = 32) and studies that clearly reported the funding support received funding from governments (n = 24), private sector (n = 11), both (n = 3), or were self‐funded (n = 3).

Excluded studies

The reasons for study exclusion are mainly due to non randomisation, not just walking but multiple interventions, intervention control groups, or the unavailability of outcome data (see Characteristics of excluded studies).

Risk of bias in included studies

We have summarised our judgments of the risks of bias in Figure 2 and Figure 3. Full details of our judgments of risk of bias are presented in Characteristics of included studies tables.

Figure 2

'Risk of bias' graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

Figure 3

'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study.

Allocation

Random sequence generation

Of the 73 included studies, 27 described a method of random sequence generation that we judged to be at low risk of bias. In most studies, researchers used a computerised random number generator. We judged 45 studies to be at unclear risk of random sequence generation due to insufficient information available to make a judgment. We judged one study (Nemoto 2007) to be a high risk of bias because there were reassignments after randomisation and it was not defined how many participants were reassigned.

Allocation concealment

Only 13 studies described a method of allocation concealment that we judged to be at low risk of bias. For the majority of studies (n = 59), we were unable to judge the risk of allocation bias as these studies failed to report sufficient information on which to make a judgment. We judged one study (Nemoto 2007) to be a high risk of allocation bias because some participants were moved from their allocated group to be in the same group as their partner or to a more convenient administrative centre.

Blinding

Blinding of participants and personnel

Given the nature of the intervention, it was difficult to blind participants and personnel and thus we judged 42 of the 73 included to be at high risk of performance bias. We judged five studies to be at low risk of performance bias. The authors for the remaining 26 studies failed to provide sufficient information regarding blinding of participants and personnel and we, therefore, judged these studies to be at unclear risk of performance bias.

Blinding of outcomes assessors

Fifty‐two studies failed to report information on the blinding of outcomes assessors and therefore we judged the risk of detection bias to be unclear. Blinding of outcome assessment was deemed appropriate in 19 trials and we judged these trials to be at low risk of bias for this domain. We judged the remaining two trials (Cooper 2000; Koh 2010) to be at high risk of detection bias as both authors clearly stated that outcome assessors were not blinded to group assignment.

Incomplete outcome data

The majority of the included studies provided information regarding withdrawals or losses to follow‐up (n = 64). Among the studies that provided sufficient information, the dropout rate varied substantially from 0 to 37% in the 73 included studies. We judged 21 studies to have a high risk of bias due to incomplete outcome data, i.e. the dropout rate was equal to or greater than 20%. There are 45 studies using per‐protocol (PP) analysis, 17 studies using intention‐to‐treat (ITT), and two studies reported both ITT and PP. In addition, there are three studies that performed more than one randomisation in their trial (Nemoto 2007; Neumann 2006; Stutzman 2010). In Karstoft 2013, a total of three randomisations was carried out and there were five participants entering the trial twice firstly into the control and then into the intervention group.

Selective reporting

We judged all 73 included studies to be at low risk of selective reporting bias because they either reported the data of the primary outcome and/or secondary outcomes in the published paper or provided the outcome data we needed when we contacted them. Ten studies were prospectively registered with a clinical trial registry, and therefore the majority of studies (n = 63) were not.

Other potential sources of bias

In the study by Brenner 2020, participants in both the intervention and control groups received follow‐up phone calls after the first week of the program, and at two‐week intervals during the 12‐week intervention period. Also, in the study by Chan 2018, the participants in all trial arms were encouraged or invited to participate in weekly non‐exercised based community socialisation activities during the three‐month intervention period (Chan 2018). For both studies, these activities are likely to have highlighted the issue regarding the importance of lifestyle modification and thus may have resulted in contamination of the control group participants. This may lead to a dilution in any observed difference between the intervention and control groups in both studies.

To check for publication bias, we produced a funnel plot using the mean difference (MD) for the effects of walking on SBP and DBP against the standard error (SE). An inspection of the two funnel plots shows symmetrical plots, with the effect estimate equally distributed around the mean (Figure 4; Figure 5). This suggests that publication bias is not an issue for this review.

Figure 4

Funnel plot of comparison: 1 Walking versus non‐intervention control (overall), outcome: 1.1 systolic blood pressure [mmHg].

Figure 5

Funnel plot of comparison: 1 Walking versus non‐intervention control (overall), outcome: 1.2 diastolic blood pressure [mmHg].

Effects of interventions

See summary of findings Table 1; summary of findings Table 2; summary of findings Table 3.

Primary outcome

Overall, we found that walking reduced systolic blood pressure (SBP) compared to the non‐intervention control groups (mean difference (MD) ‐4.11 mmHg, 95% confidence interval (CI) ‐5.22 to ‐3.01, P < 0.00001, I² = 53%) on the basis of 73 trials, 5060 participants (Analysis 1.1). The funnel plot for SBP did not show serious small‐study bias (Figure 4). Using GRADE to assess the certainty of the evidence, we downgraded the evidence by one level for inconsistency because there was significant heterogeneity (moderate‐certainty evidence). We did not downgrade one level for risk of bias even though more than half of the included studies failed to report details of randomisation and allocation concealment. This is because a sensitivity analysis based on trials judged as being at low risk of overall bias showed a reduction of SBP (MD ‐4.31 mmHg, 95% CI ‐7.99 to ‐0.63, P = 0.49, I² = 0%).

Our analyses showed that walking statistically and significantly lowered SBP in participants in all three age groups. Thus, when comparing participants who received the intervention with those in the control groups, participants aged 40 years and under showed a MD of ‐4.41 mmHg (95% CI ‐6.17 to ‐2.65, P < 0.00001, I² = 0%; 14 studies, n = 491), participants aged 41 to 60 years showed a MD of ‐3.79 mmHg (95% CI ‐5.64 to ‐1.94, P < 0.001, I² = 61%; 35 studies, n = 1959), and those aged 60 years of over showed a MD of ‐4.30 mmHg (95% CI ‐6.17 to ‐2.44, P < 0.001, I² = 60%; 24 studies; n= 2610) (Analysis 2.1). We graded the evidence in the age group of less than or equal to 40 years as moderate due to the concern of risk of bias as the majority of included studies failed to report details of randomisation and allocation concealment; we graded the certainty of the evidence as low in the age groups of 41 to 60 and over 61 due to the two concerns of risk of bias when the majority of included studies failed to report details of randomisation and allocation concealment, and inconsistency when there was statistically significant heterogeneity.

Regarding sex, the outcome data of the subgroup analysis showed that walking interventions statistically lowered SBP in both females (MD ‐5.65 mmHg, 95% CI ‐7.89 to ‐3.41, P < 0.00001, I² = 44%; 22 studies, n = 1149) and males (MD ‐4.64 mmHg, 95% CI ‐8.69 to ‐0.59, P = 0.02, I² = 29%; 6 studies, n = 203) (Analysis 3.1). We graded the evidence for males and females with low certainty as there were risks of bias, imprecision (large 95% confidence interval), and inconsistency, i.e. significant heterogeneity.

Regarding intervention characteristics, when we consider only the trials with a statistically significant reduction in SBP in the current review, the average walking duration per week (mean = 151 minutes/week. range: 60 to 220 minutes) was similar to the walking duration per week in the trials with negative results (mean = 157 minutes/week. range: 10 to 845 minutes). In terms of intensity of walking, moderate walking is the major prescription (n = 14 intervention groups) in the trial with a significant reduction in SBP, five were self‐paced; one each was high and low intensity.

Secondary outcomes

see summary of findings Table 1; summary of findings Table 2; summary of findings Table 3

Overall, compared to the non‐intervention control group, we found that walking reduced both diastolic blood pressure (DBP) (MD ‐1.79 mmHg, 95% CI ‐2.51 to ‐1.07, P < 0.00001, I² = 53%; 69 studies, n = 4711) (Analysis 1.2) and heart rate (HR) (MD ‐2.76 bpm, 95% CI ‐4.57 to ‐0.95, P = 0.003, I² = 65%; 26 studies, n = 1747) (Analysis 1.3). We graded the evidence for changes in DBP and HR as low certainty as there were concerns of both inconsistency (statistically significant heterogeneity) and risk of bias as more than half of included studies failed to report details of randomisation and allocation concealment.

We found that walking reduced DBP according to subgroup analyses for all three age groups. Our analysis for study participants aged 60 years and over showed an MD of ‐1.33 mmHg (95% CI ‐2.40 to ‐0.26; 23 studies, n = 2490) while our analysis of participants in the age group 41 to 60 years showed an MD of ‐1.74 mmHg (95% CI ‐2.95 to ‐0.52; 32 studies, n = 1730), and participants aged 40 years and under showed a MD of ‐3.01 mmHg (95% CI ‐4.44 to ‐1.58; 14 studies, n = 491) (Analysis 2.2). While these reductions in DBP were statistically significant, the reduction in DBP for each age group was smaller than that seen for reductions in SBP for the corresponding age groups. We graded the certainty of evidence for the analysis for participants aged 40 years and under as moderate because we downgraded one level for risk of bias as the majority of included studies failed to report details of randomisation and allocation concealment. For the analyses of DBP and participants aged 41 to 60 years and 60 years and over we graded the evidence as low because we downgraded one level for risk of bias as the majority of included studies failed to report details of randomisation and allocation concealment and we downgraded one level for inconsistency.

As with SBP, we found that walking reduced DBP for both males and females, however, the reductions in DBP were not as great as those seen in SBP. Thus, walking interventions saw a statistically significant reduction in DBP among females (MD ‐2.69 mmHg, 95% CI ‐4.16 to ‐1.23, P = 0.0003, I² = 43%; 20 studies, n = 1000) and males (MD ‐2.54 mmHg, 95% CI ‐4.84 to ‐0.24, P = 0.03, I² = 0%; 6 studies, n = 203) when compared to females and males in control groups (Analysis 3.2). We graded the evidence for DBP and men as moderate; we downgraded the evidence one level for risk of bias due to the majority of included studies failing to report details of randomisation and allocation concealment. We graded the evidence for DBP and women as low; we downgraded the evidence one level for risk of bias due to the majority of included studies failing to report details of randomisation and allocation concealment and one level for inconsistency as there was statistically significant heterogeneity.

We found that walking significantly reduced the HR of participants in the walking groups compared to those in control groups (‐2.76 bpm, 95% CI ‐4.57 to ‐0.95, P < 0.001, I² = 65%).

Sensitivity analyses

Sensitivity analyses were undertaken to assess the effect of walking in high‐quality studies only, where high‐quality studies were defined as those with a low risk of overall bias. Only four studies met our definition of low risk of bias (Baker 2008; Stanton 1996; Venturelli 2011; Wallis 2017). Walking was still found to be effective in lowering SBP by a statistically significant mean of 4.31 mmHg (95% CI ‐7.99 to ‐0.63, P = 0.02, I² = 0%; 4 studies, n = 235) (Analysis 4.1), but did not significantly lower DBP (MD ‐0.43 mmHg, 95% CI ‐2.78 to 1.92, P = 0.72, I² = 18%) (Analysis 4.2).

A sensitivity analysis was also performed to evaluate the effect of the walking interventions in 41 studies (n = 3480) with a low risk of attrition bias. Walking was found to lower SBP by a mean of 4.67 mmHg (95% CI: ‐6.25 to ‐3.09, P < 0.001, I² = 65%) (Analysis 5.1) and significantly lower DBP by a mean of 2.23 mmHg (95% CI ‐3.20 to ‐1.26, P < 0.001, I² = 64%) (Analysis 5.2).

Adverse events

Of the 73 included trials, only 21 reported adverse events. Of this 21, 16 reported no adverse events and a total of eight events was reported by the remaining five studies with Kukkonen‐Harjula 1998 reporting two events (one participant with a stress fracture and another one with a knee injury); Li 2003 reporting one participant with a bruised foot; Tudor‐Locke 2020 reporting one participant with knee pain; Wallis 2017 reporting two participants with knee pain and one participant who tripped; and Westhoff 2007 reporting one participant with knee pain and two participants with events considered unrelated to the intervention, namely, acute cholecystitis and a change in medication. Thus, while few studies specifically reported adverse events, knee pain seemed to be the most common adverse event. (see Characteristics of included studies). Several studies reported incidences that occurred during the intervention period. Brenner 2020 reported that two participants dropped out due to hip fracture; one dropped out from the study by Chan 2018 due to health problems, 60 dropped out of the Yan (嚴華) 2010a study due to hospitalisation, and several participants were reported as injured in the studies by Baker 2008 and Karstoft 2013.

Additional analyses

Sample size may impact trial outcomes at different levels. We examined the impact of the study sample size on the effects of walking on blood pressure in the current review. We undertook a post hoc subgroup analysis that entailed comparing studies having a sample size greater than 30 participants with studies having a sample size equal to or less than 30 for the outcomes of SBP and DBP. The analyses showed a statistically significant reduction in SBP in both sample sizes. The group with a study sample size of less than or equal to 30 saw a mean reduction in SBP of 7.06 mmHg (95% CI ‐9.47 to ‐4.66, P < 0.00001, I² = 35%), while the group with trial sample sizes over 30 showed a smaller mean reduction of 3.48 mmHg (95% CI ‐4.69 to ‐2.27, P < 0.00001, I² = 54%) (Analysis 6.1). Similarly, the analyses showed a statistically significant reduction in DBP in both sample sizes. The group with a study sample size of less than or equal to 30 saw a mean reduction in DBP of 2.92 mmHg (95% CI ‐5.02 to ‐0.82, P = 0.006, I² = 61%) while the group with trial sample sizes over 30 showed a smaller mean reduction of 1.57 mmHg (95% CI ‐2.32 to ‐0.82, P < 0.0001, I² = 50%) (Analysis 6.2).

We carried out subgroup analyses using baseline SBP and DBP to classify participants into two sets of comparison groups, one is normotensives compared to high normal and hypertensive participants and the other is normotensives compared to hypertensives only. The classification was based on two current hypertension guidelines, American Heart Association (Unger 2020) and European Society of Cardiology (Williams 2018), which defined SBP as normotensives <130 mmHg, high normal ≥130 mmHg, and hypertension ≥140 mmHg; DBP as normotensives <85 mmHg, high normal ≥85 mmHg, and hypertension ≥90 mmHg. Geddes 2009 did not provide baseline SBP and DBP data for us to be able to carry out the classification and therefore was not included in these subgroup analyses.

We found a similar magnitude of walking effect on both normotensive SBP compared to either higher than high normal (MD ‐4.14 mmHg, 95% CI ‐5.28 to ‐3.00, P = 0.45; 72 studies, n = 5048, Analysis 7.1) or higher than hypertensive (MD ‐4.24 mmHg, 95% CI ‐5.52 to ‐2.97, P = 0.29; 54 studies, n = 3630, Analysis 8.1). This is similar when compared normotensive to higher than high normal DBP (MD ‐4.06 mmHg, 95% CI ‐5.24 to ‐2.88, P = 0.65; 68 studies, n = 4699, Analysis 7.2), and compared to higher than hypertensive DBP (MD ‐4.39 mmHg, 95% CI ‐5.67 to ‐3.10, P = 0.03; 60 studies, n = 4223, Analysis 8.2). There was a similar reduction between the two DBP subgroup analyses (‐4.39 versus ‐4.24) but the reduction in DBP comparing normotensive with higher than hypertensive was a statistically significant difference. Additionally, there was significant heterogeneity between the subgroups of normotensive and higher than hypertensive DBP (Chi² = 4.50, df = 1, P = 0.03, I² = 77.8%, n = 4223, Analysis 8.2), but not in other subgroup analyses to this purpose.

We carried out further statistical analyses to test the association between baseline and change SBP and so for DBP. The association is weak (SBP: r= ‐0.142; DBP: r= ‐0.285) and not statistically significant in the association of baseline and change SBP (P = 0.23) but statistically significant in DBP (P = 0.02).

Discussion

Summary of main results

Our review aimed to determine the effect of a walking intervention on blood pressure. We included 73 randomised controlled trials in the meta‐analysis and revealed that walking alone can lower both systolic and diastolic blood pressure (SBP/DBP) statistically and clinically, regardless of age, sex, or baseline blood pressure. We also found that the effect of walking on lowering blood pressure exists after undertaking sensitivity analyses with just high‐quality studies or those not at risk of attrition bias. Among the four high‐quality studies, which were defined as no risk of biases regarding allocation, performance, attrition, and measurement, our findings suggest that walking can lower SBP by 4.31 mmHg (P = 0.02), but less likely to effectively lower DBP (WMD = ‐0.43, P = 0.71). The effect of walking on lowering blood pressure is also evidenced even when we omitted the studies with a dropout rate greater than 20%. It was found that a walking intervention could significantly lower SBP by 4.67 mmHg (P < 0.00001) and DBP by 2.23 mmHg (P < 0.00001).

Previous research has shown that a reduction in blood pressure is associated with the management of the mortality of the cardiovascular disease. Lowering SBP by 2 mmHg of SBP is related to approximately a 10% decrease in stroke mortality and a 7% decrease in mortality from vascular risks in adults (Lewington 2002). A more recent paper by Ettehad 2016 showed that a reduction in SBP of 10 mmHg reduced the risk of major cardiovascular disease (CVD) events by 20%, coronary heart disease (CHD) by 17%, stroke by 27% and all‐cause mortality by 13%. Our review found that walking interventions could lower SBP from 3.01 to 5.22 mmHg (MD ‐4.11) and DBP from 1.07 to 2.51 (MD ‐1.79), which were of greater magnitude than the reduction of 2 mmHg SBP and could be considered clinically significant. These small reductions in blood pressure are similar to those reported by previous systematic reviews which investigated interventions of walking among the younger population (Hanson 2015; Tschentscher 2013). Walking may also serve as an effective, useful adjunct to pharmacological therapy for controlling hypertension. For those who are normotensive, walking interventions may be useful in further reducing or preventing an increase in blood pressure.

The age of the study participants may mediate the effect of walking on blood pressure reduction (Lee 2010a). It is noteworthy that the result of subgroup analysis by different age groups showed that walking intervention demonstrated a similar reduction of SBP in the age group of over 60 to that observed in the age group of equal to or less than 40. Though previous studies found a tendency of an association between older people and a greater reduction in SBP and DBP (Burt 1995; Lee 2010a), this effect of walking on blood pressure reduction may result from higher baseline blood pressure levels among older adult participants. In the current review, we found a similar effect of walking on both normotensive SBP and DBP compared to either higher than high normal or higher than hypertensive.

When there are no sex differences on the effect of walking on lowering blood pressure, we found that females have slightly more reduction and more precisely than males in both SBP and DBP. This finding is inconsistent with those of previous studies (Carpio‐Rivera 2016; Christou 2005) that have suggested that males appeared to have a greater reduction in blood pressure than females. The menstrual cycle and menopausal impact might confound the acute‐ and long‐term effects of physical activity on the changes in blood pressure among the female population (Christou 2005). This inconsistency might also be due to that, in the current review, the total number of female participants is around 1.5 times compared to that of males. Previous studies argued that researchers have usually neglected adult females (Carpio‐Rivera 2016), but this did not appear to be the case in walking trials. In general, this review supports the finding that age and sex are less likely to change blood pressure response to physical activity.

The sample size could impact the research outcome widely and adequate sample sizes are required to provide sufficient power to generate robust results. According to our post hoc subgroup analyses using sample sizes greater and less than 30 participants per trial for the outcomes of SBP and DBP, there was a statistically significant reduction of both SBP and DBP in the two different sample sizes, whereby the studies with sample sizes equal to or less than 30 showed a much larger effect but less precisely, i.e. wider 95% confidence intervals than those in the studies with sample sizes greater than 30. This differs from a previous systematic review that found that walking interventions are likely to be effective according to studies with larger sample sizes (Lee 2010a). Most of the included studies in the current review did not report the power calculation for estimating adequate sample size. A small sample size could result in greater bias due to variations in the participants or contribute towards a positive result when the observed effects are far larger than the true differences between the groups (Altman 1997). Small sample size could also make the generalisability of the results challenging. Therefore, a proper sample size calculation is crucial for the robust interpretation and generalisation of the effect of the intervention.

There are insufficient data to examine the long‐term effect of walking on blood pressure. As only three studies reported follow‐up data on blood pressure in the months after the intervention ceased, it is unclear whether the benefits can persist or if further intervention is needed to maintain the benefit. The evidence showed that the cessation of exercise may lead to a rapid loss of benefit with regard to blood pressure (Moker 2014). The previous research revealed that the application of behaviour modification theories, such as increased exercise self‐efficacy among older participants might prolong the ongoing benefits of walking with regard to blood pressure management (Chiu 2015).

Overall completeness and applicability of evidence

We searched and screened relevant databases carefully to identify all relevant randomised controlled trials that investigated the effect of walking intervention on blood pressure control compared with a non‐intervention control group. Our searches were carried out across multiple databases and we screened carefully all reference lists of the included studies and relevant systematic reviews, together with a hand search of all articles citing the included studies to enhance the completeness of the systematic review.

We identified 73 studies that met our inclusion criteria and included data from 5060 participants in the meta‐analysis for our primary outcome of change in SBP. We included data from 69 studies and 4711 participants in the meta‐analysis for the secondary outcome of change in DBP. Fewer studies (n = 26) and participants (n = 1747) provided data for the meta‐analysis of the secondary outcome of change in heart rate (HR). These 73 studies included walking interventions only and thus other modes of activity such as jogging or lifestyle modifications such as dietary salt reduction were excluded. There were sufficient participants to undertake subgroup analyses of changes in SBP and DBP by age and sex. Our findings that walking can result in a statistically and clinically significant reduction in SBP and DBP were robust to subgroup analysis according to age and sex.

Walking is the activity that the majority of the population can do and is seen as a low cost, low risk, common and feasible mode of physical activity in different age groups for decades (Asikainen 2004; Kraus 2019; Morris 1997; Mutrie 2004). Therefore, walking is often recommended by healthcare professionals as a form of exercise for health promotion and preventing health problems (Kraus 2019; Pate 1995). The findings from the current meta‐analysis are applicable to blood pressure management among both normotensive and hypertensive populations.

Quality of the evidence

We judged the certainty of the evidence of the effect of walking on SBP as moderate rather than high because of lack of clarity around randomisation procedures, allocation concealment and blinding of participants, study personnel, and outcome assessors. There was also some inconsistency across trials, which was related in part to differences in study populations and to differences in walking interventions. In this circumstance, we decided not to downgrade the certainty of this evidence because that sensitivity analysis on the basis of low risk of bias trials showed a significant reduction of SBP. However, we judged the certainty of the evidence of the effect of walking on DBP and HR as low because of the inconsistency across trials and the lack of clarity around randomisation procedures, allocation concealment, and blinding of participants, study personnel, and outcome assessors. A sensitivity analysis on the basis of low risk of bias trials showed a non‐significant reduction of DBP and there were data for us to carry out a similar sensitivity analysis on HR. While we assessed many of the studies at risk of performance bias, it should be noted that the outcomes of interest for this review are objective so even if participants and assessors are aware of group assignment, this knowledge is less likely to influence the outcome data than if we were analysing subjectively‐assessed outcomes.

Potential biases in the review process

Approximately one quarter (n = 19, 26%) of the 73 included trials were multi‐arm trials. An example is a study by Brown 2014, where one intervention consisted of a nature walking group with participants following a walking route through trees and parks while a second intervention comprised a built walking group(BW) following a route through housing estates, and a third control arm followed normal activities. With such studies, where the walking intervention groups met our inclusion criteria, we combined them and calculated a mean change in outcome measures for the combined group, thus creating a single‐pair wise comparison with the control group. In some multi‐arm trials, one or more of the intervention groups did not meet our inclusion criteria and thus we excluded those findings from our analyses. Where we did combine groups, we were cautious to ensure that combining groups did not result in double‐counting of participants. A number of studies, for example, Chan 2018 and Moreau 2001 collected outcome data at a number of time points. We used the data collected at the shortest intervention period so that the data collection was most similar for the majority of studies. However, our findings may have changed if we used data from the last time period of data collection as it may be that fewer participants continued with the intervention as time went on. For those studies that did not provide sufficient data, we contacted study authors and received responses from approximately 10%. Some study details and data remain missing which may influence the findings of our review.

Agreements and disagreements with other studies or reviews

Our meta‐analysis investigated the effect of a walking intervention compared to a non‐intervention control group on blood pressure control using randomised controlled trials and revealed that walking significantly lowered both systolic and diastolic blood pressure, and heart rate among the adult participants, regardless of their age or sex. The results of the current meta‐analysis support the findings of earlier reviews that a walking intervention can lower either SBP (Bravata 2007) or DBP (Murphy 2007; Qui 2014), or both (Hanson 2015; Herrod 2018; Kelley 2001; Oja 2018; Tschentscher 2013). These findings are also consistent with a previous systematic review, which found that group walking could cause a statistically significant reduction in both SBP (3.72 mmHg, P < 0.001) and DBP (3.14 mmHg, P < 0.001) (Hanson 2015). Herrod 2018 reported that undertaking aerobic exercise regularly over at least three months can lead to 5 mmHg to 6 mmHg reduction in SBP and 2 mmHg to 3.5 mmHg in DBP among participants aged over 65 years (Herrod 2018).

However, one systematic review found no effect of walking on SBP and DBP control (Cai 2014), and two did not find a statistically significant reduction in SBP (Murphy 2007; Qui 2014). One systematic review using standardised mean differences and a random‐effects model found a small but statistically significant reduction in both SBP (‐0.213 mmHg, P = 0.001) and DBP (‐0.166 mmHg, P = 0.006) (Oja 2018). The systematic review undertaken by Bravata 2007 found that the use of pedometers has a similar effect on SBP reduction (‐3.8 mmHg, P < 0.001) as our finding, but a relatively small reduction in DBP (‐0.3 mmHg, P = 0.001). This slightly differs from the findings of Cai 2014 that the use of a pedometer was not statistically effective in reducing neither SBP (‐1.13 mmHg, P = 0.18) nor DBP (‐1.49 mmHg, P = 0.25). Among patients with type 2 diabetes, a recent meta‐analysis by Qui 2014 found that walking was associated with DBP reduction but not a significant reduction in SBP.

Walking prescriptions in the included studies of the current review mainly followed the general recommendations of physical activity for adults (ACSM 2018; US Dept of Health & Human Sciences 2018; US Dept of Health & Human Sciences 2018; Bull 2020), which involved participating in moderate‐intensity aerobic physical activity for a minimum of 30 minutes on five days per week or vigorous‐intensity exercise for a minimum of 20 minutes on three days per week. Walking can be considered as either a low‐intensity activity (e.g. walking at an easy or moderate pace) or moderate exercise (e.g. brisk or very brisk walking) (Hamilton 2008; Tanasescu 2002; US Dept of Health & Human Sciences 2018), and occasionally greater than moderate‐intensity (Murtagh 2002; Tanasescu 2002).

The previous review (Brown 1995) and guideline (ACSM 2018) pointed out that low‐ to moderate‐intensity exercise could have a similar effect on blood pressure reduction as does high‐intensity training among hypertensive people, while low‐ to moderate‐intensity exercise may even have a greater impact on SBP (Hagberg 2000). Among the trials that found a statistically significant reduction in SBP (n = 21 trials) with clearly stated intensity prescription (n = 16 intervention groups), the present review observed that moderate‐intensity walking is the major prescription of walking (n = 14 groups), with only one trial prescribing high‐intensity walking, and one trial prescribing low‐intensity walking. Consistent with this finding, previous studies found a greater, longer‐lasting blood pressure reduction after reaching exercise intensity of 75% VO_2max (Quinn 2000; Huang 2006; Cox 2001), which were seen as the moderate‐intensity level of exercise.

Previous studies have found that higher baseline blood pressure was associated with a greater reduction in blood pressure (Lee 2007; Nemoto 2007). Given the similar reduction in BP we saw among normotensive and hypertensive people and the weak association between baseline and change in blood pressure, we conclude that the effect of walking is similarly beneficial to those defined as normotensive and hypertensive. This is consistent with a later study (Rahman 2019) that found the benefits of medicinal blood pressure treatment, regardless of baseline blood pressure.

Figure 1

Figure 2

'Risk of bias' graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.

Figure 3

'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study.

Figure 4

Funnel plot of comparison: 1 Walking versus non‐intervention control (overall), outcome: 1.1 systolic blood pressure [mmHg].

Figure 5

Funnel plot of comparison: 1 Walking versus non‐intervention control (overall), outcome: 1.2 diastolic blood pressure [mmHg].

Analysis 1.1

Comparison 1: Walking vs non‐intervention control, Outcome 1: systolic blood pressure

Analysis 1.2

Comparison 1: Walking vs non‐intervention control, Outcome 2: diastolic blood pressure

Analysis 1.3

Comparison 1: Walking vs non‐intervention control, Outcome 3: heart rate [beats/min]

Analysis 2.1

Comparison 2: Walking vs non‐intervention control: subgroup analysis by age, Outcome 1: SBP by Age

Analysis 2.2

Comparison 2: Walking vs non‐intervention control: subgroup analysis by age, Outcome 2: DBP by Age

Analysis 3.1

Comparison 3: Walking vs non‐intervention control: subgroup analysis by sex, Outcome 1: SBP by Sex

Analysis 3.2

Comparison 3: Walking vs non‐intervention control: subgroup analysis by sex, Outcome 2: DBP by Sex

Analysis 4.1

Comparison 4: Walking vs non‐intervention control: sensitivity analysis for studies at low risk of overall bias, Outcome 1: systolic blood pressure

Analysis 4.2

Comparison 4: Walking vs non‐intervention control: sensitivity analysis for studies at low risk of overall bias, Outcome 2: diastolic blood pressure

Analysis 5.1

Comparison 5: Walking vs non‐intervention control: sensitivity analysis for studies at low risk of attrition bias, Outcome 1: systolic blood pressure

Analysis 5.2

Comparison 5: Walking vs non‐intervention control: sensitivity analysis for studies at low risk of attrition bias, Outcome 2: diastolic blood pressure

Analysis 6.1

Comparison 6: Walking vs non‐intervention control: sample size per trial ≦30 vs. >30, Outcome 1: SBP

Analysis 6.2

Comparison 6: Walking vs non‐intervention control: sample size per trial ≦30 vs. >30, Outcome 2: DBP

Analysis 7.1

Comparison 7: Walking vs non‐intervention control: subgroup analysis (normotensive vs. high normal), Outcome 1: SBP

Analysis 7.2

Comparison 7: Walking vs non‐intervention control: subgroup analysis (normotensive vs. high normal), Outcome 2: DBP

Analysis 8.1

Comparison 8: Walking vs non‐intervention control: subgroup analysis (normotensive vs. hypertensive), Outcome 1: SBP

Analysis 8.2

Comparison 8: Walking vs non‐intervention control: subgroup analysis (normotensive vs. hypertensive), Outcome 2: DBP

Summary of findings 1. Walking compared to no intervention (overall) for control of blood pressure

Outcomes	*Anticipated absolute effects^ (95% CI)**		№ of participants (studies)	Certainty of the evidence (GRADE)	Comments
Walking compared to no intervention (overall) for hypertension
Patient or population: adults with or without hypertension Setting: general population Intervention: walking Comparison: no intervention (overall)
Outcomes	Effect with no intervention mmHg	Effect with Walking mmHg	№ of participants (studies)	Certainty of the evidence (GRADE)	Comments
Systolic blood pressure	The mean systolic blood pressure was ‐1.30	MD 4.11 lower (5.22 lower to 3.01 lower)	5060 (73 RCTs)	⊕⊕⊕⊝ MODERATE ^{1 2}	Walking interventions probably reduce systolic blood pressure.
Diastolic blood pressure	The mean diastolic blood pressure was ‐0.73	MD 1.79 lower (2.51 lower to 1.07 lower)	4711 (69 RCTs)	⊕⊕⊝⊝ LOW ^{2 3}	Walking interventions may reduce diastolic blood pressure.
Heart rate [beats/min]	The mean heart rate [beats/min] was ‐0.41 beats/min	MD 2.76 beats/min lower (4.57 lower to 0.95 lower)	1747 (26 RCTs)	⊕⊕⊝⊝ LOW ^{2 4}	Walking interventions may reduce heart rate.
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: Confidence interval; DBP: diastolic blood pressure; MD: mean difference; RCT: randomised controlled trial; SBP: systolic blood pressure.
GRADE Working Group grades of evidence High certainty: we are very confident that the true effect lies close to that of the estimate of the effect. Moderate certainty: we are moderately confident in the effect estimate; the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. Low certainty: our confidence in the effect estimate is limited; the true effect may be substantially different from the estimate of the effect. Very low certainty: we have very little confidence in the effect estimate; the true effect is likely to be substantially different from the estimate of effect.
¹ Not downgraded one level for risk of bias even though more than half of included studies failed to report details of randomisation and allocation concealment. This is because a sensitivity analysis based on trials judged as being at low risk of bias also showed a statistically significant reduction of SBP: Weighted Mean Difference= ‐4.31, 95% CI: ‐7.99 to ‐0.63, P = 0.02, I² = 0%, n = 235. ² Downgraded one level for inconsistency on the basis of statistically significant heterogeneity. ³ Downgraded one level for risk of bias; More than half of the included studies failed to report details of randomisation and allocation concealment. The sensitivity analysis based on trials judged as being at low risk of bias failed to show a statistically significant reduction of DBP: Weighted Mean Difference = ‐0.47, 95% CI: ‐2.54 to 1.61, P = 0.66, I² = 18%, n = 235. ⁴ Downgraded one level for risk of bias; More than half of included studies failed to report details of randomisation and allocation concealment and there is no data for further sensitivity analysis.

Summary of findings 1. Walking compared to no intervention (overall) for control of blood pressure

Summary of findings 2. Walking compared to no intervention by age for control of blood pressure

Outcomes	*Anticipated absolute effects^ (95% CI)**		№ of participants (studies)	Certainty of the evidence (GRADE)	Comments

Patient or population: adults with or without hypertension Setting: general population Intervention: walking Comparison: no intervention, by age
Outcomes	Effect with no intervention mmHg	Effect with Walking mmHg	№ of participants (studies)	Certainty of the evidence (GRADE)	Comments
SBP age <=40	The mean SBP was 1.71	MD 4.41 lower (6.17 lower to 2.65 lower)	491 (14 RCTs)	⊕⊕⊕⊝ MODERATE ¹	Walking interventions probably reduce systolic blood pressure in adults aged equal to or less than 40 years.
SBP age 41‐60	The mean SBP was ‐1.88	MD 3.79 lower (5.64 lower to 1.94 lower)	1959 (35 RCTs)	⊕⊕⊝⊝ LOW ^{1 2}	Walking interventions may reduce systolic blood pressure in adults aged 41 to 60 years.
SBP age >60	The mean SBP was ‐2.21	MD 4.30 lower (6.17 lower to 2.44 lower)	2610 (24 RCTs)	⊕⊕⊝⊝ LOW ^{1 2}	Walking interventions may reduce systolic blood pressure in adults aged over 60 years.
DBP age <=40	The mean DBP was ‐0.24	MD 3.01 lower (4.44 lower to 1.58 lower)	491 (14 RCTs)	⊕⊕⊕⊝ MODERATE ¹	Walking interventions probably reduce diastolic blood pressure in adults aged equal to or less than 40 years.
DBP age 41‐60	The mean DBP by age 41‐60 was ‐0.87	MD 1.74 lower (2.95 lower to 0.52 lower)	1730 (32 RCTs)	⊕⊕⊝⊝ LOW ^{1 2}	Walking interventions may reduce diastolic blood pressure in adults aged 41 to 60 years.
DBP age >60	The mean DBP was ‐0.86	MD 1.33 lower (2.40 lower to 0.26 lower)	2490 (23 RCTs)	⊕⊕⊝⊝ LOW ^{1 2}	Walking interventions may reduce diastolic blood pressure in adults aged over 60 years.
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: Confidence interval; DBP: diastolic blood pressure; MD: mean difference; RCT: randomised controlled trial; SBP: systolic blood pressure.
GRADE Working Group grades of evidence High certainty: we are very confident that the true effect lies close to that of the estimate of the effect. Moderate certainty: we are moderately confident in the effect estimate; the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. Low certainty: our confidence in the effect estimate is limited; the true effect may be substantially different from the estimate of the effect. Very low certainty: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect
¹ Downgraded one level for risk of bias; the majority of included studies failed to report details of randomisation and allocation concealment. ² Downgraded one level for inconsistency; there was statistically significant heterogeneity.

Summary of findings 2. Walking compared to no intervention by age for control of blood pressure

Summary of findings 3. Walking compared to no intervention by sex for control of blood pressure

Outcomes	Effect with no intervention mmHg	Effect with Walking mmHg		№ of participants (studies)	Certainty of the evidence (GRADE)	Comments

Patient or population: adults with or without hypertension Setting: general population Intervention: walking Comparison: no intervention, by sex
Outcomes	*Anticipated absolute effects^ (95% CI)**			№ of participants (studies)	Certainty of the evidence (GRADE)	Comments
SBP in males	The mean SBP was ‐1.22	MD 4.64 lower (8.69 lower to 0.59 lower)	‐	203 (6 RCTs)	⊕⊕⊝⊝ LOW ^{1 2}	Walking interventions may lower systolic blood pressure in male adults.
SBP in females	The mean SBP was ‐0.48	MD 5.65 lower (7.89 lower to 3.41 lower)	‐	1149 (22 RCTs)	⊕⊕⊝⊝ LOW ^{2 3}	Walking interventions may reduce systolic blood pressure in female adults.
DBP in males	The mean DBP was ‐1.81	MD 2.54 lower (4.84 lower to 0.24 lower)	‐	203 (6 RCTs)	⊕⊕⊕⊝ MODERATE ²	Walking interventions probably reduce diastolic blood pressure in male adults.
DBP in females	The mean DBP was 0.53	MD 2.69 lower (4.16 lower to 1.23 lower)	‐	1000 (20 RCTs)	⊕⊕⊝⊝ LOW ^{2 3}	Walking interventions may reduce diastolic blood pressure in female adults.
*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: Confidence interval;
GRADE Working Group grades of evidence High certainty: We are very confident that the true effect lies close to that of the estimate of the effect Moderate certainty: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different Low certainty: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect Very low certainty: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect
¹ Large 95% confidence intervals. ² Downgraded one level for risk of bias; the majority of included studies failed to report details of randomisation and allocation concealment. ³ Downgraded one level for inconsistency; there was statistically significant heterogeneity.

Summary of findings 3. Walking compared to no intervention by sex for control of blood pressure

Table 1. Baseline characteristics of included studies

Study ID	Participants randomised n	Country	Study population	Mean age (SD) or range	Male/total (%)	Mean baseline SBP (SD)(mmHg)	Mean baseline DBP (SD)(mmHg)	Mean baseline HR (SD)(beats/min)
Araiza 2006	30	USA	type 2 diabetes mellitus, free from advanced secondary complications of diabetes.	Range 33 to 69; IG: 49 (SD 11); CG:51 (SD 10)	NR	IG: 140.6 (SD 21.4); CG: 136.6 (SD 19.3)	IG: 80.7 (SD 12.2); CG: 77.6 (SD 8.9)	NR
Arija 2017	419	Spain	Older primary health‐care patients (attending primary health care facilities)	IG: 64.5 (SD 9.2); CG: 66.99 (SD 10.28)	84/364 (23.2%)	IG: 131.06 (SD 15.94); CG: 135.32 (SD 16.62)	IG: 76.75 (SD 9.09); CG: 75.96 (SD 9.86)	NR
Baker 2008	80	UK	Sedentary general population	Range 18 to 65; IG: 47.3 (SD9.3); CG: 51.2 (SD7.9)	16/79 (20.3%)	IG: 118.2 (SD 17.9); CG: 119.9 (SD 15.9)	IG: 75.1(SD 11.4); CG: 75.5 (SD 11.8)	IG: 68.6 (SD 7.2); CG: 67.9 (SD 8.6)
Bang 2016	60	Korea	General population (Office workers)	IG: 42.22 (SD 11.44); CG: 37.37 (SD 9.32)	3/45 (6.67%)	IG: 121.39 (SD 16.02); CG: 112.52 (SD 12.49)	IG: 79.00 (SD 9.37); CG: 72.85 (SD 9.35)	NR
Baross 2017	24	UK	Sedentary young adults	IG: 20.9 (SD 2.0); CG: 21.3 (SD 2.0)	13 (54%)	IG: 126.7 (SD 3.7); CG: 127.9 (SD 4.2)	IG: 77.7 (SD 3.0); CG: 77.0 (SD 1.8)	IG: 66.0 (SD 3.1); CG: 67.4 (SD 2.7)
Bayat 2018	120	Iran	Woman with Type 2 Diabetes	IG: 53.77 (SD 6.52); CG: 52.06 (SD 6.28)	0 (0%)	IG: 126.04 (SD 16.69), CG: 130.9 (SD 15.64)	IG: 74.9 (SD 10.85); CG: 85.0 (SD 10.0)
Bell 2010	140	Canada	Sedentary general population	Male: 49 (SD 11); Female: 50 (SD 9)	NR	IG: 124 (SD 14); CG: 125 (SD 13)	IG: 78 (SD 9); CG: 80 (SD 9)	IG: 73 (SD 9); CG: 76 (SD 11)
Braith 1994	30	USA	Normotensive elderly adults	Range 60 to 79; IG: 66 (SD 5); CG: 66 (SD 5)	NR	IG: 121 (SD 10); CG: 121 (SD 12)	IG: 72 (SD 8); CG: 74 (SD 5)	IG: 71 (SD 8); CG: 65 (SD 8)
Brandon 2006	52	USA	Obese sedentary adults	(total: 37.93; AAE: 34.0 (SD 7.2); AAC: 36.0 (SD 8.4); WE: 40.5 (SD 7.1); WC: 42.0 (SD 9.7)	0 (0%)	AAE: 110.0 (SD 11.9); AAC: 103.9 (SD 15.6); WE: 111.0 (SD 14.9); WC: 115.0 (SD 18.1)	AAE: 69.7 (SD 8.9); AAC: 63.8 (SD 14.6) WE: 67.0 (SD 10.3); WC: 68.5 (SD 10.2)	NR
Brenner 2020	48	Canada	Patients with vascular problems	IG 68.6 (SD 6.87); CG 63.7 (SD 8.47)	21/33 (63.6%)	IG: 124 (SD 15); CG: 132 (SD 14)	IG: 67 (SD 8); CG: 69 (SD 11)	IG: 63 (SD 12); CG: 66 (SD 13)
Brown 2014	94	UK	General population (Office workers)	IG1: 46.3 (SD 9.4); IG2: 39.3 (SD 10.3); CG: 40.2 (SD 11.0)	74 (78.7%)	IG1: 135.1 (SD 12.3); IG2: 128.9 (SD 15.1); CG: 133.3 (SD 10.5)	IG1: 86.0 (SD 7.6); IG2: 81.5 (SD 11.9); CG: 79.5 (SD 7.1)	IG1: 67.1 (SD 10.0); IG2: 63.6 (SD 10.1); CG: 64.6 (SD 12.5)
Chan 2018	164	Hong Kong	Hypertensive patients	IG: 63.22 (SD 11.11); CG: 65.13 (SD 10.22)	80 (48.8%)	IG: 138.15 (SD17.39); CG: 142.49 (SD19.12)	IG: 79.74 (SD 10.51); CG: 82.59 (SD 10.68)	NR
Chiang 2019	32	Taiwan	College students with obesity	IG1: 19.17 (SD 1.03); IG2: 20.64 (SD 1.80); CG: 19.36 (SD 1.12)	NR	IG1: 121.92 (SD 15.70); IG2: 121.36 (SD 11.48); CG: 127.00 (SD 17.18)	IG1: 76.92 (SD 12.06); IG2: 79.55 (SD 8.85); CG: 74.33 (SD 11.06)	IG1: 75.92 (SD 10.13) IG2: 78.3 (SD 10.02) CG: 79.78 (SD 7.85)
Coghill 2008	67	UK	Hypercholesterolaemic men	Range 45 to 65	67 (100%)	IG: 138.04 (SD 15.61); CG: 140 (SD 15.63)	IG: 89.90 (SD 9.93); CG: 88.32 (SD 9.52)	NR
Cooper 2000	90	UK	Sedentary adults with unmedicated hypertension 150‐180 mmHg	Range 25 to 63; IG: 46.2 (SD 9.4); CG: 49.4 (SD 8.9)	72 (80%)	IG: 139.8 (SD 12.7); CG: 135.7 (SD 9.3)	IG: 89.5 (SD 9.6); CG: 87.6 (SD 8.5)	NR
Dong 2007	120	China	Patients with chronic heart failure	IG: 61.7 (SD 12.3); CG: 61.9 (SD 12.1)	66 (55%)	IG: 149.10 (SD 44.50); CG: 147.2 (SD 44.1)	NR	IG: 104 (SD 25); CG: 105 (SD 21)
Dong 2012	51	China	White coat hypertension patients	Range 45 to 71; IG: 53.75 (SD 16.42); CG: 54.26 (SD 17.18)	29 (56.9%)	IG: 129.51 (SD 25.42); CG: 127.96 (SD 23.13)	IG: 82.09 (SD 17.23); CG: 83.46 (SD 18.52)	NR
Duncan 1991	102	USA	Sedentary pre‐menopausal women	Range 20 to 40	0 (0%)	IG1: 105 (SD 8); IG2: 109 (SD 9); IG3: 108 (SD 6); CG: 108 (SD 8)	IG1: 70 (SD 7); IG2: 74 (SD 8); IG3: 73 (SD 9); CG: 74 (SD 7)	NR
Dureja 2014	10	India	Young adults (post‐graduate students)	Range 19 to 25	10 (100%)	IG: 116 (SD 5.47); CG: 123 (SD 10.36)	IG: 79 (SD 8.94); CG: 82.0 (SD 11.51)	NR
Foulds 2014	90	Canada	General population	Range 20 to 65; total: 44 (SD 13)	21/58 (36.2%)	IG1: 116 (SD 16.11); IG2: 111.22 (SD 11.39); IG3: 108.28 (SD 11.58); IG4: 115.15 (SD 11.31);CG: 114.6 (SD 16.97)	IG1: 75.2 (SD 10.3); IG2: 72.3 (SD 7.14); IG3: 68.2 (SD 9.17); IG4: 74.9 (SD 11);CG: 69.2 (SD 8.6)	NR
Fritz 2013	213	Sweden	Overweight general population, & individuals with IGT or T2DM	Range 45 to 69; total: 60 (SD 5.3)	95 (44.6%)	IG1_NGT: 138 (SD 12.5); IG2_IGT: 141 (SD 14.0); IG3_T2DM: 143 (SD 13.2);CG1_NGT: 137 (SD 15.0); CG2_IGT: 141 (SD 13.0); CG3_T2DM: 144 (SD 12.6)	IG1_NGT: 85 (SD 7.9); IG2_IGT: 84 (SD 7.8); IG3_T2DM: 85 (SD 7.6);CG1_NGT: 84 (SD 8.8); CG2_IGT: 86 (SD 9.4); CG3_T2DM: 83 (SD 7.4)	NR
Geddes 2009	15	USA	Multiple sclerosis adults	IG: Range 40 to 64; CG: Range 22 to 50	3/12 (25%)	NR baseline SBP	NR baseline DBP	NR
Gilson 2007	70	UK	General population (University employees office workers)	Male: 41 (SD 11); Female: 42 (SD 11)	7 (10%)	IG1: 121.7 (SD 17.3); IG2: 119.0 (SD 7.4); CG: 121.6 (SD 9.9)	IG1: 85.6 (SD 12.1); IG2: 85.7 (SD 10); CG: 82.9 (SD 7.3)	NR
Gradidge 2018	132	South Africa	Obese women (university staff)	IG: 44.4 (SD 11.5); CG: 37.4 (SD 8.78)	0 (0%)	IG: 127 (SD 14.7); CG: 122 (SD 15.6)	NR	NR
Hamdorf 1999	49	Australia	Elderly sedentary women	Range 79 to 91; IG: 82.4 (SEM 0.66); CG: 83.1 (SEM 0.69)	0 (0%)	IG: 144.6 (SEM 4.9); CG: 149.3 (SEM 5.1)	IG: 72.6 (SEM 2.2); CG: 77.7 (SEM 2.5)	IG: 74.4 (SEM 2.1) CG: 72.7 (SEM 1.7)
Headley 2017	49	USA	Stage 3 chronic kidney disease adults	IG: 58 (SD 8.0); CG: 57.1 (SD 9.0)	30/46 (65.2%)	IG: 126.4 (SD 17.8); CG: 133.7 (SD 19.2)	IG: 79.5 (SD 10.2); CG: 79.1 (SD 10.7)	IG: 64.3 (SD 8.9); CG: 65.5 (SD 12.3)
Herzig 2014	78	Finland	Impaired fasting glucose/ glucose tolerance adults	IG: 58.1 (SD 9.9); CG: 59.5 (SD 10.8)	18/68 (26.5%)	IG: 138.5 (SD 16.4); CG: 150.4 (SD 20.2)	IG: 83.8 (SD 8.0); CG: 85.4 (SD 9.5)	NR
Higashi 1999b	27	Japan	Essential hypertensive adults	IG: 53 (SD 10); CG: 51 (SD 8)	20 (74%)	IG: 155.0 (SD 6.6); CG: 155.4 (SD 8.3)	IG: 96.0 (SD 4.9); CG: 97.6 (SD 4.3)	IG: 71.8 (SD 9.7); CG: 73.1 (SD 6.4)
Holloway 1997	102	USA	Sedentary middle‐aged	Range 20 to 50	unknown	IG1_XS: 113.6 (SD 9.8); IG2_T: 113.4 (SD 11.1); IG3_S: 116.7 (SD 10.0); CG: 114.5 (SD 12.3)	IG1_XS: 80.0 (SD 7.3); IG2_T: 81.9 (SD 9.1); IG3_S: 83.5 (SD 8.7); CG: 82.7 (SD 6.0)	IG1_XS: 76.4 (SD 9.0) IG2_T:77.0 (SD 8.8) IG3_S: 75.9 (SD 6.3) CG:78.6 (SD 10.1)
Hua 2006	47	Canada	Hypertensive adults	IG‐Male:55.8 (SD 9.5); IG‐Female: 56.3 (SD 9.6) CG‐Male: 55.9 (SD 10.2) CG‐Female:58.5 (SD 11.3)	20/40 (50%)	IG‐Male: 140 (SD 11); IG‐Female: 141 (SD 16); CG‐Male: 142 (SD 15); CG‐Female: 141 (SD 17)	IG‐Male: 92 (SD 7); IG‐Female: 87 (SD 9); CG‐Male: 91 (SD 11); CG‐Female: 88 (SD 9)	IG‐Male: 69 (SD 7); IG‐Female: 75 (SD 12); CG‐Male: 75 (SD 15); CG‐Female: 70 (SD 12)
Karstoft 2013	34	Denmark	Type 2 diabetes adults	IG_CWT: 60.8 (SD 2.2); IG_IWT: 57.5 (SD 2.4); CG: 57.1 (SD 3.0)	20/32 (62.5%)	IG_CWT: 155 (SD 5.4); IG_IWT: 138 (SD 3.3); CG: 142 (SD 4.3)	IG_CWT: 90.0 (SD 1.8); IG_IWT: 85.0 (SD 2.8); CG: 86.6 (SD 3.5)	NR
Khalid 2013	30	Egypt	Hypertensive post‐menopausal women	Range 40 to 50; IG: 52.9 (SD 2.6); CG: 52.7 (SD 2.2)	0 (0%)	IG: 148 (SD 5.6); CG: 154 (SD 6.7)
Koh 2010	43	Australia	Long‐term haemodialysis patients	IG: 52.1 (SD 13.6); CG: 51.3 (SD 14.4)	19/31 (61.3%)	IG: 143 (SD 32) CG: 145 (SD 18)	IG: 78 (SD 16); CG: 80 (SD 9)	IG: 73 (SD 9); CG: 74 (SD 10)
Kukkonen‐Harjula 1998	116	Finland	Healthy middle‐aged adults	Range 30 to 55; IG: 42.1 (SD 5.1); CG: 40.3 (SD 4.5)	55 (47.4%)	IG: 118 (SD 12)	CG: 75 (SD 11)	NR
Kurban 2011	60	Turkey	Type 2 diabetes adults	IG: 53.77 (SD 8.2); CG: 53.57 (SD 6.6)	29 (48%)	IG: 129.17 (SD 12.1); CG: 124.83 (SD 14.59)	IG: 78.83 (SD 6.78); CG: 77.88 (SD 10.53)	NR
Lee 2007	202	Taiwan	Hypertensive adults (mild / moderate)	IG: 71.3 (SD 6.4); CG: 71.3 (SD 5.7)	118 (58.4%)	IG: 152.0 (SD 10.5); CG: 152.4 (SD 11.1)	IG: 83.5 (SD 11.2); CG: 80.6 (SD 8.8)	NR
Li 2018	100	China	University teachers	IG: 42.26 (SD 8.63); CG: 42.39 (SD 8.35)	48/100 (48%) (22+26)	IG: 112.69 (SD 13.74); CG: 118.95 (SD 14.99)	NR	NR
Li 2003	48	USA	Elderly sedentary adults	Range 60 and above; IG: 72 (SD 6.4); CG: 73.3 (SD 7.3)	9/40 (22.5%)	IG: 133.64 (SD 9.68); CG: 132.17 (SD 13.62)	IG: 81.5 (SD 9.41); CG: 81.22 (SD 8.59)	NR
Lin 2000	22	Taiwan	Borderline hypertensive adolescents / students	Range 16 to 18	22 (100%)	IG1: 140 (SD 11.14); IG2: 137.75 (SD 6.69); CG: 145.67 (SD 10.33)	IG1: 92.25 (SD 3.45); IG2: 91.75 (SD 4.06); CG: 93.67 (SD 4.27)	NR
Ming 2018	64	China	Elderly patients with Coronary Heart Disease and Hypertension	IG: 63.18 (SD 5.42); CG: 62.76 (SD 5.54)	40 (62.5%)	IG: 136.79 (SD 7.03); CG: 137.32 (SD 7.44)	IG: 95.88 (SD 4.10); CG: 96.30 (SD 4.52)	IG: 83.18 (SD 8.14); CG: 83.55 (SD 8.09)
Moreau 2001	24	USA	Postmenopausal women with borderline stage 1 hypertension	IG: 53 (SE 2); CG: 55 (SE 1)	0 (0%)	IG: 142 (SE 3); CG: 142 (SE 3)	IG: 84 (SE 1); CG: 86 (SE 2)	IG: 77 (SE 3); CG: 77 (SE 3)
Murphy 1998	47	UK	Sedentary middle‐aged women	IG1: 44.8 (SD 8.4); IG2: 48.0 (SD 5.5); CG: 47.3 (SD 4.1)	0 (0%)	IG1_short bout: 125.5 (SD10.8); IG2_long bout: 124.2 (SD11.1); CG: 128.6 (SD13.3)	NR	NR
Murphy 2006	37	UK	Sedentary general population (civil servants)	IG: 41.4 (SD 7.5); CG: 40.8 (SD 10.0)	13 (35%)	IG: 120.4 (SD 19.7); CG: 116.5 (SD 1 3)	IG: 77.2 (SD 9.4); CG: 74.6 (SD 9.0)	NR
Murtagh 2005	48	UK	Sedentary general population (university staff/students)	45.7 (SD 9.4)	17 (35%)	IG1_single bout: 117.9 (SD 12.0); IG2_accumulated bout: 121.7 (SD 11.2); CG: 117.5 (SD 18.1)	IG1_single bout: 74 (SD 9.8) IG2_accumulated bout: 75.4 (SD 6.6); CG: 73.1 (SD 10.6)	NR
Nemoto 2007	246	Japan	General population adults	Range 44 to 78; 63 (SD 6)	60 (24%)	W_cnt_male: 141 (SE 2); W_cnt_female: 135 (SE 3); W_int_male: 146 (SE 2); W_int_female: 140 (SE 3); CG_male: 143 (SE 2); CG_female: 142 (SE 3)	W_cnt_male: 85 (SE 2); W_cnt_female: 81 (SE 2); W_int_male: 87 (SE 3); W_int_female; 85 (SE 2); CG_male: 84 (SE 2); CG_female: 83 (SE 2)	W_cnt_male: 81 (SE 3); W_cnt_female: 78 (SE 1); W_int_male: 75 (SE 3); W_int_female; 81 (SE 2); CG_male: 80 (SE 3); CG_female: 79 (SE 1)
Neumann 2006	25	USA	Older adults with Silent Myocardial Ischaemia	Range 56 to 83; IG: 71 (SE 2); CG: 63 (SE 2)	17 (68%)	IG: 134 (SE 3); CG: 140 (SE 6)	IG: 76 (SE 3); CG: 80 (SE 2);	IG: 71 (SE 3); CG: 71 (SE 3)
Pagonas 2014	72	Germany	Hypertensive outpatients	IG: Range 42 to 79CG: Range 43 to 77	31 (43.1%)	IG: 137.9 (SD 12.3); CG: 133.1 (SD 12.1)	IG: 78.1 (SD 8.9); CG: 73.8 (SD 6.4)	NR
Palmer 1995b	27	USA	Sedentary middle‐aged premenopausal women	Range 29 to 50; 37.4	0 (0%)	IG: 117.1 (SD 14); CG: 122.6 (SD 13.8)	IG: 80.9 (SD 10.6); CG: 77.6 (SD 11.2)	IG: 74 (SD 10.8); CG: 71 (SD 6.5)
Pernar 2017	41	Sweden	Prostate cancer patients	Range 54.5 to 81.7	41 (100%)	IG: 170; CG: 162	IG: 93; CG: 89	NR
Pospieszna 2017	39	Poland	Postmenopausal women (healthy volunteers)	Range 52 to 72; IG: 62 (SD 3.79); CG: 62 (SD 1.12)	0 (0%)	IG: 134.7 (SD 21.23); CG: 132.16 (SD 3.8)	IG: 75.8 (SD 7.06); CG: 78.58 (SD 1.96)	NR
Ready 1996	79	Canada	Sedentary postmenopausal women	Range 50 and above; 61.3 (SD 5.8)	0 (0%)	IG1_3D: 134 (SD 18); IG2_5D: 131 (SD 20); CG: 131 (SD 16)	IG1_3D: 77 (SD 11); IG2_5D: 76 (SD 9) CG: 77 (SD 10)	NR
Romero 2019	55	USA	Sedentary elderly female	Range 60 to 75	0 (0%)	IG: 143.67 (SD 21.91); CG: 146.07 (SD 24.18)	IG: 84.41 (SD 15.19); CG: 82.96 (SD 10.29)	NR
Sakuragi 2006	20	Japan	Sedentary general population (female college students)	Range 20 to 22; IG: 19.4 (SD 1.4); CG: 20.1 (SD 1.2)	0 (0%)	IG：93.324(SD17.55);CG：100.13(SD18.09)	IG：43.779(SD14.18);CG：50.054(SD11.72)	Figure 2
Salesi 2014	32	Iran	Elderly women	Range 50 to 55	0 (0%)	IG: 136.0 (SD 12.1); CG: 131.1 (SD 8.7)	IG: 83.1 (SD 10.1); CG: 80.3 (SD 3.8)	NR
Saptharishi 2009	58	India	Confirmed hypertensive / pre‐hypertensive patients	IG: 22.4 (SD 1.3); CG: 22.5 (SD 1.4)	39 (67.2%)	IG: 128.6 (SD 7.7); CG: 123.1 (SD 10.2)	IG: 87.4 (SD 4.8); CG: 82.9 (SD 7.1)	NR
Serwe 2011	60	USA	Sedentary office women	Range 18 to 50; IG1: 37.1 (SD 7.2); IG2: 38.2 (SD 7.3); CG: 36.3 (SD 8.1)	0 (0%)	IG1: 115.1 (SD 10.5); IG2: 117.7 (SD 12.1); CG: 120.9 (SD 9.2)	IG1: 73.4 (SD 8.1); IG2: 73.2 (SD 8.7); CG: 72.7 (SD 7.2)	IG1: 68.4 (SD 10.4); IG2: 65.8 (SD 6.0); CG: 72.7 (SD 9.5)
Shenoy 2010	40	India	T2DM patients	Range 40 to 70; IG: 53.15 (SD 4.4); CG: 51 (SD 5.4)	29 (73%)	IG: 122 (SD 13.8); CG: 131 (SD 12.7)	IG: 85.6 (SD 16.1); CG: 86.0 (SD 7.2)	IG: 82.7 (SD 10.6); CG: 81.0 (SD9.7)
Stanton 1996	102	New Zealand	Sedentary, essential hypertension volunteers	IG: 55.2 (SE 1.4); CG:53.8 (SE 1.5)	42/89 (47.2%)	IG: 142.9 (SE 2.5); CG: 145.3 (SE 2.6)	IG: 88.4 (SE 1.4); CG: 94.0 (SE 1.4)	NR
Stutzman 2010	25	Canada	Sedentary normal & overweight 20 weeks pregnant women	IG_normal weight: 30.4 (SD 4.2); IG_overweight: 28.8 (SD 6.9); CG_normal weight: 25.8 (SD 3.0); CG_overweight: 26.2 (SD 5.6)	0 (0%)	IG_normal weight: 111 (SD 12); IG_overweight: 114 (SD 14); CG_normal weight: 109 (SD 7); CG_overweight: 107 (SD 8)	IG_normal weight: 76 (SD 11); IG_overweight: 75 (SD 10); CG_normal weight: 74 (SD 4); CG_overweight: 72 (SD 4)	NR
Tudor‐Locke 2004	60	Canada	Sedentary overweight T2DM patients	Range 40 to 60; total: 52.7 (SD 5.2); IG: 52.8 (SD 5.7) CG: 52.5 (SD 4.8)	26/47 (55.3%)	IG: 138.2 (SD 17.2); CG: 130.1 (SD 15.9);	IG: 81.5 (SD 9.5); CG: 78.9 (SD 8.0)	IG: 76.4 (SD 11.8) CG: 77.0 (SD 9.7)
Tudor‐Locke 2020	120	USA	Sedentary overweight/obese and postmenopausal women	Range 45 to 75; IG1: 62.6 (SD 6.5); IG2: 61.7 (SD 6.2); CG: 58.4 (SD 5.8)	0 (0%)	IG1: 127.6 (SD 16.6); IG2: 125.2 (SD 12.7); CG: 122.5 (SD 13.9)	IG1: 78.7 (SD 8.0); IG2: 75.5 (SD 7.6); CG: 77.3 (SD 7.3)	NR
Tully 2005	31	UK	Sedentary middle‐aged adults	Range 50 to 65; IG: 55.52 (SD 3.99); CG: 57.75 (SD 4.64)	13 (42%)	IG: 129.94 (SD 8.61); CG: 125.78 (SD 14.02)	IG: 78.47 (SD 4.16); CG: 77.22 (SD 7.74)	NR
Tully 2007a	106	UK	Sedentary middle‐aged adults (civil servants)	Range 40 to 61; IG1_3D: 47.8 (SD 5.97); IG2_5D: 46.37 (SD 4.76); CG: 49.05 (SD 6.31)	42 (39.6%)	IG1_3‐Day: 134 (SD 15); IG2_5‐Day: 133 (SD 15); CG: 128 (SD 15)	IG1_3‐Day: 87 (SD 11); IG2_5‐Day: 87 (SD 11); CG: 83 (SD 10)	IG1_3‐Day: 69 (SD 12); IG2_5‐Day: 72 (SD 10); CG: 75 (SD 11)
Tully 2011	12	UK	Sedentary university students	21.16 (SD 6.17)	2 (16.7%)	IG: 120 (SD 15.62); CG: 131.67 (SD 11.85)	IG: 79.00 (SD 8.23); CG: 86.33 (SD 8.50)	NR
Venturelli 2011	24	Italy	Late stage Alzheimer's disease patients	Range 65 and above; IG: 83 (SD 6); CG: 85 (SD 5);	0 (0%)	IG: 132 (SD 10); CG: 133 (SD 6)	IG: 84 (SD 5); CG: 84 (SD 3)	NR
Wallis 2017	46	Australia	Severe OA patients rated as grade III or IV affecting at least one of the tibiofemoral compartments	Range 50 to 84; IG: 68 (SD 8); CG: 67 (SD 7)	26 (56.5%)	IG: 142 (SD 10); CG: 138 (SD 24)	IG: 82 (SD 10); CG: 81 (SD 11.1)	NR
Wang (王正斌) 2014	62	China	Patients with hypertension and Diabetes Mellitus	Range 40 to 70; IG: 55.8 (SD 9.3); CG: 57.4 (SD 8.9)	39 (62.9%)	IG: 143 (SD 11); CG: 141 (SD 14)	IG: 81 (SD 11); CG: 88 (SD 9)	NR
Wang 2014	53	Taiwan	Sedentary postmenopausal women	Range 45 to 70; IG: 56.9 (SD 6.2) CG: 55.1 (SD 7.8)	0 (0%)	IG: 124.6 (S D9.2); CG: 127 (SD 10.1)	IG: 76.8 (SD 8.1) CG: 79 (SD 9.4)	NR
Wang 2016	61	China	Hypertensive coal miners	Range 18 to 64; IG: 49.61 (SD 4.91); CG: 48.50 (SD 6.31)	31/48 (64.6%)	IG: 134.83 (SD 17.43); CG: 143.97 (SD 20.91)	IG: 82.39 (SD 12.94); CG: 87.63 (SD 10.48)	NR
Westhoff 2007	54	Germany	Sedentary Isolated Systolic Hypertension elderly patient	Range 60 and above; IG: 67.2 (SD 4.8); CG: 68.9 (SD 5.2)	26 (48.1%)	IG: 136.6 (SD 12.7); CG: 134.8 (SD 11)	IG: 76.3 (SD 7.3); CG: 72.8 (SD 7.2)	Figure 2
Xiao 2010	124	China	Elderly Type 2 Diabetes Mellitus patients	IG: 65.84 (SD 6.32); CG 65.82 (SD 6.39)	36/112 (32.1%)	IG: 141.82 (SD 16.23); CG 141.05 (SD 20.06)	IG: 82.91 (SD 9.94); CG 84.04 (SD 10.15)	NR
Yan 2010	418	China	Patients with Congestive Heart Failure	IG: 61.2 (SD 11.8); CG: 62.5 (SD 11.6)	261 (62.4%)	IG: 123.1 (SD 21.9); CG: 125.6 (SD 20.2)	IG: 68.6 (SD 10.8); CG: 68.5 (SD 10.6)	IG: 74.2 (SD 15.7) CG: 77.1 (SD 15.2)
Yu 2018	231	China	Elderly patients with Isolated Systolic Hypertension	IG1: 82.96 (SD 2.06); IG2: 83.01 (SD 2.09); CG: 83.44 (SD 1.99)	139/211 (65.9%)	IG1: 141.67 (SD 5.95); IG2: 140.87 (SD 6.45); CG: 141.94 (SD 5.22)	IG1: 63.2 (SD 3.59); IG2: 62.36 (SD 2.84); CG: 63.43 (SD 3.11)	NR
CG: control group; CWT: continuous walking training; IG: intervention group; IGT: impaired glucose tolerance; IWT: intermittent walking training; NGT: normal glucose tolerance; NR: not reported; OA: Osteoarthritis; SD: standard deviation; SE: standard error; T2DM: type 2 diabetes mellitus; W_cnt : moderate‐intensity continuous walking training group; W_int : high‐intensity interval walking training group

Table 1. Baseline characteristics of included studies

Comparison 1. Walking vs non‐intervention control

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1.1 systolic blood pressure Show forest plot	73	5060	Mean Difference (IV, Random, 95% CI)	‐4.11 [‐5.22, ‐3.01]

1.2 diastolic blood pressure Show forest plot	69	4711	Mean Difference (IV, Random, 95% CI)	‐1.79 [‐2.51, ‐1.07]

1.3 heart rate [beats/min] Show forest plot	26	1747	Mean Difference (IV, Random, 95% CI)	‐2.76 [‐4.57, ‐0.95]

Comparison 1. Walking vs non‐intervention control

Comparison 2. Walking vs non‐intervention control: subgroup analysis by age

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
2.1 SBP by Age Show forest plot	73	5060	Mean Difference (IV, Random, 95% CI)	‐4.12 [‐5.22, ‐3.01]

2.1.1 Age <=40	14	491	Mean Difference (IV, Random, 95% CI)	‐4.41 [‐6.17, ‐2.65]
2.1.2 Age 41‐60	35	1959	Mean Difference (IV, Random, 95% CI)	‐3.79 [‐5.64, ‐1.94]
2.1.3 Age >60	24	2610	Mean Difference (IV, Random, 95% CI)	‐4.30 [‐6.17, ‐2.44]
2.2 DBP by Age Show forest plot	69	4711	Mean Difference (IV, Random, 95% CI)	‐1.79 [‐2.51, ‐1.07]

2.2.1 Age <=40	14	491	Mean Difference (IV, Random, 95% CI)	‐3.01 [‐4.44, ‐1.58]
2.2.2 Age 41‐60	32	1730	Mean Difference (IV, Random, 95% CI)	‐1.74 [‐2.95, ‐0.52]
2.2.3 Age >60	23	2490	Mean Difference (IV, Random, 95% CI)	‐1.33 [‐2.40, ‐0.26]

Comparison 2. Walking vs non‐intervention control: subgroup analysis by age

Comparison 3. Walking vs non‐intervention control: subgroup analysis by sex

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
3.1 SBP by Sex Show forest plot	26	1352	Mean Difference (IV, Random, 95% CI)	‐5.49 [‐7.43, ‐3.56]

3.1.1 Male	6	203	Mean Difference (IV, Random, 95% CI)	‐4.64 [‐8.69, ‐0.59]
3.1.2 Female	22	1149	Mean Difference (IV, Random, 95% CI)	‐5.65 [‐7.89, ‐3.41]
3.2 DBP by Sex Show forest plot	24	1203	Mean Difference (IV, Random, 95% CI)	‐2.67 [‐3.85, ‐1.48]

3.2.1 Male	6	203	Mean Difference (IV, Random, 95% CI)	‐2.54 [‐4.84, ‐0.24]
3.2.2 Female	20	1000	Mean Difference (IV, Random, 95% CI)	‐2.69 [‐4.16, ‐1.23]

Comparison 3. Walking vs non‐intervention control: subgroup analysis by sex

Comparison 4. Walking vs non‐intervention control: sensitivity analysis for studies at low risk of overall bias

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
4.1 systolic blood pressure Show forest plot	4	235	Mean Difference (IV, Random, 95% CI)	‐4.31 [‐7.99, ‐0.63]

4.2 diastolic blood pressure Show forest plot	4	235	Mean Difference (IV, Random, 95% CI)	‐0.43 [‐2.78, 1.92]

Comparison 4. Walking vs non‐intervention control: sensitivity analysis for studies at low risk of overall bias

Comparison 5. Walking vs non‐intervention control: sensitivity analysis for studies at low risk of attrition bias

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
5.1 systolic blood pressure Show forest plot	41	3480	Mean Difference (IV, Random, 95% CI)	‐4.67 [‐6.25, ‐3.09]

5.2 diastolic blood pressure Show forest plot	41	3480	Mean Difference (IV, Random, 95% CI)	‐2.23 [‐3.20, ‐1.26]

Comparison 5. Walking vs non‐intervention control: sensitivity analysis for studies at low risk of attrition bias

Comparison 6. Walking vs non‐intervention control: sample size per trial ≦30 vs. >30

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
6.1 SBP Show forest plot	73	5040	Mean Difference (IV, Random, 95% CI)	‐4.12 [‐5.23, ‐3.02]

6.1.1 sample size <= 30	15	321	Mean Difference (IV, Random, 95% CI)	‐7.06 [‐9.47, ‐4.66]
6.1.2 sample size >30	58	4719	Mean Difference (IV, Random, 95% CI)	‐3.48 [‐4.69, ‐2.27]
6.2 DBP Show forest plot	69	4691	Mean Difference (IV, Random, 95% CI)	‐1.79 [‐2.51, ‐1.08]

6.2.1 sample size <= 30	15	321	Mean Difference (IV, Random, 95% CI)	‐2.92 [‐5.02, ‐0.82]
6.2.2 sample size >30	54	4370	Mean Difference (IV, Random, 95% CI)	‐1.57 [‐2.32, ‐0.82]

Comparison 6. Walking vs non‐intervention control: sample size per trial ≦30 vs. >30

Comparison 7. Walking vs non‐intervention control: subgroup analysis (normotensive vs. high normal)

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
7.1 SBP Show forest plot	72	5048	Mean Difference (IV, Random, 95% CI)	‐4.14 [‐5.28, ‐3.00]

7.1.1 Normotensive <130	33	2057	Mean Difference (IV, Random, 95% CI)	‐3.68 [‐5.12, ‐2.24]
7.1.2 High normal and Hypertensive ≧130	39	2991	Mean Difference (IV, Random, 95% CI)	‐4.54 [‐6.23, ‐2.85]
7.2 DBP Show forest plot	68	4699	Mean Difference (IV, Random, 95% CI)	‐4.06 [‐5.24, ‐2.88]

7.2.1 Normotensive <85	53	3920	Mean Difference (IV, Random, 95% CI)	‐3.91 [‐5.26, ‐2.55]
7.2.2 High normal and Hypertensive ≧85	15	779	Mean Difference (IV, Random, 95% CI)	‐4.57 [‐7.07, ‐2.07]

Comparison 7. Walking vs non‐intervention control: subgroup analysis (normotensive vs. high normal)

Comparison 8. Walking vs non‐intervention control: subgroup analysis (normotensive vs. hypertensive)

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
8.1 SBP Show forest plot	54	3630	Mean Difference (IV, Random, 95% CI)	‐4.24 [‐5.52, ‐2.97]

8.1.1 Normotensive <130	33	2057	Mean Difference (IV, Random, 95% CI)	‐3.68 [‐5.12, ‐2.24]
8.1.2 Hypertensive ≧140	21	1573	Mean Difference (IV, Random, 95% CI)	‐5.21 [‐7.66, ‐2.76]
8.2 DBP Show forest plot	60	4223	Mean Difference (IV, Random, 95% CI)	‐4.39 [‐5.67, ‐3.10]

8.2.1 Normotensive <85	53	3920	Mean Difference (IV, Random, 95% CI)	‐3.91 [‐5.26, ‐2.55]
8.2.2 Hypertensive ≧90	7	303	Mean Difference (IV, Random, 95% CI)	‐7.82 [‐11.16, ‐4.47]

Comparison 8. Walking vs non‐intervention control: subgroup analysis (normotensive vs. hypertensive)