Nordic Walking Promoted Weight Loss in Overweight and Obese People: A Systematic Review for Future Exercise Prescription

Abstract

The aim of this systematic review was to analyze the effect of Nordic Walking (NW) on anthropometric parameters, body composition, cardiovascular parameters, aerobic capacity, blood sample, and glucose tolerance in overweight and obese subjects. The main keywords “Nordic Walking” or “Pole Walking”, associated with either “obese”, “obesity”, “overweight”, or “weight loss” were used on the online database MEDLINE, PubMed, SPORTDiscus and Scopus. Additionally, references of the studies included were screened to identify eligible articles. Applying the inclusion and exclusion criteria, ten manuscripts were considered as eligible for this review. The results of the studies were categorized in several domains with regard to “anthropometric parameters and body composition”, “cardiovascular parameters and aerobic capacity”, and “blood sample and glucose tolerance”. The results showed positive effects on the anthropometric parameters, body composition, cardiovascular parameters, blood sample, and glucose tolerance. The greatest improvements were observed in supervised and high weekly frequency of NW interventions. NW could be considered as an effective modality through which to involve the obese in physical activity. For weight loss, NW should be prescribed 4–5 times per week, at least 60 min per session, preferably combined with diet control.

Full text

Journal of
Functional Morphology
and Kinesiology
Review
Nordic Walking Promoted Weight Loss in Overweight
and Obese People: A Systematic Review for Future
Exercise Prescription
Stefano Gobbo 1, †, Valentina Bullo 1, †, Enrico Roma 1, Federica Duregon 1,
Danilo Sales Bocalini 2, Roberta Luksevicius Rica 3, Andrea Di Blasio 4, Lucia Cugusi 5,
Barbara Vendramin 1, Manuele Bergamo 1, David Cruz-Diaz 6, Cristine Lima Alberton 7,
Andrea Ermolao 1and Marco Bergamin 1, *,†
1Sport and Exercise Medicine Division, Department of Medicine, University of Padova, Via Giustiniani, 2,
35128 Padova, Italy; stefano.gobbo@unipd.it (S.G.); valentina.bullo@unipd.it (V.B.);
romaenrico94@gmail.com (E.R.); federica.duregon@unipd.it (F.D.); vendramin.barbara@gmail.com (B.V.);
manuele.bergamo@gymhub.it (M.B.); andrea.ermolao@unipd.it (A.E.)
2Laboratorio de Fisiologia e Bioquimica Experimental, Centro de Educacao Fisica e Deportos, Universidade
Federal do Espirito Santo (UFES), Vitoria, ES, Rua Vergueiro, 235, Liberdade, Sao Paulo, SP 01504-00, Brazil;
bocaliniht@hotmail.com
3Departamento de Educacao Fisica e Ciencias do Envelhecimento, Laboratorio de Percepcao Corporal e
Movimento, Universidade Sao Judas Tadeu, Sao Paulo, SP 05503-001, Brazil; robertarica@hotmail.com
4Department of Medicine and Sciences of Aging, G. d’Annunzio University of Chieti-Pescara IT, 100,
66100 Chieti, Italy; andiblasio@gmail.com
5
Department of Medical Sciences and Public Health, University of Cagliari IT, SS 554, 09042 Monserrato, Italy;
lucia.cugusi@tiscali.it
6Department of Health Sciences, Faculty of Health Sciences, University of Jaén, 23001, 23009 Jaén, Spain;
dcruz@ujuan.es
7
Physical Education School, Federal University of Pelotas, Rua Lu
í
s de Cam
õ
es, Pelotas, RS 96055630, Brazil;
tinialberton@yahoo.com.br
*Correspondence: marco.bergamin@unipd.it; Tel.: +39-049-8214429; Fax: +39-049-8215862
†These Authors equally contributed to the manuscript.
Received: 15 May 2019; Accepted: 12 June 2019; Published: 18 June 2019


Abstract:
The aim of this systematic review was to analyze the effect of Nordic Walking (NW) on
anthropometric parameters, body composition, cardiovascular parameters, aerobic capacity, blood
sample, and glucose tolerance in overweight and obese subjects. The main keywords “Nordic
Walking” or “Pole Walking”, associated with either “obese”, “obesity”, “overweight”, or “weight
loss” were used on the online database MEDLINE, PubMed, SPORTDiscus and Scopus. Additionally,
references of the studies included were screened to identify eligible articles. Applying the inclusion
and exclusion criteria, ten manuscripts were considered as eligible for this review. The results of the
studies were categorized in several domains with regard to “anthropometric parameters and body
composition”, “cardiovascular parameters and aerobic capacity”, and “blood sample and glucose
tolerance”. The results showed positive effects on the anthropometric parameters, body composition,
cardiovascular parameters, blood sample, and glucose tolerance. The greatest improvements were
observed in supervised and high weekly frequency of NW interventions. NW could be considered
as an effective modality through which to involve the obese in physical activity. For weight loss,
NW should be prescribed 4–5 times per week, at least 60 min per session, preferably combined with
diet control.
Keywords: nordic walking; obesity; review; exercise prescription; weight loss
J. Funct. Morphol. Kinesiol. 2019,4, 36; doi:10.3390/jfmk4020036 www.mdpi.com/journal/jfmk

J. Funct. Morphol. Kinesiol. 2019,4, 36 2 of 16
1. Introduction
Physical inactivity is the primary cause of most chronic diseases and is responsible for accelerating
biological aging becoming one of the risk factors for premature death worldwide [
1
]. Insufficient level
of PA predispose people to an increased risk for developing chronic conditions, including diabetes,
cardiovascular disease, and cancer [
2
]. Moreover, the abundance of energy-enriched food associated
with a sedentary lifestyle has caused an increase in the number of overweight and obese people
worldwide, including in developing countries [
3
]. The American College of Sport Medicine 2018
Guidelines recommendation for overweight and obese subjects suggest a dose-response relationship
for weight loss. Namely, less than 150 min of weekly PA induces a minimal weight loss, more than
150 min induce a moderate weight loss, while 225–420 min of weekly PA results in a large weight loss.
To promote long-term weight loss, PA should be performed 5–7 days per week for at least 250 min
of weekly PA [
4
]. Compared to sedentary people, any level of leisure-time PA reduces the risk of
mortality [
5
], also in the overweight and obese population [
6
]. Moreover, people who were physically
active were less likely to gain weight [
7
], and the less active people had the greatest benefits from
increasing their level of PA [8].
Walking is the most common modality to increase PA in sedentary people. Despite this, in
young and healthy subjects, walking alone is not enough to reach the intensity necessary to induce
training modification. Furthermore, an increase in walking speed should be required to reach the
optimal training intensity. Unfortunately, in some morbid population such as people with obesity,
that walking speed is difficult to be reached [
9
]. For this reason, Nordic Walking (NW) could be
considered as an alternative method to increase exercise intensity and energy expenditure, especially
for people with mobility impairments [
9
]. NW is a combination of walking and cross-country skiing
performed with poles that are specifically developed for this activity. The involvement of the upper
and lower limb, simultaneously induces an increase in energy expenditure, during NW practice, in
comparison to normal walking [
10
]. The use of Nordic poles facilitates the practice in people with
mobility impairments, like the elderly [
11
] and Parkinson disease patients [
12
]. In comparison with
simple walking, the poles reduce the articular load on the lower limb during NW, preventing damage
and pain to the knee joint, with potential benefits for people with obesity [13].
In light of these perspectives, the aim of this systematic review was to analyze the effect of
NW programs on anthropometric parameters, body composition, cardiovascular parameters, aerobic
capacity, blood sample, and glucose tolerance in overweight and obese subjects. Awaiting future and
more solid evidences, the final goal of this review was to recommend an initial scheme to introduce
NW in the exercise prescription for overweight and obese individuals.
2. Materials and Methods
2.1. Study Design
This systematic review of the literature aimed to analyze the effects of NW on anthropometric
parameters, body composition, cardiovascular parameters, aerobic capacity, blood sample, and glucose
tolerance on overweight and obese subjects. The Preferred Reporting Items for Systematic Reviews
and Meta-Analyses (PRISMA) guidelines and flow chart diagram were used as a reporting structure
for this systematic review [14,15].
2.2. Literature Search
The literature research was performed between June and July 2018. The main keywords “Nordic
Walking” or “Pole Walking”, and “obese”, “obesity”, “overweight”, or “weight loss” were used on
the online database MEDLINE, PubMed, SPORTDiscus, and Scopus. In addition, references of the
included studies were screened to identify the eligible articles.

J. Funct. Morphol. Kinesiol. 2019,4, 36 3 of 16
2.3. Inclusion and Exclusion Criteria
Only studies published in English on peer-reviewed journals were considered for the inclusion.
To be included, articles had to meet the following inclusion criteria, according to PICO model [
15
]—(a)
Body Mass Index (BMI) higher than 25; (b) supervised or not supervised NW intervention; (c) the
presence or not of a control group; (d) evaluation of anthropometric parameters, body composition,
cardiovascular parameters, aerobic capacity, blood sample, and glucose tolerance; and (e) randomized
controlled trial (RCTs) and no-randomized controlled trial (noRCTs). Both males and females from all
races and different states of health were included. All studies that did not evaluate the outcomes through
pre- and post-intervention comparisons, with mixed activity intervention, as well as cross-sectional
studies and case reports, were excluded. Published abstracts, dissertation materials, or conference
presentations were not considered as eligible documents.
2.4. Study Quality Assessment
The quality of the studies was assessed by applying an adapted nine criteria checklist, provided
by the Cochrane Collaboration Back Review Group [
16
]. As in the previous review [
17
,
18
], the checklist
had to be marginally adapted to rate the strength of the evidence. Each study in the review was
scored on the basis of the following nine criteria: (1) “Was the method of randomization adequate?”;
(2) “Were the groups similar at baseline regarding the outcome measures?”; (3) “Were inclusion and
exclusion criteria adequately specified?”; (4) “Was the drop-out rata described adequately?”; (5) “Were
all randomized participants analyzed in the group to which they were allocated?”; (6) “Was compliance
reported for all groups?”; (7) “Was intention-to-treat analysis performed?”; (8) “Was the timing of
outcomes assessment similar in all groups?”; and (9) “Was a followed up performed?”. When the paper
provided a satisfactory description, a positive value was assigned (+). If the criterion descriptions was
considered absent, unclear, or lacked the specified content, a negative value was assigned (
−
). A study
was qualitatively estimated as high quality, if it showed a positive score on 5 out of 9 of the criteria;
otherwise, it was considered a low-quality study.
2.5. Data Extraction and Synthesis
Two researchers independently examined all abstracts of the sourced studies. Several studies
were analyzed in more details to be included in the review. Additional articles were sourced, reviewing
the reference sections of the included studies. The individual searches were combined, compared, and
reviewed for applicability, where a consensus was made regarding the study inclusion. In case of
discrepancies, the review process was repeated and a third researcher was consulted. A K-Cohen’s
coefficient of 0.87 indicated a perfect agreement between researchers. Quality assessment was applied
independently by the two researchers, using the modified Cochrane methodological quality criteria,
and was discussed before the final quality scores assignation (Table 1). The same researchers who
screened the titles, abstracts, full texts, and references, also performed the quality assessment. Several
domains were identified for categorization of the study results. In particular, studies were analyzed
with regards to “anthropometric parameters and body composition”, “cardiovascular parameters and
aerobic capacity”, and “blood sample and glucose tolerance”.

J. Funct. Morphol. Kinesiol. 2019,4, 36 4 of 16
Table 1. Quality assessment of the included studies.
Citation Randomization
Procedure
Similarity
of Study
Groups
Inclusion or
Exclusion
Criteria
Dropouts Blinding Compliance Intention-To-Treat
Analysis
Timing of
Outcomes
Assessment
Follow-Up Results
Kucio et al. (2017) [19]− − + + − − − − − 2/9
Pilch et al. (2017) [20]− − − − − − − +−1/9
Derengowska et al. (2015) [21]− − − − − − − − − 0/9
Derengowska et al. (2015) [22]− − + + − − − − − 2/9
Wiklund et al. (2014) [23]+− − + + −+ + −5/9
Trabka et al. (2013) [24]+−+ + − − − − − 3/9
Fritz et al. (2013) [25]+−+ + − − +− − 4/9
Venojärvi et al. (2013) [26]+−+ + −+− − − 4/9
Fabre et al. (2011) [27]−+ + − − +− − − 3/9
Gram et al. (2010) [28]+−+ + −+− − +5/9

J. Funct. Morphol. Kinesiol. 2019,4, 36 5 of 16
3. Results
3.1. Description of the Study
Two hundred and three studies were found from the literature search. Applying the inclusion and
exclusion criteria, 10 were considered eligible for this review (Figure 1). Sample sizes ranged from 17 to
213 subjects, aged from 20 to 80. A single session of NW lasted from 30 to 90 min, and was performed
for 1 to 3 times per week (Table 2). The duration of the different study protocols were from 4 to 16 weeks.
The intensity of the NW program was reported in 6 studies [
19
,
20
,
23
,
24
,
26
,
28
], and 3 of them provided
for the intensity progression [
23
,
24
,
26
]. There was only one case of follow-up, after 32 weeks [
28
]. Two
studies were classified as high quality, while were classified 8 as low [
19
–
22
,
24
,
25
,
27
,
28
]. Randomization
procedures were performed in 5 studies [
23
–
26
,
28
], and similarity among group was performed in only
1 study [
27
]. The inclusion and exclusion criteria were adequately reported in 7 studies [
19
,
22
,
24
–
28
],
and only 2 studies described the timing of outcome assessments [
20
,
23
]. Blinding procedures were
applied in 1 study [
23
], 7 specified the dropout [
19
,
22
–
26
,
28
], and 3 performed the intention-to-treat
analyses [
23
,
25
,
28
]. Finally, 3 papers reported the compliance [
26
–
28
]. All results were classified
and analyzed with regards to the “anthropometric parameters and body composition” [
19
–
28
],
“cardiovascular parameters and aerobic capacity” [
19
,
20
,
23
–
28
], and “blood sample and glucose
tolerance” [19,21–26,28] (Table 3).
J. Funct. Morphol. Kinesiol. 2019, 4, x FOR PEER REVIEW 5 of 16
3. Results
3.1. Description of the Study
Two hundred and three studies were found from the literature search. Applying the inclusion
and exclusion criteria, 10 were considered eligible for this review (Figure 1). Sample sizes ranged
from 17 to 213 subjects, aged from 20 to 80. A single session of NW lasted from 30 to 90 minutes, and
was performed for 1 to 3 times per week (Table 2). The duration of the different study protocols were
from 4 to 16 weeks. The intensity of the NW program was reported in 6 studies [19,20,23,24,26,28],
and 3 of them provided for the intensity progression [23,24,26]. There was only one case of follow-
up, after 32 weeks [28]. Two studies were classified as high quality, while were classified 8 as low
[19–22,24,25,27,28]. Randomization procedures were performed in 5 studies [23–26,28], and similarity
among group was performed in only 1 study [27]. The inclusion and exclusion criteria were
adequately reported in 7 studies [19,22,24–28], and only 2 studies described the timing of outcome
assessments [20,23]. Blinding procedures were applied in 1 study [23], 7 specified the dropout [19,22–
26,28], and 3 performed the intention-to-treat analyses [23,25,28]. Finally, 3 papers reported the
compliance [26–28]. All results were classified and analyzed with regards to the “anthropometric
parameters and body composition” [19–28], “cardiovascular parameters and aerobic capacity”
[19,20,23–28], and “blood sample and glucose tolerance” [19,21–26,28] (Table 3).
Figure 1. Flow chart.
Records identified through
database searching
(n = 203)
Screening
Included
Eligibility
Identification
Additional records identified
through other sources
(n = 1)
Records after duplicates removed
(n = 67)
Records screened
(n = 67)
Records excluded
Review (n = 8)
No obese or overweight (n = 8)
No NW intervention (n = 10)
No English language (n = 12)
Note, letter, short report, case
report (n = 5)
Full-text articles assessed
for eligibility
(n = 24)
Full-text articles excluded, with
reasons
No obese or overweight (n = 4)
No NW intervention (n = 5)
No physical performance
evaluation (n = 5)
Studies included in
qualitative synthesis
(n = 10)
)
Figure 1. Flow chart.

J. Funct. Morphol. Kinesiol. 2019,4, 36 6 of 16
Table 2. Characteristics of the studies.
Study Subjects and Grouping Training Modality, Program, and Intensity Duration and Frequency
Kucio et al. (2017) [19]
26 M
47–66 y.o
NW (15)
CG (11)
Supervised NW
Warm up: 10’
Main part: week 1, 30’ of NW at 3 km/h. week 2–4, 40’ of NW at 5 km/h. HR
40–70% of HMmax
4 weeks
5 d/w
40–50 min
Pilch et al. (2018) [20]
17 F
mean 57 y.o.
NW (17)
Supervised NW
Warm-up: 15’ of walking and dynamic stretching
Main part: 60’ of NW on grass and natural surface at 60–70% of HRmax
Cool-down: 10–15’ of stretching and relaxing exercises
6 weeks
3 d/w
90 min
Derengowska et al. (2015) [21]
32 F
50–68 y.o.
NW (32)
Supervised NW
Warm-up
10 weeks
5 d/w
60 min
Derengowska et al. (2015) [22]
89 F
50–75 y.o.
NW (69)
CG (20)
Supervised and no supervised NW
Warm-up and cool-down
(3 supervised and 3 no supervised)
10 weeks
6 d/w
60 min
Wiklund et al. (2014) [23]
90 F
20–50 y.o.
NW (45)
DI (45)
Supervised NW
Week 1: 60% HRmax
Week 2–3: 65% HRmax
Week 4–5: 70% HRmax
Week 6: 75% HRmax
DI
Reduction of portion size, control meal rhythm, change the composition of
food (light margarine, vegetable oil, low-fat milk and meat, vegetables, fruits,
increase fiber intake). Drink water, light beverage, mild juice, coffee and tea.
6 weeks
3–4 d/w
30–60 min
Trabka et al. (2013) [24]
46 F
NW (25)
DI (21)
Supervised NW
Warm-up: 10 min
Main part: 40 min of NW and 20 min of strength training. HR increased
progressively from 50% to 80% of HR
res
, 10% every 2 weeks. Strength exercise
was performed in 3 sets. Repetitions were 15 squats, 30 heel-raises, sit-ups
until exhaustion, and 15 push-ups on knees.
Cool-down: 10 min of stretching
DI
No high-fat and high-glycemic food
Eating 5 times per day, no after 7.00 p.m. or 3 h before sleep
Drinking at least 1.5 L of water
10 weeks
3 d/w
80 min

J. Funct. Morphol. Kinesiol. 2019,4, 36 7 of 16
Table 2. Cont.
Study Subjects and Grouping Training Modality, Program, and Intensity Duration and Frequency
Fritz et al. (2013) [25]
213 (118 F, 95 M)
45–69 y.o.
NW-NGT (87)
NW-IGT (14)
NW-T2DM (20)
CG-NGT (75)
CG-IGT (21)
CG-T2DM (30)
No supervised NW
Participants were instructed to increase their weekly level of physical activity
by 5 h of NW.
4 months
5 h/w
Venojärvi et al. (2013) [26]
79 M 40–65 y.o.
NW (39)
CG (40)
Supervised NW
Warm-up: walking and stretching of the main muscle group for 5’.
Main part: weeks 1–4 at 55% of HR
res
; weeks 5–8 at 65% of HR
res
; weeks 9–12
at 75% of HRres.
Cool-down: stretching of the main muscle group for 5’.
12 weeks
3 d/w
60 min
Fabre et al. (2011) [27]
23 F
NW (12)
WT (11)
Supervised and no supervised NW
4 weeks of learning of NW technique before the intervention
Warm-up: 5–10’
Main part: 30’ of interval training, 6 bouts of 5 min (4’ at preferred walking
speed followed by 1’ at maximal walking speed)
Cool-down: 5–10’
1 supervised and 2 unsupervised NW
Supervised and no supervised WT
Follow NW but without poles.
1 supervised and 2 unsupervised WT
12 weeks
3 d/w
40–50 min
Gram et al. (2010) [28]
44 (37 M, 31 F)
25–80 y.o.
NW (22)
CG (22)
Supervised NW
Warm-up: 10’
Main part: 30’ (>40% of VO2max).
Cool-down: 5’
4 months
1–2 d/w
45 min
d/w: day/week; h/w: hour/week; NW: Nordic Walking; CG: Control Group; DI: Diet Group; WT: Walking Training; NGT: Normal Glucose Tolerance; IGT: Impaired Glucose Tolerance;
T2DM: Type 2 Diabetes.

J. Funct. Morphol. Kinesiol. 2019,4, 36 8 of 16
3.2. Anthropometric Parameters and Body Composition
All included studies evaluated the anthropometric parameters, and 6 of them recorded significant
improvement [
19
–
22
,
25
,
27
]. Significant reductions on body weight and BMI were recorded after
4 weeks (body weight
−
1.3%, BMI
−
1.3% [
19
]), 6 weeks (body weight
−
0.7%, BMI—1.1% [
20
]), 10 weeks
(body weight
−
5.6%, BMI
−
5.6% [
21
]; body weight
−
6.4%, BMI
−
6.4% [
22
]), while after 12 weeks Fabre
and colleagues found significant reduction only in body weight (
−
1.7%) [
27
]. Fritz and colleagues [
25
]
separately analyzed obese with normal glucose tolerance (NGT), impaired glucose tolerance (IGT),
and type 2 diabetes mellitus (T2DM). Sixteen weeks of NW, induced significant reduction of body
weight in obese subjects with NGT and T2DM (
−
2.3%,
−
1.1%), such as for BMI (
−
2.4%,
−
1.3%), while
no significant change was found in obese participants with IGT. On the contrary, the authors recorded
a significant reduction in waist circumference (WC) in all three groups (NGT
−
4.9%, IGT
−
2.2%, and
T2DM −1.2%) [25].
Five studies analyzed the body composition [
20
,
23
,
26
–
28
]. Significant reduction in body fat mass
(BFM) was recorded after 6 weeks of NW (
−
0.6%) [
20
], such as after 12 weeks (
−
2.2%) [
27
]. Moreover,
Fabre and colleagues found significant reduction in the skin-fold thickness (−7.4%) [27].
3.3. Cardiovascular Parameters and Aerobic Capacity
Six studies evaluated the cardiovascular parameters, including the systolic blood pressure (SBP),
diastolic blood pressure (DBP), and heart rate (HR) [
19
,
20
,
25
–
28
]. The significant changes were, the
reduction of HR, at rest, after 6 weeks of NW (−5.9% [20]), and DBP after 12 weeks (−8.1% [27]).
The effects of NW on the aerobic capacity were evaluated in 5 studies [
19
,
23
,
24
,
26
,
28
]. After
4 weeks of NW, Kucio and colleagues found a significant improvement in exercise tolerance, expressed
as metabolic equivalent values (+17.3%) and time to exhaustion (+14.3%) [
19
]. After 10 weeks, maximal
oxygen consumption (VO2max) improved by 17.5% [24].
3.4. Blood Sample and Glucose Tolerance
Blood sample was measured and analyzed in 8 studies [
19
,
21
–
26
,
28
]. Low-density lipoprotein
(LDL) improved significantly after 10 weeks of NW (
−
12.2% [
21
],
−
16.4% [
22
]), such as high density
lipoprotein (HDL) (+9% [
21
], +8.1% [
22
]). Additionally, Fritz and colleagues found a significant
difference in HDL between the NW and CG of the NGT group [
25
]. Total cholesterol (TC) decreased
significantly after 4 weeks (
−
10.3% [
19
]), and 10 weeks (
−
9% [
21
],
−
12.1% [
22
]) of NW, while Fritz
and colleagues found significant difference between NW and CG in T2DM group [
25
]. Similarly,
triglycerides (TG) decreased after 4 weeks (
−
33% [
19
]) and 10 weeks (
−
21.5% [
21
],
−
17.2% [
22
]) of NW.
Glucose tolerance was analyzed with different methods in 4 studies [
23
,
25
,
26
,
28
]. In the fasting
glucose test, 6 weeks of NW induced a significant decrease in glucose level, monitored for 8-h
(
−
9.6%) [
23
]. The 2-h oral glucose tolerance test (OGTT-2h) showed a significant improvement
after 16 weeks of NW in the IGT (
−
7.9%) and the T2DM (
−
11.4%) groups [
25
]. Homeostasis model
assessment of insulin resistance (HOMA-IR) recorded a significant improvement after 6 weeks of NW
(
−
27.8%) [
23
]. After 6 weeks of NW, the insulin level decreased significantly (
−
19.3%) [
23
], and the
glycated hemoglobin A1c (HbA1c) decreased after 16 weeks of NW in T2DM group (
−
4.2%,
−
6.1%) [
25
].

J. Funct. Morphol. Kinesiol. 2019,4, 36 9 of 16
Table 3. Results of the included studies.
Study Group Comparison Results
Kucio et al. (2017) [19] NW vs. CG
Anthropometric parameters and body composition
Weight (kg): ↓NW*; =CG
BMI (kg/m2): ↓NW*; ↓CG
Cardiovascular parameters and aerobic capacity
M24-h SBP (mmHg): ↓NW; ↓CG
M24-h DBP (mmHg): ↓NW; ↓CG
M24-h MAP (mmHg): ↓NW; ↓CG
M-daily SBP (mmHg): ↓NW; ↓CG
M-daily DBP (mmHg)#: ↓NW; ↓CG
M-daily MAP (mmHg): ↓NW; ↓CG
M-nightly SBP (mmHg): ↓NW; ↓CG
M-nightly DBP (mmHg): ↓NW; ↓CG
M-nightly MAP (mmHg): ↓NW; ↓CG
Time to exhaustion (min): ↑NW*; ↑CG*
MET (mL/kg/min): ↑NW*; ↑CG
Blood sample and glucose tolerance
TC (mg%): ↓NW*; ↓CG
LDL (mg%): ↓NW; ↓CG
HDL (mg%): ↓NW; ↓CG
TG (mg%): ↓NW*; ↑CG
Pilch et al. (2017) [20] NW
Anthropometric parameters and body composition
Weight (kg): ↓NW*
BMI (kg/m2): ↓NW*
BFM (%): ↓NW*
LBM (kg): ↓NW
Cardiovascular parameters and aerobic capacity
HRrest (bpm): ↓NW*
Derengowska et al.
(2015) [21]NW
Anthropometric parameters and body composition
Weight (kg): ↓NW*
BMI (kg/m2): ↓NW*
Blood sample and glucose tolerance
TC (mg/dL): ↓NW*
LDL (mg/dL): ↓NW*
HDL (mg/dL): ↑NW*
TG (mg/dL): ↓NW*
Derengowska et al.
(2015) [22]NW vs. CG
Anthropometric parameters and body composition
Weight (kg): ↓NW*; ↑CG
BMI (kg/m2)#: ↓NW*; ↑CG
Blood sample and glucose tolerance
TC (mg/dL): ↓NW*; ↑CG
LDL (mg/dL): ↓NW*,**; ↑CG
HDL (mg/dL): ↑NW*,**; ↓CG
TG (mg/dL): ↓NW*; ↑CG
nHDL (mg/dL): ↓NW*,**; ↑CG
Glucose (mg/dL): ↓NW*,**; ↓CG
Wiklund et al.
(2014) [23]NW vs. DI
Anthropometric parameters and body composition
Weight (kg)#: ↓NW*; ↓DI*
BMI (kg/m2)#: ↓NW; ↓DI*
BFM (kg)#: ↑NW; ↓DI
VFA (cm2): ↓NW; ↓DI*
FFM (kg): ↓NW; ↓DI*
Cardiovascular parameters and aerobic capacity
VO2max (mL/kg/min): ↑NW; ↑DI
Blood sample and glucose tolerance
TC (mmol/L): ↑NW; ↑DI
LDL (mmol/L): ↑NW; ↑DI
HDL (mmol/L): ↑NW; =DI
TG (mmol/L): =NW; =DI
Insulin (µU/L): ↓NW*; ↓DI
Fasting glucose (mmol/L): ↓NW*,**; ↑DI
HOMA-IR: ↓NW*,**; ↓DI

J. Funct. Morphol. Kinesiol. 2019,4, 36 10 of 16
Table 3. Cont.
Study Group Comparison Results
Trabka et al. (2013) [
24
]
NW vs. DI
Anthropometric parameters and body composition
Weight (kg): ↓NW; ↓DI
BMI (kg/m2): ↓NW; ↓DI
WC (cm): ↓NW; ↑DI
HC (cm): ↓NW; ↑DI
WHR: ↑NW; ↓DI
Cardiovascular parameters and aerobic capacity
VO2max (mL/kg/min): ↑NW*; ↑DI
Blood sample and glucose tolerance
TC (mmol/L): ↑NW; ↓DI
LDL (mmol/L): ↓NW; =DI*
HDL (mmol/L): ↑NW; =DI
TG (mmol/L): =NW; =DI
Fritz et al. (2013) [25]
NW vs. CG (NGT)
Anthropometric parameters and body composition
Weight (kg): ↓NW*,**; ↓CG
BMI (kg/m2): ↓NW*,**; ↓CG
WC (cm): ↓NW*,**; ↓CG*
Cardiovascular parameters and aerobic capacity
SBP (mmHg): ↑NW; ↓CG
DBP (mmHg): ↑NW; ↓CG
Blood sample and glucose tolerance
TC (mmol/L): =NW; =CG
LDL (mmol/L): =NW; ↑CG
HDL (mmol/L): =NW**; ↓CG*
TG (mmol/L): =NW; =CG
Fasting glucose (mmol/L): =NW; ↓CG*
HOMA-IR: ↓NW; =CG
OGTT 2h (mmol/L): ↓NW; ↑CG
HbA1c (%): =NW; =CG
HbA1c (mmol/L): =NW; ↑CG
NW vs. CG (IGT)
Anthropometric parameters and body composition
Weight (kg): ↓NW; ↓CG
BMI (kg/m2): ↓NW; ↓CG
WC (cm): ↓NW*; ↓CG*
Cardiovascular parameters and aerobic capacity
SBP (mmHg): ↓NW; ↑CG
DBP (mmHg): ↑NW; ↓CG
Blood sample and glucose tolerance
TC (mmol/L): ↑NW; ↓CG
LDL (mmol/L): ↑NW; ↓CG
HDL (mmol/L): =NW; ↓CG
TG (mmol/L): ↓NW; ↓CG
Fasting glucose (mmol/L): ↓NW; ↓CG
HOMA-IR: ↑NW; ↑CG
OGTT 2h (mmol/L): ↓NW*; ↓CG
HbA1c (%): ↓NW**; ↑CG
HbA1c (mmol/L): ↓NW; ↑CG
NW vs. CG (T2DM)
Anthropometric parameters and body composition
Weight (kg): ↓NW*; ↓CG
BMI (kg/m2): ↓NW*; ↓CG
WC (cm): ↓NW*; ↓CG
Cardiovascular parameters and aerobic capacity
SBP (mmHg): ↑NW; ↓CG
DBP (mmHg): ↓NW; ↓CG
Blood sample and glucose tolerance
TC (mmol/L): ↓NW**; ↑CG*
LDL (mmol/L): =NW; ↑CG*
HDL (mmol/L): =NW; =CG
TG (mmol/L)#: ↓NW; ↑CG
Fasting glucose (mmol/L): ↓NW; ↓CG*
HOMA-IR: ↑NW; ↓CG
OGTT 2h (mmol/L): ↓NW*; ↓CG*
HbA1c (%): ↓NW*; ↓CG
HbA1c (mmol/L): ↓NW*; ↓CG

J. Funct. Morphol. Kinesiol. 2019,4, 36 11 of 16
Table 3. Cont.
Study Group Comparison Results
Venojärvi et al. (2013)
[26]NW vs. CG
Anthropometric parameters and body composition
Weight (kg): ↓NW**; ↓CG
WC (cm): ↓NW; ↓CG
BFM (%): ↓NW**; ↓CG
FFM (kg): ↑NW; ↓CG
Cardiovascular parameters and aerobic capacity
SBP (mmHg): ↓NW; ↓CG
DBP (mmHg): ↓NW; ↓CG
2-km UKK walk test: ↑NW**; ↑CG
Blood sample and glucose tolerance
TC (mmol/L): ↓NW; ↑CG
LDL (mmol/L): ↓NW; ↑CG
HDL (mmol/L): =NW; ↑CG
TG (mmol/L): ↓NW; ↓CG
Glucose (mmol/L): =NW; ↓CG
Insulin (µIU/L)#: ↓NW; ↑CG
Insulin 2h (µIU/L)#: ↓NW; ↓CG
HOMA-IR#: ↓NW; ↑CG
OGTT 2h (mmol/L): ↓NW; ↓CG
HbA1c (%): =NW; ↑CG
Fabre et al. (2011) [27] NW vs. WT
Anthropometric parameters and body composition
Weight (kg): ↓NW*; ↓WT*
BMI (kg/m2): ↓NW; ↓WT
BFM (%): ↓NW*; ↓WT*
Skin-fold thickness (cm): ↓NW*; ↓WT*
Cardiovascular parameters and aerobic capacity
SBP (mmHg): ↓NW; ↓WT
DBP (mmHg): ↓NW*; ↓WT*
HR (bpm): ↑NW; ↑WT
Gram et al. (2010) [28] NW vs. CG
Anthropometric parameters and body composition
Weight (kg): ↓NW; ↓CG
BMI (kg/m2): ↓NW; ↓CG
WC (cm): ↓NW; ↑CG
HC (cm)#: ↓NW; ↑CG
BFM (kg): ↓NW**; ↑CG
FFM (kg): ↓NW; ↓CG
Cardiovascular parameters and aerobic capacity
SBP (mmHg): ↓NW; ↓CG
DBP (mmHg): ↓NW; ↓CG
VO2max (L/min): ↑NW; ↑CG
Blood sample and glucose tolerance
TC (mmol/L): ↑NW; ↓CG
LDL (mmol/L): =NW; ↓CG
HDL (mmol/L): =NW; =CG
TG (mmol/L): ↓NW; ↑CG
HbA1c (%): ↓NW; ↑CG
p<0.05, * intra-group difference; ** between group difference; #: significant difference at baseline;
↑
: increase;
↓
:
decrease; =: not change. NW: Nordic Walking; CG: Control Group; DI: Diet Group; NGT: Normal Glucose Tolerance;
IGT: Impaired Glucose Tolerance; T2DM: Type 2 Diabetes; WT: Walking Training. T0—baseline; Twn—evaluation
after n weeks. BMI—body max index; M-24 h—median 24-h; SBP—systolic blood pressure; DBP—diastolic
blood pressure; MAP—mean arterial pressure; M-daily—median daily; M-nightly—median nightly; TC—total
cholesterol; LDL—low-density lipoprotein; HDL—high-density lipoprotein; TG—triglycerides; MET—metabolic
equivalent; BFM—body fat mass; HRrest—heart rate at rest; nHDL—non-HDL; VFA—visceral fat area; FFM—free
fat mass; VO2
max
—maximal oxygen consumption; HOMA-IR—homeostasis model assessment of insulin resistance;
WC—waist circumference; HC—hip circumference; WHR—waist-hip ratio; OGTT—oral glucose tolerance test;
HbA1c—glycated hemoglobin.
4. Discussion
This systematic review aimed to analyze the effects of NW programs on overweight and obese
subjects. The current results showed positive effects on the anthropometric parameters, body
composition, cardiovascular parameters, blood sample, and glucose tolerance. The involvement

J. Funct. Morphol. Kinesiol. 2019,4, 36 12 of 16
of the upper and lower limb for performing NW, increased the energy expenditure during the
workout, compared to normal walking alone. Moreover, the use of poles reduced the lower limb
muscular activation [
29
], potentially, encouraging individuals with lower exercise tolerance to perform
physical activity.
4.1. Anthropometric Parameters and Body Composition
Weight control in overweight and obese people was strongly recommended to reduce the risk of
developing chronic diseases such as metabolic syndrome and type 2 diabetes. For this reason, lifestyle
change, including PA increase and dietary modification was an effective way to improve the overall
health. Moreover, weight loss lower than 5% was considered to be not clinically meaningful [
30
].
According to the previous studies [
31
,
32
], a major reduction in body weight and BMI were found in
the Derengowska et al. studies, due to the integration of NW and diet control. Moreover, these studies
were characterized of a high frequency and duration (60 min 5/6 times per week), with an overall
weekly PA of about 300–360 min per weeks [
21
,
22
]. A significant reduction in body weight and BMI
(5.6% to 6.4%) could be considered as clinically meaningful, confirming the need for a combined PA
and diet interventions, for weight loss in overweight and obese people.
From another point of view, even if BMI was found to be the main indicator that helps identify
overweight and obese people, WC was a stronger predictor for the risk to develop diabetes than BMI.
Indeed, WC was an indicator of body fat distribution, which could identify people with an increased
risk for cardio-metabolic disease [
33
]. Fritz and colleagues analyzed the effect of the non-supervised
NW program on the overweight and obese people with NGT, IGT, and T2DM. Despite the long protocol
(16 weeks), a significant reduction in body weight and BMI was only recorded in the NGT and T2DM
groups. On the contrary, WC was significantly reduced in all the three groups (NGT
−
4.9%; IGT
−
2.2%; and T2DM
−
1.2%). Unfortunately, body fat was not evaluated in this study [
25
]. Body fat
mass were analyzed in three studies that recorded a significant reduction after 12 or 16 weeks of NW
(
−
7.4% [
26
],
−
3.4% [
28
], and
−
2.2% [
27
]) despite the minimal weight loss (
−
2.4% [
26
],
−
1.8% [
28
], and
−
1.7% [
27
]). These results highlighted the importance of body composition evaluation, in addition to
body weight. In fact, the reduction in total body fat, abdominal obesity or both, without significant
weight loss (more than 5%) showed improvements in the cardio-metabolic risk factors, such as insulin
sensitivity [
34
]. Moreover, a major reduction on BFM was recorded in the supervised protocol with
intensity progression from 55% to 75% of HRrest [26].
4.2. Blood Sample and Glucose Tolerance
Lifestyle change was the primary recommendation for the management of hematic parameters.
The lipid profile changes after NW intervention showed contrasting results. Most studies reported
improvement in blood lipid profile, but only three investigation displayed a significant reduction of
TC, TG, LDL [
19
,
21
,
22
], and only the Derengowska et al. studies found a significant improvement in
HDL [
21
,
22
]. As described in other research, the integration of diet and PA was more effective on HDL
modification [35], and Derengowska and colleagues protocol included both the intervention.
With regards to the metabolic profile, Fritz and colleagues analyzed the effect of 16 weeks of
non-supervised NW programs on glucose tolerance and HbAc1 in obese, with or without glucose
impairment, such as diabetes mellitus. In their study, participants were required to reach a target of
300 min of non-supervised NW every week. As expected, the results showed a significant reduction in
OGTT-2h in obese with IGT and T2DM, while HbAc1 only in T2DM [
25
]. This protocol was one of the
longest and the extensive duration of the NW program, also with the higher adherence (78–96%) and
higher minutes of exercise per week, could have concurred to produce these positive results.
In conclusion, exercise frequency and the weekly minutes of non-supervised NW seemed to
positively influence the improvement of metabolic control. Results also indicated that a supervised
NW program with a shorter duration (6 weeks) could lead to significant improvements in both glucose

J. Funct. Morphol. Kinesiol. 2019,4, 36 13 of 16
blood profile and glucose tolerance in middle-aged men with IGT that performed 240 min of activity,
with an intensity of 60–75% of HRmax [23].
4.3. Cardiovascular Parameters and Aerobic Capacity
Aerobic exercise was largely recommended to reduce blood pressure in hypertensive patients. In a
recent document, Lopes et al. reported significant reductions in blood pressure, after at least 4 weeks
of aerobic exercise, with a different magnitude of improvement among hypertensive, pre-hypertensive,
and normal subjects [
36
]. Despite the protocols of our review being longer than 4 weeks, only one
study depicted a significant reduction in DBP [
27
]. Likewise, these results did not significantly
change with a change in heterogeneity of the groups and the hypertensive conditions of the recruited
individuals. Despite this, results were aligned with a previous investigation that reported a mean
reduction of 3.4 for SBP and 2.4 mmHg of DBP, after aerobic exercise [
37
]. In fact, the average blood
pressure reduction of the included studies reported a 3.4 mmHg reduction for SBP and 2.8 mmHg
reduction for DBP. As expected, the aerobic capacity increased after NW intervention. Nevertheless,
non-supervised protocol [
24
] and low weekly minutes of training (only 90 min) [
28
] reported no
significant improvements after NW. On the contrary, it seemed that supervised NW, in which the
intensity augmented progressively from 55% to 75% of HR
max
during the intervention and lasted about
150 to 300 min per week, induced significant improvements of aerobic capacity [19,23,26].
4.4. Limitations
This review presented several limitations. First, the included subjects were overweight and obese
people, without internal distinction into groups. Second, despite the importance of body fat reduction
in people with obesity, body composition was not evaluated in many studies. From this point of
view, future investigations should evaluate weight and body composition changes, following a NW
protocol, to detect significant clinical changes. Third, diet control was described in only one study,
despite it being well-known that the integration of PA and diet is preferable for obesity management.
Finally, training modality and intensity were not reported in all the studies and not all included studies
specified the prior level of PA in participants, or a minimal level of PA as the inclusion or exclusion
criteria for participation. As a consequence, it was difficult to identify a precise dose-response of NW
to promote an improvement in each parameter discussed in this systematic review. Moreover, it was
not possible to identify a clear and efficient intensity progression to optimize weight loss and improve
physical capacity, due to a general lack of information from the analyzed studies.
5. Conclusions
The results of this systematic review showed that NW programs could be considered as an
effective modality to involve overweight and obese patients in physical activity. Additionally, NW
was apparently able to modify different risk factors for cardiovascular diseases, even though the best
improvement seemed was observed in a combination of exercise with diet control. To the best of
our knowledge, clinicians could consider an NW program as a form of exercise in their prescription
to increase PA in overweight and obese people. To promote weight loss, the minimum quantity of
recommended NW is 4 times per week and for at least for 60 min per training session. This minimum
quantity should preferably be coupled with diet control.
Author Contributions:
Conceptualization, M.B. (Marco Bergamin) and S.G.; methodology, E.R. and A.D.B. and
D.C.-D.; formal analysis, M.B. (Manuele Bergamo), S.G. and C.L.A.; investigation, F.D. and B.V.; data curation, D.S.B.
an R.L.R.; writing—original draft preparation, V.B.; writing—review and editing, M.B. (Marco Bergamin) and A.E.;
visualization, L.C.; supervision, M.B. (Marco Bergamin) and A.E.; project administration, M.B. (Marco Bergamin).
Funding: This research received no external funding.
Conflicts of Interest: The authors declare no conflict of interest.

J. Funct. Morphol. Kinesiol. 2019,4, 36 14 of 16
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