356 Clinical Sciences

Associations of Maximal Strength and Muscular

Endurance with Cardiovascular Risk Factors

Authors J. P. Vaara1,5, M. Fogelholm2, T. Vasankari3, M. Santtila4, K. Häkkinen5, H. Kyröläinen1,5

Affiliations Affiliation addresses are listed at the end of the article

Key words Abstract
●
▶ muscular fitness
▼ associated with the clustered cardiovascular risk
●
▶ cardiorespiratory fitness
The aim was to study the associations of maximal
●
▶ cardiometabolic risk factors
strength and muscular endurance with single and
●
▶ waist circumference
clustered cardiovascular risk factors. Muscular
endurance, maximal strength, cardiorespiratory
fitness and waist circumference were measured
in 686 young men (25 ± 5 years). Cardiovascular
risk factors (plasma glucose, serum high- and
low-density lipoprotein cholesterol, triglycer-
ides, blood pressure) were determined. The risk
factors were transformed to z-scores and the
mean of values formed clustered cardiovascular
risk factor. Muscular endurance was inversely
associated with triglycerides, s-LDL-cholesterol,
glucose and blood pressure (β = − 0.09 to − 0.23,
p < 0.05), and positively with s-HDL cholesterol
(β = 0.17, p < 0.001) independent of cardiorespira-
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tory fitness. Muscular endurance was negatively
factor independent of cardiorespiratory fitness
(β = − 0.26, p < 0.05), whereas maximal strength
was not associated with any of the cardiovas-
cular risk factors or the clustered cardiovascular
risk factor independent of cardiorespiratory fit-
ness. Furthermore, cardiorespiratory fitness was
inversely associated with triglycerides, s-LDL-
cholesterol and the clustered cardiovascular
risk factor (β = − 0.14 to − 0.24, p < 0.005), as well
as positively with s-HDL cholesterol (β = 0.11,
p < 0.05) independent of muscular fitness. This
cross-sectional study demonstrated that in
young men muscular endurance and cardiores-
piratory fitness were independently associated
with the clustering of cardiovascular risk factors,
whereas maximal strength was not.

Introduction [5, 19, 20]. Nevertheless, some studies have

accepted after revision
May 24, 2013
Bibliography
DOI http://dx.doi.org/
10.1055/s-0033-1349092
Published online:
November 10, 2013
Int J Sports Med 2014; 35:
356–360 © Georg Thieme
Verlag KG Stuttgart · New York
ISSN 0172-4622
Correspondence
Jani P. Vaara
The Department of Leadership
and Military Pedagogy
National Defence University
Santahamina
00860 Helsinki
Finland
Tel.: + 358/299/530 432
Fax: + 358/299/530 431
jani.vaara@mil.fi
▼ shown attenuated or non-significant association
Adolescents and young adults are generally at a
low risk for having cardiovascular diseases. How-
ever, the risk factors may develop and especially,
track into later life in adulthood [6, 26]. The com-
mon risk factors for cardiovascular diseases
(CVD) include blood pressure, impaired glucose
metabolism, elevated concentration of triglycer-
ides and low level of high-density lipoprotein
cholesterol [10, 29]. Previous studies have shown
that cardiorespiratory fitness (CRF) and body
composition are related to cardiovascular risk
factors [11, 12, 25, 27, 29]. Although some studies
have assessed the relationship between the CVD
risk factors and muscular fitness over the recent
years, the evidence of its influence on the risk
factors independent of cardiorespiratory fitness
remains less clear [4].
Inverse associations with muscular fitness and
prevalence of metabolic syndrome have previ-
ously been reported in cross sectional studies
between muscular fitness and CVD risk factors
after adjustment for cardiorespiratory fitness
[20, 32], whereas some studies have shown sig-
nificant associations independent of cardiorespi-
ratory fitness [3, 13, 30, 32]. As a consequence,
the information available of the independent
association of muscular fitness and CVD risk fac-
tors is still scarce.
The risk for cardiovascular disease increases as
the number of risk factors increases [8]. There-
fore, the presence of multiple risk factors has
been used to estimate increased risk for cardio-
vascular diseases in previous studies [2, 12, 24].
The present study used both single and clustered
cardiovascular risk factors of plasma glucose
(GLUC) concentration and serum high-density
lipoprotein cholesterol (HDL), low-density lipo-
protein cholesterol (LDL), triglycerides (TG) as
well as blood pressure (BP) as the main outcome
(dependent) variable. We hypothesized that

Vaara JP et al. Associations of Maximal Strength … Int J Sports Med 2014; 35: 356–360

maximal strength and muscular endurance are associated with
single and the clustered cardiovascular risk factors independent
of cardiorespiratory fitness. The main question to be answered
was whether muscular or cardiorespiratory fitness is more
strongly related to the clustered cardiovascular risk factor score
independent of one another. To the best of our knowledge, this is
the first study using both muscular endurance and maximal
strength to assess the association of muscular fitness with single
and clustered risk factor for cardiovascular diseases.
Methods
▼ the present study similar to earlier studies [30, 31]. First, the val-
Participants
Participants were 846 young (25.5 ± 5.0 years) adult Finnish
men, who were called up to military refresher training organ-
ized by the Finnish Defence Forces. Only those volunteers who
completed all of the physical fitness tests, waist circumference
and blood pressure measurements as well as the blood sample
draws were included in the data analysis. As a result, the final
study sample consisted of 686 healthy young adult men free of
cardiovascular or other diseases. The present study sample was
compared to corresponding cohorts of 20–30-year old Finnish
men in the national register data (Statistics Finland) from the
years of 2007–2008 for age, education and place of residence.
The present study sample is not fully representative of the
nation, since the northern part of Finland was underrepresented
in this study sample and those with 13–15 years of education
were overrepresented. All participants provided written
informed consent. The study was conducted according to the
ethical standards of the International Journal of Sports Medi-
cine, described by [15] and was approved by the ethical commit-
tee of the Central Finland Health Care District and the
Headquarters of the Finnish Defence Forces.
Study procedures
Call up to military refresher training and information on the
study plan were sent 5 months before measurements. The meas-
urements were carried out in 8 different sessions during the
year 2008. Participants reported to bases by 2:00 p.m. The study
protocol was explained in detail to the participants before they
gave their written consent. They also completed a questionnaire
gathering background information (e. g. age, smoking), health
behaviour (e. g. leisure time physical activity, LTPA) and contain-
ing questions for screening possible health contraindications for
physical fitness tests. The participants were divided into groups
of 10 persons for the measurements, which started on the next
morning at 5:50 a.m. after a night of sleep with an overnight fast.
Blood pressure and body composition were measured, and blood
samples were drawn. The participants then ate a light breakfast
and drank a maximum of one cup of coffee or tea before under-
going measurements of bilateral maximal isometric force of leg
and arm extensors. Finally, an indirect graded cycle ergometer
test until exhaustion and tests of muscular endurance (push-
ups, sit-ups, repeated squats) were performed.
Selected cardiovascular risk factors: Blood pressure was
recorded twice at 1–2 min intervals in a seated position using an
automatic blood pressure device (Omron M6 Comfort, Nether-
lands). In the analysis, a mean of the 2 values were used. Blood
samples were drawn from the antecubital vein using Terumon
Venosafe (Terumo Europe, Leuven, Belgium) after an overnight
Vaara JP et al. Associations of Maximal Strength … Int J Sports Med 2014; 35: 356–360
Clinical Sciences 357
fast, and were centrifuged at speed of 3 500 rpm. Plasma glucose
(GLUC) and serum high density lipoprotein (HDL) and triglycer-
ides (TG) were analyzed by Konelab 20 XTi -device (Thermo Elec-
tron Co, Vantaa, Finland), and the isolated LDL fraction was used
for direct measurement of LDL-cholesterol (CHOD-PAP method).
The ranges for CHOL, TG, HDL and LDL assays varied from 0.1–15;
0.09–11; 0.04–2.84 and 0.3–8.9 mmol.l − 1, respectively. Intra- and
inter-assay coefficients of variance were 1.1 % and 2.1 % for CHOL,
1.0 % and 3.8 % for TG, 3.4 and 3.9 for LDL, and 0.5 %, 7.6 % for HDL,
respectively. Sensitivity for GLUC was 0.1 mmol/l, and intra- and
inter-assay coefficients of variance were 1.0 and 2.0 %, respec-
tively. A continuous cardiovascular risk factor score was used in
ues of each cardiovascular risk factor (plasma glucose, serum trig-
lycerides, serum high-density lipoprotein cholesterol, serum
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low-density lipoprotein cholesterol, systolic and diastolic blood
pressure) were transformed to z-scores. HDL cholesterol was
inverted before being included in the risk score. The continuous
clustered cardiovascular risk factor score was calculated from the
mean of z-score values of all cardiovascular risk factors.
Muscular endurance and maximal strength tests: Tests for
muscular endurance consisted of push-ups, sit-ups and repeated
squats. The duration of each test was 60 s. There was a recovery
period of 5 min between the tests. Participants were instructed
in correct technique before each test. Only the completed trials
with adequate technique were accepted for final results. Maxi-
mal isometric force of leg extension and bench press (both
regarded as tests for maximal strength) were measured using a
dynamometer. Knee angle was set to 107 ° with a goniometer,
and hands were set on handle grip in the leg extension test [17].
During the maximal bench press test, the participants were in a
supine position with their back flat on a bench and feet flat on
the floor with elbow and shoulder joints positioned at 90 °. A
warm-up series of at least 2 submaximal sets was performed
prior to maximal sets. 3 trials were performed using a 30 s recov-
ery period. The best performance was included in the analysis.
Each participant was advised to produce maximal force as fast as
possible and to maintain it for 3 s. The participants were verbally
encouraged during the maximal efforts by the test personnel.
Maximal force was recorded with AD-converter (CED power
1401, Cambridge Electronic Design, ltd., England) at the fre-
quency of 1-kHz on a computer. Data was analyzed with Signal
(2.16) software. The results of maximal strength and muscular
endurance were further expressed as the test score per kilogram
of body weight similar to previous studies [19, 20, 30]. The
results of the muscular endurance and maximal isometric
strength test scores were then transformed to z-scores. The
mean of z-scores of each muscular endurance test formed a
muscular endurance index (MEI), and the mean of maximal
strength tests formed a maximal strength index (MSI).
Cardiorespiratory fitness: Maximal aerobic capacity (VO2max)
was determined using an indirect graded cycle ergometer test
(Ergoline 800 S, Ergoselect 100 K, Ergoselect 200 K, Bitz, Ger-
many). A progressive protocol was used, which initially started
at power output of 50 W and was increased 25 W every 2 min
until exhaustion (volitional will to finish or a decrease of pedal-
ling cadence under 60 rpm/min). Heart rate (HR) was recorded
continuously during the test using heart rate monitors (Polar
Vantage NV or S610, S710 or S810, Kempele, Finland). Predicted
VO2max was determined from HR and maximal power (Watts,
358 Clinical Sciences

W) (Fitware, Mikkeli, Finland) with the following equation:
VO2max (ml · kg − 1 · min − 1) = 12.35*Pmax/kg + 3.5, where Pmax is
maximal power and kg body mass in kilograms. The intra-class
correlation among men has been reported to be high with this
method (ICC r = 0.82–0.94) [28].
Waist circumference was measured twice with a tape measurer
at the level of iliac crest after exhaling.
Self-reported leisure-time physical activity (LTPA) was ascer-
tained using the following question: “In which of the following
leisure time physical activity group are you engaged? – (“Think
about the last 3 months and consider all leisure time physical
activity that had lasted at least 20 min per session”). Response
categories were: (1) less than once a week, (2) no vigorous activ-
ities, but light or moderate physical activity at least once a week
(3) vigorous activity once a week (4) vigorous activity twice a
least 4 times a week. LTPA was classified as low (responses 1–2),
moderate (responses 3–4) and high (responses 5–6) activity.
Statistical analysis
The participants who reported using medication for diabetes,
high cholesterol or hypertension (n = 8) were excluded of the sta-
tistical analysis. The final study sample consisted of 686 partici-
pants. Data were analyzed with PASW-software (PASW for
Windows 18.0.1). Descriptive statistics as means and SD and
were calculated for the study sample. Multinomial logistic
regression was used to study the associations of cardiorespira-
tory and muscular fitness with single and the clustered cardio-
vascular risk factors using models with different combinations
of covariates (smoking, age, fitness variables, waist circumfer-
ence and self-reported leisure time physical activity).

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week (5) vigorous activity 3 times a week (6) vigorous activity at

Results
▼
Table 1 Characteristics of the study sample (n = 686). The descriptive data on body composition, physical fitness tests
and cardiovascular risk factors are shown in ● ▶ Table 1.
mean s.d.
Maximal strength was inversely associated with triglycerides,
age (year) 25.0 4.6
LDL-cholesterol, systolic and diastolic blood pressure after
height (cm) 180.1 6.3
adjustment for age and smoking. However, after adjustment for
body mass (kg) 80.6 13.4
waist (cm) 86.3 10.4
cardiorespiratory fitness, a positive association was found only
body mass index 24.8 3.8 between maximal strength and diastolic blood pressure. Muscu-
repeated squats (reps/min) 43.7 8.5 lar endurance was associated with all of the cardiovascular risk
sit-ups (reps/min) 38.0 10.2 factors, while the further adjustment for cardiorespiratory fit-
push-ups (reps/min) 28.8 12.8 ness attenuated these associations. However, each remained sta-
leg extension force (N) 2 943 873 tistically significant (●
▶ Table 2).

bench press force (N) 900 199 Cardiorespiratory fitness was inversely associated with all of the
VO2max (mL · min-1 · k-1) 41.6 8.1 cardiovascular risk factors except for HDL-cholesterol after
maximal heart rate (beats/min) 192 8
adjustment for age and smoking. While attenuated by the fur-
maximal load (W) 244 46
ther adjustment for maximal strength and muscular fitness,
cholesterol (mmol/L) 4.53 0.86
associations with LDL-cholesterol, HDL-cholesterol and triglyc-
HDL (mmol/L) 1.49 0.36
LDL (mmol/L) 2.43 0.63
erides remain statistically significant (●
▶ Table 2).

triglycerides (mmol/L) 1.03 0.53 Maximal strength, muscular endurance and cardiorespiratory
glucose (mmol/L) 5.40 0.41 fitness were all inversely associated with the continuous clus-
systolic blood pressure (mmHg) 123.0 11.8 tered cardiovascular risk factor score following adjustment for
diastolic blood pressure (mmHg) 76.8 8.4 age and smoking. In addition, muscular endurance was inversely
distribution of leisure-time physical activity: associated with the clustered risk factor independent of cardi-
low group 31.2 % orespiratory fitness, whereas maximal strength was not inde-
moderate group 38.7 % pendently associated. Cardiorespiratory fitness was inversely
high group 30.1 % associated with the clustered risk factor independent of maxi-

Table 2 The associations of maximal strength, muscular endurance and cardiorespiratory fitness with single cardiovascular risk factors (the standardized
β-coefficients from multivariate regression models).

s-LDL s-HDL Serum- Plasma Systolic blood Diastolic blood

cholesterol cholesterol triglycerides glucose pressure pressure
maximal strength index (MSI)
model A − 0.12 *** 0.07 − 0.12 *** − 0.04 − 0.07 * − 0.14 ***
model B ‡ − 0.05 0.003 − 0.02 0.0001 − 0.04 0.08 *
muscular endurance index (MEI)
model A − 0.23 *** 0.24 *** − 0.25 *** − 0.16 *** − 0.22 *** − 0.21 ***
model B ‡ − 0.15 ** 0.17 *** − 0.09 * − 0.14 ** − 0.23 *** − 0.17 ***
cardiorespiratory fitness (CRF)
model A − 0.22 *** 0.21 *** − 0.30 *** − 0.13 *** − 0.11 ** − 0.17 ***
model B † − 0.14 ** 0.11 * − 0.24 *** − 0.02 0.03 − 0.08
Model A adjusted for age and smoking
‡ Model B adjusted for age, smoking and CRF
† Model B adjusted for age, smoking, MSI and MEI
***p < 0.001, ** p < 0.005, *p < 0.05

Vaara JP et al. Associations of Maximal Strength … Int J Sports Med 2014; 35: 356–360

Table 3 Associations of maximal strength, muscular endurance and cardio-
respiratory fitness with continuous clustered cardiovascular risk factor score
(the standardized β-coefficients from multivariate regression models).
Maximal Muscular Cardiorespira-
strength endurance tory fitness
model A − 0.16 *** − 0.37 *** − 0.32 ***
model B 0.06 ‡ − 0.26 * ‡ − 0.16 *** †
model C 0.04 ‡ − 0.05 ‡ − 0.08 †
Model A adjusted for age and smoking
‡ Model B adjusted for age, smoking and CRF
† Model B adjusted for age, smoking, MSI and MEI
‡ Model C adjusted for age, smoking, waist circumference and CRF
† Model C adjusted for age, smoking, waist circumference, MSI and MEI
***p < 0.001, ** p < 0.005, *p < 0.05
mal strength and muscular endurance (●
▶ Table 3). In addition,
when waist circumference was further adjusted in the regres-
sion models, the associations of cardiorespiratory fitness and
muscular endurance with single and the clustered CVD risk fac-
tors became non-significant. Moreover, in a model that includes
waist circumference and all fitness parameters, the strongest
relationship was observed between waist circumference and the
clustered CVD risk factor score (β = 0.41, p < 0.001), leaving all fit-
ness parameters non-significant. Additional adjustment for lei-
sure time physical activity did not have a significant effect on
the associations between maximal strength, muscular endur-
ance, cardiorespiratory fitness and the single or clustered cardi-
ovascular risk factor score.
Discussion
▼ [9, 18, 23, 25]. Nevertheless, rather similar magnitudes of cardi-
The main findings of the present cross-sectional study of young
adult men demonstrate that muscular endurance was inversely
associated with the clustered cardiovascular risk factor score
independent of cardiorespiratory fitness, whereas maximal
strength was not associated therewith. Secondly, cardiorespira-
tory fitness was inversely associated with the clustered cardio-
vascular risk factor score independent of muscular fitness, and
the strongest association was found between waist circumfer-
ence and the clustered cardiovascular risk factor score inde-
pendent of muscular and cardiorespiratory fitness.
Muscular endurance was inversely associated with blood pres-
sure, glucose, triglycerides, LDL-cholesterol and the clustered
cardiovascular risk factor, and positively associated with HDL-
cholesterol independent of cardiorespiratory fitness. On the
other hand, maximal strength was not associated with any of the
single or the clustered cardiovascular risk factor independent of
cardiorespiratory fitness in the present study. Earlier cross-sec-
tional studies have shown an inverse association between car-
diovascular risk factors and muscular fitness index [3, 13, 21, 30]
and maximal strength [5, 19, 20, 32]. After adjustment for cardi-
orespiratory fitness, these associations have, however, attenu-
ated and decreased to non-significant in some [20, 32] but not all
studies [3, 13, 21, 30, 32].
The previous cross-sectional studies have measured either max-
imal strength only or a combination of muscular endurance and
maximal strength to form a muscular fitness index. Therefore,
the comparison between the present and earlier findings is
rather difficult. The comparison of the previous studies is also
challenged by the fact that correction for body composition dif-
fers between the studies. In some studies, no corrections for
Vaara JP et al. Associations of Maximal Strength … Int J Sports Med 2014; 35: 356–360
Clinical Sciences 359
muscular fitness scores have been used [21, 22, 30], whereas in
others the muscular fitness score has been divided by body mass
[3, 19, 20, 30] or fat-free mass [5, 32]. The findings from the
present study suggest that future studies are warranted to
clearly distinguish between muscular endurance and maximal
strength due to their different associations to cardiovascular risk
factors, body composition and other fitness parameters [31].
Maximal strength was, however, associated positively with
diastolic blood pressure. Similarly in a previous cross-sectional
study, an adverse association has been found between maximal
strength and high-density lipoprotein cholesterol as well as trig-
lycerides after being controlled for age, cardiorespiratory fitness
and sum of skinfolds [22]. In addition, some cross-sectional
studies have also reported adverse relationships between physi-
cal activity and blood pressure [7, 16]. The biological mecha-
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nisms for these remain unknown. However, some confounders
may play a role as mediators, such as nutritional factors (salt
intake) or stress, none of which were studied in the previous or
the present study. It is, however, of noteworthy that maximal
strength has other health benefits, especially for older individu-
als, including prevention of sarcopenia and maintenance of
mobility.
Cardiorespiratory fitness was associated with the clustered CVD
risk factor independent of muscular fitness in line with previous
studies [11, 12, 25, 27, 32]. The present study revealed similar
relationships in single cardiovascular risk factors except for glu-
cose and blood pressure.
The present study observed a stronger association between
waist circumference and the clustered cardiovascular risk factor
compared to cardiorespiratory fitness and muscular endurance,
which is in line with most of the cross-sectional studies
orespiratory fitness and waist circumference as predictors of
CVD risk factors have also been observed [12]. The physiological
mechanisms behind the potential cardioprotective effect of car-
diorespiratory fitness include reduced concentrations of inflam-
matory markers and oxidized LDL lipids, improved endothelial
function, lipoprotein subclass distribution and postprandial
lipoprotein metabolism [1, 14].
Strength and limitations
The strength of the present study is the extensive data set
including physical fitness of cardiorespiratory and the dimen-
sions of muscular fitness. The detailed measurements of muscu-
lar fitness (muscular endurance, maximal strength) are rare in
the previous studies. Nevertheless, there are some limitations
that have to be considered. Predicted VO2max was used instead
of a direct measurement in the present study. Moreover, we
were not able to take into account some possible confounding
factors, such as nutrition and stress. Finally, due to the cross-
sectional study design, the causality of the relationships cannot
be assessed.
In conclusion, the present study showed that both cardiorespira-
tory fitness and muscular endurance are independently associ-
ated with cardiovascular risk factors, whereas no association
between maximal strength and cardiovascular risk factors were
observed in young adult men. These findings may suggest that in
addition to aerobic training, resistance training, which also
induces sufficiently strong training response in the cardiovascu-
lar system, is beneficial for the cardiovascular health. This, how-
ever, needs to be further confirmed by more prospective studies
and randomized clinical trials.
360 Clinical Sciences

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Finnish Defence Forces, Personnel Division, Helsinki, Finland cardiometabolic risk factors among sixth-grade youth. Med Sci Sports
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