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PHYSIOLOGICAL RESPONSES OF ZUMBA: AN OVERVIEW UNDERSTANDING THE POPULAR FITNESS

TREND

Manjula Suri1, Rekha Sharma2 Namita Saini3 Affiliations:

1. Department of Physiology and Promotive Health, University of Delhi, Institute of Home Economics,

mnjlsuri@gmail.com

2. Department of Physical Education, University of Delhi, Institute of Home Economics,

drrekhasharma1984@gmail.com

3. Department of Physical Education, University of Delhi, Institute of Home Economics, Hauz Khas, Delhi-

110016, drnamitasaini@rediffmail.com,
ABSTRACT

Physical inactivity is a commonly observed cause of increasing incidence of lifestyle diseases. As dancing

is a physical activity that can be tailored to fit a target population's age and culture therefore, zumba is

becoming a global dance fitness activity to reduce lifestyle disease epidemic . It has a mixture of popular

entertaining music, different dance styles and aerobic exercises which improves the health of all age

groups. Thus, physiological effects of zumba can be used as an adjuncts to conventional medicine for

prevention of various lifestyle diseases e.g. diabetics and obesity. Several neurological benefits of zumba

have been identified which ranges from memory improvement to strengthened neuronal connections.

Zumba is able to enhance cardio vascular endurance and cardio respiratory functions. It incorporates

movement of large muscle groups for aerobic endurance, strength training and flexibility thereby

contributing to improved health in all ages, especially in the geriatric population. It also maintains bone

density and prevents osteoporosis in postmenopausal women. Various researchers have recorded the

positive effect of Zumba on weight, BMI, body fat mass, hormonal profile and reproductive function.

Psychosocial aspect of health also shows encouraging results in Zumba intervention. To summarize,

these findings reflect that Zumba intervention can be explored further as a therapeutic tool in

Complementary and alternative medicine for improving health and preventing lifestyle diseases.

Keywords: Zumba, Musculoskeletal, Psychosocial, Geriatric, cardio vascular endurance INDIAN

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1. INTRODUCTION Zumba is a global dance fitness program focused on whole-body rhythmic

movements which fuses fitness and entertainment. It was designed by Alberto "Beto" Perez during the

1990s (Lloyd, 2011) and involved Latin dance, Aerobic exercises, Hispanic music, Latino music and a

mixture of pop music. It has gained much popularity in the last two decades. Zumba is chosen as review

domain as it is gaining rapid popularity especially in youngsters. Its motto is “Ditch the workout. (Join
the Party. Parcher A., Zumba website). There are a wide variety of Zumba classes targeting specific

participant groups, including children and elderly persons (Parcher A., Zumba website). The goals of

Zumba are to improve strength, balance, coordination and cardiovascular endurance (Parcher A., Zumba

website). Dimondstein (1985) states that, ‘The practice of making dance an adjunct of physical

education has placed it in the same category as athletics or physical skills. Zumba although dance

orientated is perceived as a physical exercise activity. This paper reviews the understanding of the

popular novel emerging discipline Zumba which can be used worldwide as non-pharmacological form of

promotive and preventive measure for various life style diseases. To summarize, the purpose of the

current review was to examine the effectiveness of Zumba in improving the physical health of all, both

those with health conditions and those considered healthy. 1.1 Zumba : Dance intervention

Approximately 15 million people take weekly Zumba classes in over 200,000 locations across 180

countries. Zumba classes are typically 45 minutes-1 hour long and are taught by instructors licensed by

Zumba Fitness, LLC. The exercises include music with fast and slow rhythms, as well as resistance

training. The music comes from the following dance styles: Cumbia, Salsa, Merengue, Mambo,

Flamenco, Chachacha, Reggaeton, Soca, Samba, Hip hop music, Axé music and Tango. Squats and lunges

are also included in it. There are nine different types of classes for different levels of age and exertion.

Zumba Gold is a program designed for the needs of the elderly. Zumba Step is a lower-body workout

that incorporates Zumba routines and step aerobics with Latin dance rhythms. Zumba Toning is for the

people who do their workouts with toning sticks. Zumba Toning will target the abs, thighs, arms, and

other muscles throughout the body. Zumba Toning provides participants with a cardio workout and

strength training. Aqua Zumba classes are held in a swimming pool. The instructor leads the class

poolside while participants follow in shallow water. Moves have been specially adapted to combine the

same dance movements used in a Zumba Fitness class with those used in aqua fitness classes. Zumba in

the Circuit combines dance with circuit training. These classes usually last 30 minutes and feature
strength exercises on various stations in timed intervals. Zumba Kids and Zumba Kids Jr. classes are

designed for children between the ages of 4 and 12. Zumba Sentao is a chair workout that focuses on

using body weight to strengthen and tone the body. Strong by Zumba was launched in 2016. This

specialty combines high intensity interval training with Synced Music Motivation (Wikipedia: Zumba).

1.2 Zumba: Physiological Mechanism

Zumba involves dance and aerobic exercise performed to energetic music. Convincing benefits of

dancing activities on physiologic, endocrine, cognitive and psychological levels have previously been

shown (Kattenstroth, J.C.; et.al. .; 2013, Belardinelli, R 2007, Kim, S.H.et.al.; 2011, Shimamoto, H.; 1998,

Murrock, C.J.; 2014, Coubard, O.A.; et.al.; 2011, Duberg, A.; et.al.; 2013). Several studies revealed

improved fitness, weight loss, reductions in cholesterol levels or inflammatory markers in women at risk

after various forms of aerobic dancing Shimamoto, H.; et.al.; 1998, Gillett, P.A.; et.al.,1987, Murrock,

C.J.; Gary, F.A. ; 2010, Gullu, E.; et.al.; 2013, Okura, T.; et.al. .; 2007, Mosher, P.E.; et.al, 2005, Williford,

H.N et.al. 1998) including “aerobics”, “step aerobics” and “cultural dances”. Zumba as a type of fitness

dance that combines Latin rhythms and aerobics has rapidly reached tremendous popularity lately

(Thomson, W.R., 2012). Among the recognized benefits of doing regular aerobic exercise are: (Aerobic

exercise: the health benefits. 2010.)

Strengthening the muscles involved in respiration, to facilitate the flow of air in and out of the lungs

Strengthening and enlarging the heart muscle, to improve its pumping efficiency and reduce the

resting heart rate, known as aerobic conditioning

Improving circulation efficiency and reducing blood pressure

Increasing the total number of red blood cells in the body, facilitating transport of oxygen
 Improved mental health, including reducing stress and lowering the incidence of depression, as well as

increased cognitive capacity .

Reducing the risk for diabetes and lowering Hb A1C levels for type 2 diabetics. (Snowling, N. J. ;

Hopkins, W. G. .; 2006)

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As a result, aerobic exercise can reduce the risk of death due to cardiovascular problems. In addition,

high-impact aerobic activities (such as jogging or using a skipping rope) can stimulate bone growth, as

well as reduce the risk of osteoporosis for both men and women. In addition to the health benefits of

aerobic exercise, there are numerous performance benefits: (Snowling, N. J. ; Hopkins, W. G. .; 2006)

Increased storage of energy molecules such as fats and carbohydrates within the muscles, allowing for

increased endurance

Neovascularization of the muscle sarcomeres to increase blood flow through the muscles

Increasing speed at which aerobic metabolism is activated within muscles, allowing a greater portion

of energy for intense exercise to be generated aerobically

Improving the ability of muscles to use fats during exercise, preserving intramuscular glycogen

Enhancing the speed at which muscles recover from high intensity exercise

Neurobiological effects: improvements in brain structural connections and increased gray matter

density, new neuron growth, improved cognitive function (cognitive control and various forms of
memory), and improvement or maintenance of mental health.(Aerobic exercise', Food and Fitness: A

Dictionary of Diet and Exercise, Michael Kent, Oxford University Press, 1997).

Various researchers suggest that aerobic group exercise classes e.g. cycling, tabata, and Zumba taken

regularly are effective in controlling weight, blood pressure, and body composition. (Delextrat.; 2016;

Faulkner.; et al.; 2015; Lbujojevic.; et al., 2016; Tabata.; 1996; Thompson, 2016). Acute short term

physiological responses to aerobic exercise include increased heart rate, blood pressure, breathing rate,

and tidal volume. Long-term aerobic exercise participation is proven to increase the amount of maximal

oxygen consumption during intense aerobic exercise (VO2 max), lower resting blood pressure and heart

rate, lower body fat mass, and increase muscle mass, while low levels of cardiovascular fitness are

associated with increased risk of premature death (Ehrman.; et al.; 2009). Hence, Aerobic exercise plays

an important role in decreasing the risk of cardiovascular disease (CVD), pulmonary diseases, and

metabolic diseases (Pescatello; Arena; Riebe; Thompson; 2013). Both aerobic dance and Zumba

incorporate large muscle groups for movement during class for aerobic endurance, strength training and

flexibility. Exercise will also help to regulate hormonal changes during menopause (Eshbach.; 2016) and

it reduces back pain, limit body weight gain and fat retention post pregnancy, (Ehrman et al.; 2009). As

Zumba is a form of aerobic exercise therefore, above mentioned physiological effects may be seen in

Zumba dancers. These physiological benefits can be used as an alternatives or adjuncts to conventional

medicines (Complementary and alternative medicine, CAM) for prevention of various diseases as well as

promotion of health. 1.3 Zumba : Physiological effects on Human Body 1.3.1 Effect on Nervous System:

Various researchers began to investigate neurological effects of dance which requires complex mental

coordination synchronizing music and movement. Dance constitutes a pleasurable intervention where

brain’s reward centers are stimulated by music and sensory motor circuits are activated by dance.

Studies using PET imaging have identified regions of the brain that contribute to dance learning and
performance. These regions include the motor cortex, somatosensory cortex, basal ganglia, and

cerebellum. The motor cortex is involved in the planning, control, and execution of voluntary

movement. The somatosensory cortex, located in the mid region of the brain, is responsible for motor

control and also plays a role in eye-hand coordination. The basal ganglia, a group of structures deep in

the brain, work with other brain regions to smoothly coordinate movement, while the cerebellum

integrates input from the brain and spinal cord and helps in the planning of fine and complex motor

actions (Brown 2006; Calvo-Merino B; 2008 Cruz-Garza J. G.; 2014).

While some imaging studies have shown which regions of the brain are activated by dance, others have

explored how the physical and expressive elements of dance alter brain function. For example, much of

the research on the benefits of the physical activity associated with dance links with those gained from

physical exercise, benefits that range from memory improvement to strengthened neuronal

connections. Dance therapy is a creative arts therapy that has been defined by the American Dance

Therapy Association as “the psychotherapeutic use of movement to further the emotional, cognitive,

physical, and social integration of the individual.” (American Dance Therapy Association. 2013) Cross-

sectional studies have shown that older adults who dance on a regular basis have greater flexibility,

postural stability, balance, physical reaction time, and cognitive performance than older adults who do

not dance on a regular basis. (Kattenstroth JC.; 2011) Zumba improves cognitive skills, such as visual

recognition and decision-making. Hufner; et. al.; (2011) stated that INDIAN JOURNAL OF PHYSICAL

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long-term balance training with its extensive vestibular, visual and sensorimotor stimulation is

associated with altered hippocampal formation volumes in professional ballet dancers and hippocampus

is crucial for long-term memory consolidation, learning and spatial navigation, but also for balancing. In

addition, dance is included in the interdisciplinary field of neuroaesthetics, which unites the various
forms of artistic expression and the neuroscientific examination of how the human brain perceives

processes and executes various arts, such as dance. (Yarrow K.; 2009; Fairhall S. L.; 2008)

Neuroaesthetics researchers have focused on how dance training affects the human mind in terms of

the intrinsic workings of the human brain’s neural architecture and the forces underlying the

coordinated patterns of activity that support the thought, reasoning, action, and emotion that are

involved in dance (Yarrow K.2009; Stevens C. 2010; Blasing B. 2012; Grosbras M.-H.2012; Cross E. S

.2011; Cruz-Garza J. G. 2014). By neuroaesthetics studies neuroscience researchers can investigate the

integration of the sensorimotor functions (Haggis J., 2010), elements of aesthetics (Cross E. S., 2011;

Calvo-Merino B., 2008) and emotion (Sawada M., 2003) that arise from dance. To summarize, Dance

form like Zumba seems a promising intervention for neuroplasticity in nervous system. 1.3.2 Effect on

Cardio-respiratory System: The first studies on Zumba revealed its sufficiency as a training method that

is able to enhance cardio respiratory fitness (Luettgen, M.; 2012, Otto, R.M.; 201). The cardiovascular

benefits of dance have been observed through aerobic dance forms such as Zumba (Jitesh. S.; et al.;

2016). The volunteers were made to practice zumba dance for two months and the variation in the

blood pressure were evaluated. This study verified that blood pressure is altered by Zumba dance

among hypertensive patients. Another study looked at the changes in aerobic fitness with Zumba

performance (Delextrat.; Warner.; Graham.; Neupert.; 2016). It suggests that the Zumba participants

showed a greater increase in VO2 max. Anja Rossmeissl et. al. (2016) assessed the feasibility and effect

of a 12-week Zumba Beat dance intervention on cardio respiratory fitness. Postmenopausal women with

a body mass index (BMI) >30 kg/m2 or a waist circumference >94 cm who were not regularly physically

active were asked to complete a 12-week Zum Beat dance intervention with instructed and home-based

self-training sessions. Before and after the intervention, peak oxygen consumption (VO2peak) was

assessed on a treadmill. There was no apparent change in VO2peak after the 12-week intervention

period .The study concluded that 12-week Zumba Beat dance intervention may not suffice to increase
cardio respiratory fitness in postmenopausal women. A pilot study conducted in a population of middle-

aged obese women with metabolic syndrome reported improvements in systolic and diastolic blood

pressure after a 12-week intervention (Araneta. M. R.; Tanori. D.; [2005). Zumba is considered more

technical than running and spinning, thus the inexperienced Zumba subjects exercised at a lower %HR

max. Zumba is the only exercise session where the subjects had a significant correlation of 0.5-0.6

between rating of perceived exertion (RPE) and %HR max, accelerometer counts, and energy

expenditure (EE). Zumba was perceived 18.8 to 23.3% less exhaustive. (Kjell Hausken.; Sindre M.;

Dyrstad.; 2013) As Zumba dance helps to reduce blood pressure in hypertensive patients therefore, it

can be recommended as adjuvant therapy with regular hypertensive medication. (S.Jitesh et. al.; 2016)

To conclude, Zumba dance intervention improves cardiovascular endurance and cardio-respiratory

function. 1.3.3 Effect on Musculoskeletal System: Researchers have shown that Zumba reduces neck-

shoulder pain in the setting of a workplace intervention (Barene, S.; 2014). In young normal weight

females, Zumba improves trunk strength endurance and balance (Donath, L.et.al.; 2014) .Similarly

resistance training, high intensity aerobic exercise and outdoor sports activities have beneficial effects

on the musculoskeletal system (Paffenbarger RS.; Blair SN.; Lee IM.; 2001; Warburton DER.; Nicol CW.;

Bredin SSD.; 2006.; Welsh L.; Rutherford O.; 1996.; Schuenke M.; Mikat R.; McBride J.; 2002, Borer KT.;

2005). Some of the benefits are described below: 1.3.3.1 Increased Lean Muscle and Bone Density

Exercise increases lean muscle mass which has numerous advantages e.g. improved energy metabolism,

improved vascularity, improved posture, and improved support to the skeletal framework. Furthermore,

exercise has also been shown to strengthen muscles and improve balance and co-ordination. These

effects reduce the risk of falls and fractures especially in the elderly and contribute towards improved

health. (Borer KT.; 2005)

Physical activity, esp. weight bearing exercise (resistance training) has been shown to be beneficial to

bone health (Borer KT.; 2005). Exercise not only stimulates bone growth and the accumulation of
minerals but also prevents osteoporosis in later life (Borer KT.; 2005; B+®rard A.; Bravo G.; Gauthier P.;

1997). Borer, in his study on neurohormonal influences on exercise induced growth, observed that high

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a ‘growth gene’ in the tissues exercised and this occurs without the intermediation of growth hormone

or in the absence of abundant nutrients (Borer KT.; 1994). Brisk walking (above 6.14 k/h and heart rate:

82.3% of age-specific maximum) provides sufficient mechanical loading on the bones to maintain bone

density and prevent osteoporosis in postmenopausal women (Budgett R.; 1990). Similarly, high impact

aerobic activity was shown by Welsh and Rutherford to preserve bone density ,in addition to

strengthening muscles in postmenopausal women and men over 50 (Welsh L; Rutherford O.;1996).

1.3.3.2 Strong and Supple Joints with Improved Joint Range of Motion Exercise acts as the primary

stimulus for production of synovial fluid and regular physical activity thus ensures healthy joints.

Increased production of synovial fluid keeps joints well oiled, resistant to friction and makes them

supple. This, combined with exercise induced improvements in suppleness of ligaments, contributes to

an improved joint range of motion. Mobility exercises like ‘little circles’ with arms or knees for mobilizing

shoulders and knees respectively in dance interventions cause secretion of synovial fluid with resultant

improvement in joint range of motion. 1.3. 4 Effect on Body Weight and BMI: A study done in two

Bosnian universities showed that Zumba was effective in lowering body fat mass in women participating

in the class for three times a week, for eight weeks (Ljubojevic; Jovanovic; Zrnic; Sebic; 2016). A pilot

study conducted in a population of middle-aged obese women with metabolic syndrome reported

weight reductions of 2.07 pounds on average, as well as improvements in fasting triglycerides after a 12-

week Zumba intervention (Araneta, M.R.; Tanori, D.; 2015). Quite recently, studies also started to

examine aspects of motivation, self-perceived fitness and autonomy. (Krishnan, S.; et. al.; 2015;
Delextrat, A.A.; 2015). One of these studies found enhanced intrinsic motivation associated with fitness

improvements, as well as reductions in body weight and fat mass after 16 weeks of Zumba dance in

obese middle-aged women (Krishnan, S.; et.al. 2015).

Furthermore, Zumba is considered more technical than running and spinning, thus if the goal is

maximum calories burned or maximum aerobic fitness, then, beginners should choose simpler exercises

such as running or spinning. (Kjell Hausken; Sindre M. Dyrstad; 2013). Zumba has been shown to reduce

fat mass and improve aerobic fitness in the setting of a workplace intervention (Barene, S. et. al.;

2014).The study which examined the exercise intensity of Zumba was conducted at Adelphi University

(Otto et al.; 2011). It reported caloric expenditure during Zumba to be between 6.6 and 7.4 Kcal·min-1

depending on the particular dance style being performed. Therefore Zumba may be promoted as a

lifestyle intervention in reducing weight, BMI and incidence of obesity. 1.3. 5 Effect on Reproductive

System: Several studies have shown that physical activity improves hormonal profile and reproductive

function. These improvements include a decrease in abdominal fat, blood glucose, blood lipids and

insulin resistance, as well as improvements in menstrual cyclicity, ovulation and fertility, decreases in

testosterone levels and Free Androgen Index (FAI) and increases in sex hormone binding globulin

(SHBG). Exercise will also help in controlling symptoms of menopause, including hot flashes, fatigue,

weight gain, joint aches and pain, sleep disturbances, loss of bone density minerals, and depression and

anxiety in elderly (Eshbach.; 2016).

In a study on dance labor group, women were instructed to do standing upright with pelvic tilt and rock

their hips back and forth or around in a circle while their partner-who was instructed to stand in front of

them, massaged their back and sacrum for a minimum of 30 minutes. During these movements,

participants were instructed to rest their arms on their partner’s shoulders. Women in this group were

instructed to remain upright at least for 30 minutes to record pain score. Dance labor, which is a

complementary treatment with low risk, can reduce the intensity of pain and increase the satisfaction of
mothers with care during the active phase of labor. (S. Abdolahian et. al.; 2014). These studies suggest

that physical activity like Zumba may improve reproductive health. 1.3. 6 Effect on Endocrine System:

Ballet dancers and highly trained runners of either sex demonstrate suppression of gonadal function

caused by chronic HPA activation .These subjects have increased evening plasma cortisol and ACTH

levels, increased urinary free cortisol excretion, and blunted ACTH responses to exogenous CRH; males

have low LH and testosterone levels, and females have amenorrhea.( Luger A, 1987;. Beitins IZ. 1986;

Brooks-Gunn J, 1985)

Exercise initiates an endocrine response through activation of the sympathetic system in a feed-forward

manner by the motor centre in the brain which is reflected by the increases in sympathoadrenal INDIAN

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activity. Exercise also leads to an increase in the production and release of growth hormone,

testosterone, adrenocorticotrophic hormone, cortisol and prolactin that each has local and systemic

effects (D Ball - 2015). This suggests effects of dance and exercise on the major endocrine axes in the

body .Therefore further studies are needed to explore the effect of zumba on endocrine health. 1.3. 7

Effect on Psychosocial Health: Multiple studies have also shown that the energetic dance class is

effective in increasing psychological well-being and quality of life for women (Delextrat et al.; 2017; Nieri

& Hughes, 2017). In young normal weight females, Zumba improves fitness and quality of life (Donath,

L.; 2014). Similarly Anja Rossmeissl et. al. (2016) assessed the feasibility and effect of a 12-week Zum

Beat dance intervention on psychosocial health. Postmenopausal women who were not regularly

physically active were asked to complete a 12-week ZumBeat dance intervention. Before and after the

intervention, several psychometric parameters (including quality of life, sports-related barriers and

menopausal symptoms) were investigated. Result suggests quality of life had increased, and sports-

related barriers had decreased. A 12-week ZumBeat dance intervention may increase women’s quality
of life. To summarize, Zumba is an exercise fitness program which can help in improving psychosocial

health. 1.3. 8 Effect on Geriatric Health:

Dance has been found to be therapeutic for patients with Parkinson’s disease. The primary motor

symptoms of Parkinson’s disease include bradykinesia (slowed movement), stiffness of the limbs and

trunk, tremors, and impaired balance and coordination. It is these symptoms that dance may help

alleviate. Dance can be considered a form of rhythmic auditory stimulation (RAS). In this technique, a

series of fixed rhythms are presented to patients, and the patients are asked to move to the rhythms.

Studies of the effects this technique has on patients with Parkinson’s or other movement disorders have

found significant improvements in gait and upper extremity function among participants. Interactive

RAS offers a flexible, portable, low-cost, non-invasive therapeutic intervention that may improve the

mobility, stability, and quality of life of Parkinson's Disease patients.( Michael J. Hove,2012) Similarly,

Zumba Gold has been shown to be safely applied in elderly or even chronically-ill people (Bennett, P.

et.al; 2012; Sanders, M.E.; Prouty, J.; 2012), although two studies warn of possible injuries associated

with Zumba fitness and the wrong footwear (Inouye, J. et.al.; 2013; Schrimpf, C.; et.al; 2014). To

conclude, further research is needed to explore the role of Zumba in improving geriatric health. 2.

CONCLUSION Zumba intervention is both a dance and a fitness regime which leads to health benefits

through aerobic activity. Further studies are required to have an in depth knowledge of mechanism of

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SECOND RRL ABOUT ZUMBA

sports

Article

ZumBeat: Evaluation of a Zumba Dance Intervention

in Postmenopausal OverweightWomen

Anja Rossmeissl 1,*, Soraya Lenk 1, Henner Hanssen 1, Lars Donath 2, Arno Schmidt-Trucksäss 1,*

and Juliane Schäfer 1,3

1 Division of Sports and Exercise Medicine, Department of Sport, Exercise and Health, University of

Basel,

Birsstrasse 320 B, Basel 4052, Switzerland; soraya.lenk@unibas.ch (S.L.); henner.hanssen@unibas.ch

(H.H.);

juliane.schaefer@unibas.ch (J.S.)

2 Division of Movement and Exercise Science, Department of Sport, Exercise and Health, University of

Basel,

Birsstrasse 320 B, Basel 4052, Switzerland; lars.donath@unibas.ch

3 Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, Spitalstrasse 12,

Basel 4031, Switzerland

* Correspondence: anja.rossmeissl@unibas.ch (A.R.); arno.schmidt-trucksaess@unibas.ch (A.S.-T.);

Tel.: +41-61-377-8740 (A.R. & A.S.-T.); Fax: +41-61-377-8742 (A.R. & A.S.-T.)
Academic Editor: Eling de Bruin

Received: 10 November 2015; Accepted: 19 January 2016; Published: 25 January 2016

Abstract: Physical inactivity is a major public health concern since it increases individuals’ risk

of morbidity and mortality. A subgroup at particular risk is postmenopausal overweight women.

The aim of this study was to assess the feasibility and effect of a 12-week ZumBeat dance intervention

on cardiorespiratory fitness and psychosocial health. Postmenopausal women with a body mass

index (BMI) >30 kg/m2 or a waist circumference >94 cm who were not regularly physically active

were asked to complete a 12-week ZumBeat dance intervention with instructed and home-based

self-training sessions. Before and after the intervention, peak oxygen consumption (VO2peak) was

assessed on a treadmill; and body composition and several psychometric parameters (including

quality of life, sports-related barriers and menopausal symptoms) were investigated. Of 17 women

(median age: 54 years;median BMI: 30 kg/m2) enrolled in the study, 14 completed the study.

Therewas no

apparent change inVO2peak after the 12-week intervention period (average change score:

_0.5mL/kg/min;

95% confidence interval: _1.0, 0.1); but, quality of life had increased, and sports-related barriers and

menopausal symptoms had decreased. A 12-week ZumBeat dance intervention may not suffice to

increase cardiorespiratory fitness in postmenopausal overweight women, but it increases women’s

quality of life.
Keywords: menopause; dance; cardiorespiratory fitness; Zumba; barriers; quality of life

1. Introduction

Many physiologic changes are brought about during menopause and the shifting levels of

hormones, associated with a considerable increase in cardiovascular risk [1,2]. In addition to the

health

hazard associated with the metabolic changes and increasing abdominal fat commonly concurring

with menopause, many women experience weight gain as a function of aging [3,4]. The weight gain

is partly explained by decreasing basal metabolic rates and decreasing energy expenditure due to

diminished physical activity [5,6]. Therefore, the observed decline in physical activity around the age

of 55 years is a crucial issue in the postmenopausal phase [7,8], since inactive postmenopausal

women

who are overweight or obese have a substantially increased risk for cardiovascular diseases [9].

Much research has documented the tremendous benefits of physical activity on various health

aspects [10]. Previous studies have additionally enhanced our understanding for the causes of

inactivity

Sports 2016, 4, 5; doi:10.3390/sports4010005 www.mdpi.com/journal/sports

Sports 2016, 4, 5 2 of 15

and identified various categories of barriers associated with inactivity behavior in women at midlife

[11–13].

Dance, on the other hand, is the second most popular leisure time physical activity after walking
in women across all ages (25 to 75 years plus) [14]. Convincing benefits of dancing activities on

physiologic, endocrine, cognitive and psychological levels have previously been shown [15–21].

Several studies revealed improved fitness, weight loss, reductions in cholesterol levels or

inflammatory

markers in women at risk after various forms of aerobic dancing [18,22–27], including “aerobics”,

“step aerobics” and “cultural dances”. Zumba as a type of fitness dance that combines Latin rhythms

and aerobics has rapidly reached tremendous popularity lately [28]. The first studies on Zumba

revealed its sufficiency as a training method that is able to enhance cardiorespiratory fitness [29,30].

Moreover Zumba Gold has been shown to be safely applied in elderly or even chronically-ill people

[31,32],

although two studies warn of possible injuries associated with Zumba fitness and the wrong

footwear [33,34]. In young normal weight females, Zumba improves fitness, trunk strength

endurance,

balance and quality of life [35]. Furthermore, Zumba has been shown to reduce neck-shoulder pain,

as well as fat mass and to improve aerobic fitness in the setting of a workplace intervention [36–38].

A pilot study conducted at the same time as our study in a population of middle-aged obese

women with metabolic syndrome reported weight reductions of 2.07 pounds on average, as well

as improvements in systolic and diastolic blood pressure and fasting triglycerides after a 12-week

intervention [39]. Quite recently, studies also started to examine aspects of motivation, self-perceived
fitness and autonomy [40,41]. One of these studies published in 2015 found enhanced intrinsic

motivation associated with fitness improvements, as well as reductions in body weight and fat mass

after 16 weeks of Zumba dance in obese middle-aged women [40]. However, there is still a paucity of

data on physical and mental health benefits from Zumba-style dancing activities in the older,

sedentary

overweight population. The aim of this study was to assess the feasibility of a 12-week ZumBeat

dance intervention in sedentary, postmenopausal overweight women and to generate preliminary

effect size estimates regarding cardiorespiratory fitness (primary outcome) and anthropometric and

psychometric parameters (secondary outcomes).

2. Materials and Methods

2.1. Study Design

In this single-arm, monocentric, prospective interventional study, participants were examined

before and after a 12-week Zumba dance intervention (ClinicalTrials.gov Identifier: NCT02384694).

The 12-week intervention comprised a total of three planned weekly training sessions. Participants

were

asked to attend at least 2 out of 3 weekly sessions offered in-person at the facilities of the University

of Basel. In addition, they were asked to complete at least one weekly session as home-based

training.

The study was approved by the local ethics committee (Ethikkommission Nordwest-und

Zentralschweiz,
Basel, Switzerland). Written informed consent was obtained from all participants prior to the start of

the study.

2.2. Participants

Sedentary women were recruited from the community through leaflet advertisements in doctor’s

offices and pharmacies (700 pieces), on online marketplaces, University pin boards and during public

talks. Moreover, heads of local clinics (e.g., endocrinology, internal medicine) were contacted via

e-mail as mediators to address possible candidates. Potential participants contacted the study staff

and were screened for eligibility. The inclusion criteria were: (1) postmenopausal woman between

45 and 65 years of age; (2) body mass index (BMI) >30 kg/m2 or waist circumference >94 cm; and

(3) not regularly physically active more than once a week. Subjects were excluded, when they: (1)

were

presently enrolled in another research study; (2) were unable to attend the training sessions; or

(3) had medical contraindications for exercise (such as pulmonary and/or cardiovascular disease,

epilepsy or an elevated risk of falls or other limitations for safe study participation). Women with

Sports 2016, 4, 5 3 of 15

renal dysfunctions, active malignancies or recent chemotherapies (<6 months) were also excluded.

Contraindications for exercise were determined via assessment of medical history and clinical

examination. The entire enrolment, intervention and measurement phase took 6 months. The study

was conducted between May and October 2014. Participants were asked to maintain their usual
dietary habits.

2.3. Measurements

At the initial visit, participants were interviewed and examined by an experienced physician.

Anthropometric and psychometric parameters were collected before the exercise testing.

Demographic and anthropometric data, including height (in cm, stationary device, without shoes),

weight (in kg, Inbody 720® Bioimpedanzmessgerät (JP Global Markets GmbH, Eschborn, Germany),

in underwear), waist circumference (in cm, with tape directly above the iliac crest) and calculated BMI

(in kg/m2), were obtained. Blood pressure and heart rate at rest were recorded using an automated

oscillometric device (Mobil-O-Graph NG, I.E.M., Stolberg, Germany) after 10 min of rest in supine

position. The cuff was inflated 3 times to supra-systolic values (30 mmHg above the systolic blood

pressure) automatically with a succeeding pressure release at a rate of 3 mmHg/ second.

We compiled a test battery consisting of common tests for the assessment of facets of psychosocial

and physical health in association with being overweight, eating behavior, depression, menopausal

symptoms, subjective health and quality of life, as well as sports-related barriers (Supplementary

Materials, Table S1).

2.4. Exercise Testing

Peak oxygen consumption (VO2peak) and maximum heart rate (HRmax) were assessed during

spiroergometric cardiopulmonary exercise testing on a treadmill (H/P/Cosmos Pulsar 2005, H/P

Cosmos Sports and Medical GmbH, Nussdorf-Traunstein, Germany) equipped with a suspension
system and an emergency stop as routine safety measures. Participants were allowed to use handrails

in

case of instability and advised to look straight ahead during the testing. The space behind the

treadmill

was three meters; no sharp surfaces or material were in reach of the treadmill. One participant

stumbled

while stepping partly off the running belt, and the treadmill was stopped immediately (see flow chart

Figure 1). As a consequence, safety measures were formally reinforced prior to the testing of the

following participants. Before each exercise test, the spirometry system (Cortex Metalyzer® 3B (Cortex

Biophysik GmbH, Leipzig, Germany)) was calibrated by two-point gas calibration with gases of known

composition. After a 5-min period of familiarization and safety instruction while standing on the

treadmill, participants performed a graded exercise test (pepper ramp protocol [42]). Throughout the

entire duration of the test, cardiac function was recorded on a 12-lead electrocardiogram (custo

cardio 100, CustoMed, Ottobrunn, Germany) under the supervision of a staff physician. Peak blood

pressure values were obtained to rule out hypertensive blood pressure. To determine subjective

effort,

ratings of perceived exertion were acquired (Borg Scale [43]). The test was terminated upon reaching

volitional exhaustion or fulfilment of absolute cardiorespiratory exhaustion criteria (2 or more out

of the following: heart rate >80% of the predicted HRmax (= (220-age) _ 10%), ratings of perceived

exertion ¥18 (Borg scale: 6 to 20), respiratory exchange ratio ¥1.05, no further increment in VO2peak,
supervisor’s impression).

Sports 2016, 4, 5 4 of 15

Figure 1. Flow of participants through the trial. Abbreviations: BMI, body mass index.

2.5. Dance Intervention

We modified the original higher impact Zumba-style and composed a set of ZumBeat choreographies

aiming at a reduced strain for the musculoskeletal system by avoiding high impact jumping

movements, appropriate for an overweight population (Supplementary Materials, Figures S1 and S2),

similar to Zumba Gold®. During the 12-week intervention period, 3 instructed 60-min classes were

provided per week, of which participants were instructed to attend a minimum of 2. Participants were

allowed to join the in-person training up to three times per week and, thus, compensate for missed

trainings in earlier or later weeks. Positive feedback and verbal encouragement were used to enhance

adherence during the in-person sessions. Participants also received a DVD with dance moves,

recorded

by our team, for the home-based self-trainings. Participants were instructed to perform home-based

self-trainings at least once a week by choosing from a set of 10 dances on a menu plus additional

warm-up and cool-down sections. Self-monitoring is considered the cornerstone of behavioral obesity

treatment as it enhances self-awareness and self-regulatory capabilities [44,45]. Although a causal

relationship has not been established, the literature suggests that consistent self-monitoring of

exercise
is associated with a greater amount of exercise and weight loss, as well as fewer difficulties with

exercise [46]. We therefore instructed our participants to record their home-based training sessions

on a log.

During 3 instructed training sessions inWeeks 1, 5 and 12, heart rate was recorded on a Polar watch

(RS 400, Polar Electro Oy, Kempele, Finland) during the whole course of the session. Training heart

rates were calculated from dancing periods only (40 to 45 min).

2.6. Statistical Analyses

The primary outcome of this study was the change in VO2peak (in mL/kg/min) after the 12-week

intervention period; secondary outcomes were changes in BMI, weight, waist circumference, percent

body fat, visceral fat mass, muscle mass, systolic blood pressure, diastolic blood pressure, resting

heart

Sports 2016, 4, 5 5 of 15

rate, quality of life, sports-related barriers, menopausal symptoms, depression, psychiatric symptoms,

impulsivity and eating behavior. Paired t-tests were used to assess changes in outcome after the

intervention period. In sensitivity analyses, we removed a few unusual data points to see whether

our analyses were robust to outliers. For each analysis, we report the estimated change in outcome

with its 95% confidence interval in order to emphasize clinical relevance over statistical significance.

To facilitate use of our data for planning future studies, we also report Cohen’s d as an effect size

measure, which can be readily interpreted as the percentage of the standard deviation of the change
scores (such that a Cohen’s d of 0.5 means the difference equals half a standard deviation). We used

R Version 3.1.2 (R Foundation for Statistical Computing, Vienna, Austria) and the R add-on package

lattice Version 0.20–30 for our analyses and graphics [47].

2.7. Power Calculation

Based on previous literature [18,22,25,48,49], we assumed a mean VO2peak of 25 to 35 mL/kg/min

in women between 45 and 65 years of age, a standard deviation of 5 mL/kg/min and a correlation

between baseline and follow-up VO2peak of 0.7. A 3.5-mL/kg/min (= 1 MET, metabolic equivalent)

higher fitness level was associated with a 13% risk reduction of all-cause mortality and a 15% lower

risk

for cardiovascular disease events or death in men and women according to epidemiological data [50].

A large scale longitudinal study observed a risk reduction of 15% all-cause and 19% cardiovascular

mortality with each MET increment in fitness [51]. Based on these previous findings, we aimed at a

risk

reduction of at least 10% for cardiovascular disease events and, therefore, considered an

improvement

in VO2peak of 3 mL/kg/min as clinically meaningful. With 17 study participants, the power was 85%

to detect such improvement (using a paired t-test at a 2-sided significance level of 0.05).

3. Results

3.1. Participant Characteristics

Thirty-seven subjects responded to our advertisements. Twenty of them did not start the intervention

because of failure to meet the eligibility criteria or refusal to participate (Figure 1). Seventeen

overweight

women were enrolled in the study, with a mean age of 55 years, median BMI of 30 kg/m2 and median

waist circumference of 103 cm (Table 1). Out of the 17 participants, 13 were on oral medications;

six took antihypertensive drugs (two _-blockers); two antidepressants; one a long-acting _2 agonist.

Table 1. Participant baseline characteristics.

Characteristic All Participants (n = 17)

Female sex, n 17

Age, years 55 (6)

Height, cm 167 (9)

Weight, kg 85 (79, 94)

BMI, kg/m2 30 (29, 33)

Waist circumference, cm 103 (102, 114)

Percent body fat, % 39 (8)

Visceral fat mass 1, cm2 130 (118, 156)

Systolic blood pressure 2, mmHg 126 (12)

Diastolic blood pressure 2, mmHg 80 (10)

Smoking, n –
Non-smoker 13

Ex-smoker 3

Current smoker 1

Abbreviations: BMI, body mass index; data are the mean (standard deviation) or median (interquartile

range)

if not stated otherwise; 1 Available in 16/17 participants; 2 after excluding one participant who forgot

to take

relevant medication on the day of the baseline visit, available in 16/17 participants.

Sports 2016, 4, 5 6 of 15

3.2. Training Completion and Intensity

Out of the 17 participants, three were lost to follow-up. The remaining 14 participants attended

a median of 20 of the recommended 24 instructed training sessions (interquartile range (IQR) 14, 24)

and completed a median of seven of the recommended 12 home-based self-training sessions (IQR 4,

9),

where one participant did not provide information on the number of completed home-based

trainings.

The overall median training performance was 30 of the recommended 36 training sessions (IQR 20,

34).

In detail: two participants completed eight and 12 instructed sessions (corresponding to an average of

¤1 attendance per week); nine completed between 13 and 24 instructed sessions (corresponding to
an average of one to two attendances per week); and three participants completed 30 instructed

sessions

(corresponding to an average of >2 attendances per week). Regarding home-based self-training, there

were 10 participants that completed between two and nine sessions (corresponding to an average of

<1 completion per week); two completed 18 sessions (corresponding to an average of 1.5 completions

per week); and one participant completed 20 sessions (corresponding to an average of >1.5

completions

per week). Overall, five participants completed between eight and 24 instructed or home-based

self-training sessions (corresponding to an average of ¤2 trainings per week); six completed between

25

and 34 sessions (corresponding to an average of two to three trainings per week); and three

participants

completed between 37 and 41 sessions (corresponding to an average of >3 sessions per week).

During the instructed training sessions inWeeks 1, 5 and 12, participants spent ¤5% of the time

at 50% to 59% of a participant’s individual HRmax, while the remaining time of the training sessions

was spent at heart rate zones ¥60% of the HRmax (Figure 2). Participants performed the instructed

training sessions in Weeks 1, 5 and 12 at a median of 69% (IQR 65, 74), 75% (IQR 69, 78) and 72% (IQR

67, 74) of the HRmax (Supplementary Materials, Figure S3).

Figure 2. Average percentage of time spent at certain heart rate zones during three (instructed)

training
sessions inWeeks 1, 5 and 12. Heart rate zones were calculated individually based on the maximum

heart rate (HRmax) during baseline exercise testing.

3.3. Effect of the Intervention on Cardiorespiratory Fitness

One participant stumbled during treadmill testing and did not complete the test protocol.

We therefore excluded this participant from the analysis of both the VO2peak and HRmax. For each

participant considered for analysis, Figure 3 shows the change in VO2peak after the 12-week

intervention

Sports 2016, 4, 5 7 of 15

period. On average, there was no apparent change in VO2peak (_0.5 mL/kg/min, 95% confidence

interval (CI) _1.0, 0.1; p = 0.114, Table 2), where all participants considered for analysis fulfilled at

least

two objective exertion criteria at baseline and follow-up testing.

Figure 3. Individual responses in peak oxygen consumption (VO2peak) showing the direction of

change.

Table 2. Effect of the 12-week ZumBeat dance intervention on cardiorespiratory fitness,

anthropometry

and cardiovascular parameters.

Parameter N 1

Intervention (n = 17) Change from

Baseline
(95% CI)

Baseline p-Value Cohen’s d

(Mean (SD))

Follow-up

(Mean (SD))

VO2peak, mL/kg/min 13 24.3 (2.9) 23.9 (3.2) _0.5 (_1.0, 0.1) 0.114 –0.47

HRmax, bpm 12 161.8 (15.5) 164.5 (17.0) 2.7 (_2.8, 8.1) 0.305 0.31

Anthropometry

Weight, kg 14 91.0 (13.1) 90.4 (11.6) _0.6 (_2.4, 1.3) 0.509 –0.18

BMI, kg/m2 14 32.7 (4.9) 32.5 (4.2) _0.2 (_0.9, 0.4) 0.444 –0.21

Waist circumference,

cm 14 108.8 (9.2) 107.2 (8.5) _1.6 (_3.3, 0.2) 0.072 –0.52

Percent body fat, % 14 39.5 (8.2) 38.1 (7.4) _1.3 (_3.6, 0.9) 0.210 –0.35

Fat mass, kg 14 36.1 (10.2) 34.7 (9.0) _1.4 (_3.7, 0.9) 0.200 –0.36

Visceral fat mass, cm2 13 140.7 (25.6) 138.4 (27.1) _2.2 (_9.6, 5.1) 0.523 –0.18

Muscle mass, kg 14 30.3 (5.3) 31.0 (5.0) 0.7 (_0.3, 1.7) 0.162 0.40

Cardiovascular parameters

SBP, mmHg 12 126.6 (14.2) 131.0 (12.3) 4.4 (_1.4, 10.2) 0.124 0.48

DBP, mmHg 12 80.4 (9.9) 83.3 (9.8) 2.9 (_1.2, 6.9) 0.146 0.45
Resting heart rate, bpm 13 63.5 (7.5) 62.3 (6.5) _1.2 (_5.5, 3.2) 0.578 –0.16

Abbreviations: VO2peak, peak oxygen consumption; HRmax, maximum heart rate; BMI, body mass

index; SBP,

systolic blood pressure; DBP, diastolic blood pressure; SD, standard deviation; CI, confidence interval;

1 Number

of participants with baseline and follow-up data available.

3.4. Effect of the Intervention on Anthropometric Parameters

On average, anthropometric parameters showed small changes in the expected direction, though

associated with considerable uncertainty (Table 2). Data on visceral fatmass were only available in 13

participants

Sports 2016, 4, 5 8 of 15

at baseline and follow-up. There were no changes in medication between the baseline and follow-up

visit, except for two women who forgot to take their antihypertensive medications at the day of

either

the baseline or follow-up visit and who were therefore excluded from the blood pressure analyses.

One of them was also excluded from the heart rate analyses (_-blocking agents) (Table 2).

3.5. Effect of the Intervention on Psychometric Parameters

3.5.1. Quality of Life

At the end of the 12-week intervention period, participants’ overall self-rated quality of life had
increased by 9.2 out of 100 points (95% CI 1.6, 16.8) on the Impact ofWeight on Quality of Life

(IWQOL)

questionnaire [52]; and self-esteem and work-related quality of life had increased by 15.6 points (95%

CI 2.8, 28.4) and 10.3 points (95% CI 0.1, 20.4) (Table 3).

Table 3. Effect of the 12-week ZumBeat dance intervention on psychometry.

Questionnaire N 1 Intervention (n = 17) Change from

Baseline (95%

CI)

p-Value Cohen’s d +/_ 2 Norm 3

Baseline

(Mean (SD))

Follow-up

(Mean (SD))

IWQOL (0–100) 14 _ _ _ _ _ _ _

Total score _ 79.4 (17.2) 88.7 (8.8) 9.2 (1.6, 16.8) 0.022 0.70 + 91.8

Physical function _ 75.5 (17.9) 83.6 (13.3) 8.1 (_1.2, 17.4) 0.082 0.50 + 90.0

Self-esteem _ 68.1 (29.0) 83.7 (19.5) 15.6 (2.8, 28.4) 0.021 0.70 + 87.5

Sexual life _ 86.2 (25.4) 92.9 (18.2) 6.7 (_2.0, 15.3) 0.119 0.45 + 95.1

Public distress _ 91.9 (14.7) 96.1 (5.3) 4.2 (_2.3, 10.7) 0.189 0.37 + 96.5
Work _ 87.5 (18.0) 97.8 (5.2) 10.3 (0.1, 20.4) 0.048 0.58 + 95.4

SBB (0 to 4) 14 2.5 (0.5) 2.1 (0.6) _0.4 (_0.7, _0.2) 0.001 _1.09 + 2.2

MRS(0 to 44) 14 11.9 (7.6) 9.5 (7.1) _2.4 (_4.6, _0.2) 0.036 _0.62 + 8.8

BDI (0 to 63) 14 7.2 (7.8) 4.8 (5.3) _2.4 (_5.6, 0.7) 0.118 _0.45 + 7.7

ISR (0 to 4) 14 0.5 (0.5) 0.4 (0.4) _0.1 (_0.2, 0.0) 0.216 _0.35 + 0.4

I-8 (0 to 4) 14 _ _ _ _ _ _ _

Urgency _ 2.3 (0.6) 2.2 (0.8) _0.1 (_0.4, 0.1) 0.314 _0.28 + 2.5

Intention _ 3.6 (1.0) 4.0 (0.6) 0.4 (_0.1, 0.9) 0.094 0.48 + 3.8

Endurance _ 4.1 (0.6) 3.9 (0.9) _0.2 (_0.6, 0.2) 0.254 _0.32 _ 4.3

Risk _ 3.6 (0.8) 3.2 (0.8) _0.4 (_0.9, 0.2) 0.156 _0.40 + 2.8

FEV 14 _ _ _ _ _ _ _

Dietary restraint

(0 to 21) _ 9.1 (3.8) 9.8 (4.4) 0.7 (_2.0, 3.4) 0.582 0.15 + 8.2

Disinhibition

(0 to 16) _ 8.2 (3.6) 7.1 (3.2) _1.1 (_2.5, 0.4) 0.132 _0.43 + 7.1

Hunger (0 to 14) _ 7.2 (3.8) 5.0 (3.7) _2.2 (_4.2, _0.3) 0.028 _0.66 + 5.7

Abbreviations: IWQOL, Impact ofWeight on Quality of Life; SBB, Sports-related Situational Barriers

Scale; MRS,
Menopause Rating Scale; BDI, Beck Depression Inventory; ISR, ICD-10-Symptom-Rating; I-8, German

Version of

the UPPS Impulsive Behavior Scale; FEV, German Version of the Dutch Eating Behavior Questionnaire

(DEBQ);

SD, standard deviation; CI, confidence interval; 1 Number of participants with baseline and follow up

data

available; 2 ”+” symbolizes improvement of the test result, “_“ symbolizes deterioration; 3 normative

values

for the general population.

3.5.2. Menopausal Symptoms

Symptoms that are frequently encountered during menopausal transition had decreased by 2.4

out of 44 points (95% CI 0.2, 4.6) on the Menopause Rating Scale (MRS) [53] (Table 3).

3.5.3. Sports-Related Barriers

Barriers towards exercise had decreased by 0.4 out of four points (95%CI 0.2, 0.7) on the Sports-

related

Situational Barriers (SBB) scale [54] (Table 3).

Sports 2016, 4, 5 9 of 15

3.5.4. Psychiatric Symptoms

Levels of depression on the Beck Depression Inventory II (BDI) had improved slightly [55].

Other psychiatric complaints, such as anxiety, compulsion, somatization or eating disorders, were
not prevalent among the study participants and were essentially unchanged after the end of the

intervention period, based on the results of the ICD-10 Symptom Rating (ISR) scale [56] (Table 3).

3.5.5. Impulsivity and Eating Behavior

While most impulsivity sub-scales were essentially unchanged after the end of the intervention

period, intentional behavior had increased slightly, with an average change from baseline of 0.4 out

of four points (95% CI _0.1, 0.9) on the I-8 questionnaire (German Version of the UPPS Impulsive

Behavior Scale) [57]. Dietary restraint and disinhibition towards food had not changed after the end of

the intervention period. However, feelings of hunger were reduced by 2.2 out of 14 points (95% CI 0.3,

4.2) on the German Version of the Dutch Eating Behavior Questionnaire [58] (Table 3).

3.6. Sensitivity Analyses

Compared to the main analysis of the VO2peak, exclusion of two participants who stopped

exercise testing prior to having reached (subjective) exertion led to a similar pattern of change after

the 12-week intervention period (average change score: _0.2 mL/kg/min, 95% CI _0.8, 0.3; p = 0.382).

Estimated changes from baseline were generally decreased after excluding a few outliers with

unusually

strong improvements in outcome (Supplementary Materials, Table S2). For example, changes in

percent

body fat and muscle mass were decreased after excluding two outliers with an unusually strong

decrease
in percent body fat and one outlier with an unusually strong increase in muscle mass, respectively.

4. Discussion

Developing, piloting, evaluating, reporting and implementing are important steps for interventions,

as suggested by the Medical Research Council [59]. Generally, studies can be declared as feasible

when

they fulfil the criteria of successful recruitment, retention/compliance/adherence and safety.

With regard to feasibility assessment in the process of evaluating and developing a future

intervention, one result of this study is that the intervention itself appears to be feasible: in our

study, only three participants (equaling 18%) discontinued the study participation. Previous literature

suggests drop-out rates due to orthopedic problems of 25% [41]. We attribute the relative success to

the

low hazardous style of the ZumBeat dance moves. Most Zumba classes demand high coordination and

experience with the choreographies. Assuming a lack of the above, the likelihood for musculoskeletal

injury is increased. The small number of complications from the training, the small drop-out rate and

good adherence in this study suggest the feasibility of the intervention itself.

We observed no benefit for cardiorespiratory fitness following a 12-week ZumBeat dance intervention

in postmenopausal overweight women and only small benefits, if any, for body composition.

However,

single items of health-related quality of life may be enhanced and menopausal symptoms and
sports-related barriers reduced. This implies possible reductions of problems often encountered

in the field of activity promotion and might contribute to a better understanding in this important

public health area. Future projects should implement and thoroughly assess this topic.

The literature suggests that Zumba dance is a suitable training method to enhance cardiovascular

fitness and strength [29,35,38]. However, older, overweight populations have rarely been studied.

A recent publication by Dalleck et al. shows that Zumba Gold® training can be categorized as

moderate

exercise and is in line with current guidelines for improving and maintaining cardiorespiratory

fitness [60]. While on average, women in this study did not improve their VO2peak, Krishnan et al.

found an improvement in VO2peak of 1 mL/kg/min in a similar study population after a 16-week,

three times weekly, 60-min per session Zumba intervention [40]. In their study, VO2peak was not

measured, but calculated after conducting a walking test. A quality criterion for our study is the direct

Sports 2016, 4, 5 10 of 15

measurement of VO2peak. Another study among female hospital workers indicated an improvement

in

VO2peak of 1.46 mL/kg/min (95% CI 0.17, 2.75) after 12 weeks of training and a reduction in fat mass

comparable to that observed in our study [60]. However, the participants were younger (mean age:

46 years), had a lower BMI (mean BMI: 26 kg/m2) and, therefore, might have adapted to the training

more easily. Moreover, this might have allowed them to exercise at greater training intensities right
from the start. The reported change in VO2peak corresponds to improvements between 0.9% and 9%,

5% on average only. This still lies in the range possible of retest adaption effects [61] or corresponds

to a 3% to 5% reduction of the relative risk for cardiovascular events [51]. The great variability in

study participation with a lack of continuity of exercise over the summer period in our study may

explain why we were not able to add to the growing body of evidence for an effect of Zumba on

fitness.

This might have diminished measurable improvements and be explanatory for the missing increment

in VO2peak, but clearly reflects real-life circumstances. The endurance section of the lessons

(excluding

warm-up and cool-down) evoked a rise in heart rates above the level necessary to acquire training

adaptions and gains in fitness, with median heart rates ranging between 69% and 75% of the HRmax

(Supplementary Materials, Figure S3) and the main portion of the lesson at heart rate zones between

60% and 79% of the participants’ HRmax (Figure 2). Exercise intensity progressed from moderate

to higher intensities over the time-course of the intervention, as recommended in exercise training

guidelines [62]. According to the subjective impression of the instructor, the training sessions were all

well tolerated. This confirms that the intensity of the training itself meets current recommendations

and, therefore, should have been sufficient to positively influence fitness [63]. Moreover, a pilot study

suggests that Zumba® dance classes might allow greater energy expenditure, but Zumba® DVD

workouts might be suitable to maintain fitness [64].

On average, participants did not showa large benefit in anthropometric parameters after the 12-week

intervention period. Single participants, however, showed extreme changes in body composition,

with one participant losing 7.4% and another losing 10.8% body fat. There was no evidence for

a change in blood pressure, but both systolic and diastolic average levels in this small sample

appeared slightly higher after the intervention. This is in line with results from an eight-week Zumba®

intervention, which did not result in relevant changes in body composition [41]. A recent publication

by Cugusi et al. showed significant weight and fat mass reductions, as well as gains in muscle mass

after a 12-week Zumba dance intervention similar to ours, in a younger overweight population (mean

age 38.9 _ 9.7 years) [65]. They also reported decreases in blood pressure levels. This indicates that

Zumba may contribute to significant improvement in body composition, but whether this is possible

in an elderly overweight population with appropriate training time and effort remains to be proven.

Cugusi et al. investigated quality of life in relation to Zumba dancing [65]. In their study, physical

functioning and emotional role were the only two out of eight domains assessed that showed

significant amelioration. Our study suggests improvements in quality of life scores associated with

being overweight. At baseline, scores were ranging between normal values for healthy people and

participants in weight reduction programs in each subscale. After the intervention, the scores

appeared

improved, but a causal attribution to the intervention cannot be made due to the study design.

Larger scaled controlled trials are needed for confirmation.

Our results suggest a reduction in sports-related barriers (0.4 out of four points (95% CI 0.2, 0.7)

on the SBB scale). Sedentariness implies the existence of manifold barriers and a lack of motivation.

One major factor accounting for inactivity is the lack of self-motivation. Greater self-efficacy, on the

other hand, has been identified as key determinant in increasing physical activity [13,66]. Studies

show

that a recent exercise experience or mastery can improve self-efficacy beliefs and increase exercise

adherence in the maintenance phase [67]. Therefore, an increase in self-esteem and a decrease in

barriers

as observed in this study could be a first step towards greater activity participation. Future controlled

studies are required to confirm our exploratory results regarding barriers and should simultaneously

monitor associated self-motivation and self-efficacy beliefs.

Sports 2016, 4, 5 11 of 15

Average baseline values of all sub-scores and the total MRS score were above the healthy European

norm [68]. While previous research has revealed ambiguous results of exercise on menopausal

symptoms,

menopausal symptoms seemed lower post-intervention in this study and may be worth future

exploration.

Two participants showed elevated levels of depression on the BDI-II at baseline, beyond the

cut-off for moderate depression; both of them had reduced their depression scores after the end of

the
intervention (one of them by more than eight points, representing a clinically-relevant improvement).

Average depression levels in our study were not elevated and remained essentially unchanged after

the

intervention, whereas other studies have reported higher depression levels among diabetic and obese

people [69–72]. Furthermore, we did not find symptoms suggestive of other psychiatric disorders nor

did they change over the course of the intervention, but due to the small sample size and single-arm

design, a generalization of these results in not feasible.

While impulsivity as a construct is strongly associated with behavioral control and adaptive

regulations to the individual’s surroundings, it is often more pronounced in patients with binge eating

disorders or obesity [73]. Physical activity, on the other hand, has been shown to moderate impulsive

behavior in addition to behavioral therapy [74]. In this study, impulsive behavior was more prevalent

at baseline compared to normative values on all four sub-scores of the I-8 questionnaire, but did not

seem to be affected by the intervention.

In addition, this study revealed encouraging results suggesting a reduction in hunger perceptions,

which could lead to a more stable eating behavior, but still needs to be proven through further

research.

Limitations

This study presents some limitations. First, due to recruitment problems, our study has a small

sample size and lacks a control group. We originally designed this study as a randomized controlled
trial, but were only able to recruit 17 participants and, therefore, changed the study design, with

approval from the ethics committee, to a prospective, interventional single-arm study. Despite our

great efforts in terms of recruitment, we were not able to meet the target total sample size as

determined

for a two-arm trial, including a control group. Interested women were too young or active, while

the targeted participants did not respond to our advertisements. The advertisements might have

been more successful if more research personnel had approached potential candidates verbally in

person or via local media. We were unable to place costly advertisements in newspapers or distribute

leaflets to private households for this study, as it was only funded by internal resources. Moreover,

future studies might consider a matching of the contact person with participants (older, overweight

woman), a more convenient location and closer telephone follow-up in order to enhance recruitment

efficiency [66]. In addition, incentives for study participation should be reconsidered. Given the low

response to advertisement in this study and even lower eligibility rates, careful reconsideration of

the strict inclusion criteria might be another approach, but simultaneously changes the purpose of

the study. Our practical experience is comparable to the Zumba pilot study reported by Araneta

et al. in which 35 women completed eligibility screening by phone, 23 were eligible for a first visit,

18 met eligibility criteria, 16 initiated Zumba classes and 13 completed the study. Therefore, these

response and retention rates may be characteristic for this type of study in a similar population.

Our recruitment strategies were insufficient to generate a sample large enough for a randomized
controlled trial, and therefore, this part of the project was not feasible. Recruitment strategies need

to

be carefully reconsidered before starting a large randomized controlled trial. This may include the

option of multi-center studies. With the above-mentioned limitation (lacking a control group) in mind,

all resulting data and their interpretations below need to be handled with caution. They should rather

be interpreted as exploratory indicators serving to generate effect sizes for future controlled trials.

Secondly, the study has a short length of follow-up, limiting the strength of findings on the midto

long-term effects of the ZumBeat dance intervention.

Thirdly, participants who dropped out of the intervention could not be included in the final

results, raising issues of effectiveness among those who stop exercising.

Sports 2016, 4, 5 12 of 15

In sum, our study suggests a decrease in sports-related barriers, better attitudes towards exercise

and improvements in weight-adjusted quality of life following a 12-week ZumBeat dance intervention.

As a result, individuals may be more active in the post-intervention period, so that cardiorespiratory

fitness and weight are then steadily improved. This has important public health implications,

since current literature suggests that postmenopausal sedentary women who are overweight have

an increased cardiovascular risk, which can be modified by physical activity [9]. A short-term ZumBeat

dance intervention may offset initially small, but steadily-increasing changes in cardiovascular risk

factors for those who eventually make long-term behavioral changes. Future studies should modify
the length of the intervention, which might result in larger fitness improvements. While our study

has a short length of follow-up, limiting the strength of findings on the mid- to long-term effects of

the ZumBeat dance intervention, prospective research should examine participants’ appraisal of the

program and physical activity levels in the follow-up period after the intervention.

5. Conclusions

A 12-week ZumBeat dance intervention may not suffice to improve cardiorespiratory fitness or

substantially improve body composition in sedentary postmenopausal overweight women. However,

it shows good feasibility in terms of adherence and safety, helps to improve weight-related quality

of life and to reduce sports-related barriers. Future studies are needed to evaluate whether the

psychosocial improvements are persistent after the intervention and whether these are

transformable

into additional health gains.

Supplementary Materials: The following are available online at www.mdpi.com/2075-4663/4/1/5/s1.

Acknowledgments: The authors thank all participants for their time and effort, which were vital to the

completion

of this research project. The authors would also like to thank the personnel of the Division of Sports

and Exercise

Medicine at the Department of Sport, Exercise and Health for their technical, logistical and mental

support.
Author Contributions: Contributions to authorship: Anja Rossmeissl, Juliane Schäfer and Arno

Schmidt-Trucksäss

designed this study. Anja Rossmeissl, Soraya Lenk and Henner Hanssen were responsible for data

collection at the

Department of Sport, Exercise and Health. Anja Rossmeissl and Soraya Lenk designed and delivered

the ZumBeat

dance intervention. Anja Rossmeissl, Arno Schmidt-Trucksäss and Juliane Schäfer carried out the

statistical

analyses and created the graphs. Anja Rossmeissl wrote the first draft of the manuscript. Anja

Rossmeissl,

Lars Donath, Arno Schmidt-Trucksäss and Juliane Schäfer revised the manuscript. All authors

reviewed,

commented on and approved the final version of the manuscript.

Conflicts of Interest: The authors declare no conflict of interest.

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