Effects of Telehealth-based Lifestyle Modification on Cardiorespiratory Fitness Among Individuals with High-normal or High Blood Pressure: Randomized Controlled Trial

BACKGROUNDCardiorespiratory fitness (CRF) is a strong predictor of cardiovascular risk, yet scalable approaches to improve CRF among adults with high-normal or high blood pressure (BP) remain limited. Telehealth lifestyle programs may address this gap, but trials with rigorous CRF endpoints are scarce. METHODSWe conducted a two-center, assessor-blinded, randomized controlled trial in Beijing and Shenzhen, China, from July 2022 to September 2024. Adults with high-normal or high BP were enrolled and randomized 1:1 to a telehealth-based lifestyle modification program (Tele-LM) or enhanced usual care (EUC), stratified by BP category. Tele-LM combined app-based dietary coaching, individualized aerobic and resistance prescriptions, home BP monitoring, and motivational interviewing. EUC comprised standardized lifestyle counseling, home BP monitoring, and educational resources. The primary outcome was change in peak oxygen uptake (VO2peak) at 3 months. Secondary outcomes included changes in VO2peak at 9 months, home, ambulatory and office BP, lifestyle behaviors, metabolic parameters, and medication use. Analyses followed the intention-to-treat principle with multiple imputation for missing data. RESULTSAmong 424 randomized participants (mean age 50 years; 65% men), 314 completed the 3-month assessment and 377 completed the 9-month assessment. At 3 months, the adjusted between-group difference in VO2peak change favored Tele-LM by 1.5 mL/kg/min (95% confidence interval [CI], 0.6 to 2.3; P=0.001); at 9 months, a smaller difference persisted (1.0 mL/kg/min [95%CI, 0.1 to 1.9]; P=0.027). Subgroup analyses by BP category (randomization strata) revealed no significant heterogeneity for VO2peak. Tele-LM produced greater 3-month reductions in home BP (systolic BP -3.3 mmHg [95% CI, -5.3 to -1.4]; diastolic BP -2.6 mmHg [95%CI, -3.9 to -1.3]) and in 24-hour ambulatory BP (systolic BP -3.3 mmHg [95%CI, -6.0 to -0.6]; diastolic BP -1.9 mmHg [95%CI, -3.6 to -0.3]); between-group differences generally attenuated by 9 months. Adverse events were infrequent and similar between groups; no serious adverse events were observed. Average antihypertensive medication intensity was modestly lower in the Tele-LM (-0.27 agents [95% CI, -0.44 to -0.10]). Findings were consistent across prespecified sensitivity analyses. CONCLUSIONSIn adults with high-normal or high BP, telehealth lifestyle modification with minimal in-person contact significantly improved CRF and modestly lowered BP, supporting its scalability as a complement to routine hypertension care. REGISTRATIONURL: https://www.clinicaltrials.gov; Unique identifier: NCT05528068. Clinical PerspectiveO_ST_ABSWhat Is New?C_ST_ABSO_LIThis randomized trial evaluated a comprehensive telehealth-based lifestyle modification program, combining app-based dietary coaching, individualized aerobic and resistance prescriptions, wearable integration and motivational interviewing, in adults with high-normal blood pressure or well-controlled hypertension. C_LIO_LITelehealth-based lifestyle modification significantly improved cardiorespiratory fitness and modestly reduced blood pressure compared with enhanced usual care. C_LI What Are the Clinical Implications?O_LITelehealth lifestyle programs can extend preventive care to large at-risk populations with minimal in-person contact. C_LIO_LIBy reducing reliance on pharmacologic intensification and conserving healthcare resources, telehealth-based strategies offer a cost-effective model for scalable cardiovascular prevention. C_LIO_LISustaining adherence remains essential to maximize long-term benefits. C_LI