IJCS | Volume 31, Nº6, November / December 2018

627 Silva et al. Virtual rehabilitation for individuals with heart disease Int J Cardiovasc Sci. 2018;31(6)619-629 Original Article undergoing the training protocol, unexpected higher fat mass gain was observed in the VRG as compared to the CRG. Ades et al., 31 have reported that, of the behavioral changes for weight control, the following are worth noting: self-monitoring with systematic observation and recording of dietary habits; environmental change associated with eating and exercising to control stimuli; and strategies to control factors that can lead to excessive caloric ingestion. The use of technologies that allow man-machine interaction in a real three-dimensional environment as a modality of treatment is increasing. 32 However, there is no substantial evidence of change in body composition by use of exergames as an alternative to other intervention types. The methods used in this study included behavioral changes for weight control. However, the duration of the intervention might have influenced the results, and an intervention longer than eight weeks might benefit body composition. Cardiovascular rehabilitation programs are usually 12-week long or shorter, and, changes in lifestyle, such as weight loss, require a longer period, such as 16 to 24 weeks. Thus, positive changes in body composition in a rehabilitation program might require a longer follow-up time. In addition, no nutritional guidance was provided. All those factors associated might explain the negative effects regarding body composition. Brennan B 33 has reported that a combined aerobic and resistance training is more effective than aerobic training alone to improve body composition in individuals with coronary artery disease. Total body water is known to reduce as body fat increases; thus, a more metabolically active muscle tissue needs more water to perform the cellular exchange of metabolites and nutrients. 34 Thus, one can infer that the greater the amount of muscle and the lower the amount of adipose tissue, the higher the total bodywater proportion. This reflects on the decrease of total water in the VRG, which had an increase in fat percentage. However, the opposite can happen: the hydration level can change resistance and lean and fat weight, influencing the results. Lima et al., 35 have compared the effects of combined aerobic and resistance training with those of aerobic training alone on blood pressure and body composition of 44 hypertensive individuals, performing three training sessions per week for ten consecutive weeks. Regarding body composition, fat mass was reduced only in the combined aerobic and resistance training group, corroborating the findings of the present study, in which the CRG (aerobic and resistance exercises) showed a decrease in fat mass, although with no statistical significance. This study showed inconsistent results regarding the food intake of individuals with CVD. The paired analysis showed an increase in the intake of sweets and desserts in a group without any significant change in body composition, while the group with an increase in the body fat percentage and fat weight showed a significant increase in the intake of vegetables, sauces and seasonings. These findings can be related to particularities of the FFQ used in the present study. Slater et al., 36 have reported sources of errors related to the FFQ due to the restrictions imposed by a defined list of food, dependence on recollection, food portion perception and the way the questions are interpreted. Thus, the FFQ proved to be a subjective tool of food frequency analysis, emphasizing the lack of nutritional guidance during the treatment protocol. Despite the limitations of the questionnaires that assess food frequency and dietary habits, such parameters should be assessed, because inadequate dietary intake can be one of the major determinants of the increase in deaths from CVD in Brazil. 37 Regarding the distance covered in the 6MWT, 25 significant improvement was observed in both groups, but, when compared, the gains did not differ. Klompstra et al., 38 have reported similar results when adopting VR, by use of Nintendo Wii, at the home of individuals with heart failure for 12weeks, with a significant improvement in the 6MWT. In addition, a systematic review has evidenced the susceptibility of the 6MWT to changes in the clinical status after cardiac rehabilitation. 39 Thus, the improvement in functional capacity is believed to relate to the increase in the maximal consumption of oxygen in individuals with CVD, which results from training-induced adaptations, specifically the aerobic component, which leads to an increase in cardiac output, maximum systolic volume, tolerance to muscle acidosis, and elevation in the anaerobic threshold that characterize improvement of the tolerance to submaximal exercise. 40 Regarding blood glucose levels, both groups showed a significant reduction after the sessions, but with no difference between them. Kempf et al., 41 have reported that the use of exergames reduced blood glucose