Hypertension is one of the most important modifiable risk factors for cardiovascular disease, and even elevated blood pressure or stage 1 hypertension can increase long-term cardiovascular risk if not properly managed [1, 2]. The 2017 American College of Cardiology/American Heart Association guideline lowered the diagnostic threshold for hypertension to systolic blood pressure (SBP) ≥ 130 mmHg or diastolic blood pressure (DBP) ≥ 80 mmHg and classified SBP 120–129 mmHg with DBP < 80 mmHg as elevated blood pressure [3, 4]. In Korea, hypertension has become increasingly prevalent, rising from approximately 3 million affected individuals in 2002 to more than 10 million in 2019 [5]—and is strongly associated with cardiovascular and renal complications such as coronary artery disease, stroke, heart failure, and chronic kidney disease [2]. Obesity frequently coexists with elevated blood pressure and contributes to hypertension through sympathetic activation, endothelial dysfunction, arterial stiffness, systemic inflammation, and adverse changes in body composition [6, 7]. Therefore, early lifestyle-based interventions that simultaneously target body composition, vascular function, and autonomic regulation may be particularly important for individuals with obesity and early-stage hypertension [4, 7].

Regular exercise is recommended as a first-line non-pharmacological strategy for blood pressure management [4]. Exercise may reduce blood pressure through several interacting mechanisms, including improved endothelial function and nitric oxide bioavailability, reduced arterial stiffness, favorable changes in body composition, and improved autonomic balance [8–10]. However, the magnitude and pathway of these adaptations may differ according to exercise modality, because aerobic, resistance, mind-body, and circuit-based exercise programs impose different combinations of metabolic, hemodynamic, muscular, respiratory, and autonomic stimuli [10–12].

Mat Pilates may be a suitable exercise modality for obese adults with elevated or stage 1 hypertension because it is low-impact, adaptable, and combines controlled breathing, postural alignment, core stabilization, flexibility, and repeated muscular activation [7, 13]. These characteristics may be clinically relevant for individuals with obesity or early hypertension who require an exercise program that can provide sufficient physiological stimulus while minimizing excessive orthopedic or cardiovascular burden [7, 14]. Previous studies have reported that Pilates training can improve blood pressure, body composition, vascular function [7], nitric oxide-related responses, inflammatory or oxidative profiles [15], and autonomic modulation in clinical or cardiometabolic populations [12, 16].

A mat Pilates program incorporating a circuit-like structure, in which repeated postures are performed continuously at a controlled rhythm and moderate intensity, may provide combined muscular endurance and cardiorespiratory stimuli while maintaining the breathing control and low-impact characteristics of Pilates [11, 13, 14]. From a mechanistic perspective, repeated dynamic muscle contractions may increase blood flow and shear stress, thereby supporting endothelial function and nitric oxide bioavailability [8, 17], while controlled breathing and focused movement may contribute to parasympathetic modulation and reduced sympathetic predominance [12, 16]. Therefore, this type of circuit-structured mat Pilates program may plausibly influence body composition, blood pressure, vascular function, and autonomic nervous system activity through overlapping but partly distinct physiological pathways [7, 12, 15].

Blood pressure regulation is closely influenced by the interaction between vascular function and autonomic nervous system regulation, rather than by a single mechanism [18]. The sympathetic nervous system and parasympathetic nervous system are key components of autonomic regulation; hypertension is often accompanied by autonomic nervous system dysfunction, typically characterized by increased sympathetic nervous system activity and reduced parasympathetic nervous system tone [9]. These alterations may contribute to cardiovascular abnormalities such as elevated plasma norepinephrine levels, increased vascular tone, and decreased heart rate variability (HRV) [19–21]. HRV is widely used as a non-invasive clinical indicator of autonomic nervous system function [6], and exercise-induced improvements in HRV may reflect a shift toward improved autonomic balance [21]. Previous studies have shown that exercise interventions can improve HRV and reduce sympathetic predominance in obese or hypertensive populations [19, 22, 23]. For instance, Kim et al. [23] reported that 12 weeks of combined aerobic and resistance training improved HRV and reduced psychological stress in obese women, while Park et al. [22] found that aerobic training enhanced parasympathetic activity and suppressed sympathetic activation in middle-aged obese women. Similarly, Edwards et al. [19] observed that a 12-week lifestyle intervention improved blood pressure via increased parasympathetic modulation in individuals with elevated blood pressure.

At the same time, vascular function is also a central determinant of blood pressure regulation because endothelial-dependent vasodilation and arterial stiffness influence peripheral vascular resistance and arterial load [24–26]. Therefore, simultaneous assessment of vascular and autonomic outcomes can help determine whether blood pressure changes following exercise are accompanied by vascular adaptation, autonomic adaptation, or both [9, 26]. This integrated approach is particularly relevant in obesity-related early hypertension, where endothelial dysfunction, arterial stiffness, sympathetic predominance, and reduced parasympathetic activity may coexist and interact [9, 26].

Although Pilates has been increasingly investigated as a therapeutic exercise modality, much of the existing evidence has been derived from female populations, including women with obesity, hypertension, diabetes, or other health conditions [7, 12, 27]. In Korea, obesity and hypertension represent particularly important cardiometabolic concerns in men, as national survey data have shown a marked increase in obesity prevalence among Korean men and a higher prevalence of hypertension in men than in women [28–30]. Nevertheless, evidence regarding the effects of Pilates-based exercise in obese men with elevated or stage 1 hypertension remains limited [31]. Therefore, focusing on male participants in the present study was clinically relevant and addressed an underexplored population in Pilates-based cardiovascular research. Therefore, the present study aimed to investigate the effects of an 8-week mat Pilates exercise program on body composition, blood pressure and vascular function, autonomic nervous system activity, and health-related physical fitness in obese men with elevated or stage 1 hypertension.

The main finding of the present study was that an 8-week mat Pilates exercise program was associated with favorable changes in body composition, blood pressure and vascular function, autonomic nervous system regulation, and health-related physical fitness in obese men with elevated or stage 1 hypertension. Compared with the CON, the exercise group showed clearer improvements in body weight, BMI, fat mass, blood pressure-related variables, arterial stiffness, endothelial function, selected HRV indices, and multiple components of health-related physical fitness. These findings support our hypothesis that a mat Pilates program designed with a circuit-like structure may provide sufficient physiological stimulus to improve cardiometabolic and functional outcomes in this population. However, because body weight and fat mass also decreased during the intervention, the cardiovascular and autonomic improvements should be interpreted as the combined result of the exercise stimulus and concurrent body composition changes, rather than as effects of Pilates training alone.

The improvement in body composition may be partly explained by the structure of the exercise program. The present mat Pilates program required participants to perform repeated postures continuously at a controlled rhythm and moderate intensity [34], which may have increased total muscular work and energy expenditure while preserving the low-impact characteristics of Pilates [14]. This format differs from a purely flexibility-oriented Pilates approach and may provide a combined muscular endurance and cardiorespiratory stimulus [14, 41]. Previous evidence indicates that Pilates training can reduce body weight, BMI, and body fat percentage in adults with overweight or obesity [42]. In addition, systematic reviews have reported that Pilates may improve cardiorespiratory fitness and physical performance in adult populations [43]. In addition, mat Pilates has been shown to reduce body fatness in individuals with elevated blood pressure [7]. Therefore, the reductions in body weight, BMI, and fat mass observed in the exercise group may reflect the combined effects of repeated muscular activation, moderate-intensity continuous movement, and the feasibility of a low-impact exercise modality for obese individuals [7, 14].

The reductions in blood pressure-related variables may have resulted from both exercise-induced cardiovascular adaptations and improvements in body composition. Exercise training can lower blood pressure through several interacting mechanisms, including improved endothelial function, increased nitric oxide bioavailability, reduced arterial stiffness, improved autonomic balance, and decreased sympathetic activity [4, 44, 45]. In the present study, the reductions in body weight and fat mass may also have contributed to the blood pressure improvements [46, 47]. Obesity-related hypertension is closely associated with sympathetic activation, endothelial dysfunction, increased vascular tone, renin-angiotensin-aldosterone system activation, and insulin resistance [46, 47]. Thus, the blood pressure changes observed in the exercise group should not be attributed solely to the Pilates intervention itself. Rather, they likely reflect the combined influence of the structured exercise stimulus and concurrent reductions in adiposity. This interpretation is important because it avoids overestimating the independent effect of Pilates training and acknowledges the potential role of weight and fat loss as contributing mechanisms.

The improvements in vascular function provide a plausible physiological pathway linking the intervention to blood pressure reduction. In the exercise group, baPWV decreased, whereas ABI and FMD increased, suggesting favorable changes in arterial stiffness and endothelial-dependent vasodilation. Repeated dynamic muscle contractions during exercise can increase blood flow and shear stress, which may stimulate endothelial nitric oxide production and improve vascular responsiveness [44]. Improved endothelial function may reduce peripheral vascular resistance and contribute to better blood pressure regulation [26, 44]. These findings are consistent with previous evidence showing that mat Pilates improved arterial stiffness, vascular function, nitric oxide-related responses, and body fatness in individuals with elevated blood pressure [7]. In the present study, vascular improvements may have been promoted by repeated moderate-intensity muscular activation, reduced vascular tone, and improved endothelial responsiveness [45]. At the same time, the reduction in body weight and fat mass may also have reduced arterial load and obesity-related vascular stress [46, 48]. Therefore, the vascular findings should be interpreted as potentially resulting from both exercise-related shear-stress stimulation and body composition improvement.

The changes in autonomic nervous system function further suggest that the intervention may have influenced blood pressure regulation through multiple pathways. The exercise group showed increases in pNN50 and HF and a decrease in LF/HF, indicating a shift toward greater parasympathetic modulation and improved sympathovagal balance [21]. Hypertension and obesity are commonly associated with autonomic dysfunction, including increased sympathetic predominance and reduced parasympathetic activity [9, 47, 49]. Several features of mat Pilates may be relevant to autonomic regulation, including controlled breathing, focused movement, postural control, and moderate-intensity repeated muscle activation [12, 43]. Controlled breathing and mindful movement may support vagal modulation [50], while improvements in fitness and body composition may reduce sympathetic drive [47]. Previous studies have reported that Pilates training can improve indices of cardiac autonomic modulation in hypertensive or clinical populations [12]. However, the autonomic findings in the present study should be interpreted with caution because not all HRV indices changed significantly. RMSSD improved within the exercise group, but the interaction effect was not significant, and SDNN did not show a significant change. Therefore, the intervention appears to have improved selected HRV indices rather than producing a uniform enhancement of all autonomic parameters.

The improvements in health-related physical fitness may also help explain the broader cardiometabolic effects observed in this study. The exercise group improved in muscular strength, muscular endurance, flexibility, balance, and VO₂peak, indicating that the circuit-structured mat Pilates program provided a multidimensional functional stimulus. These findings are consistent with previous studies reporting that Pilates can improve muscular performance, flexibility, functional capacity, and cardiorespiratory fitness [14, 41, 43]. The improvement in VO₂peak is particularly meaningful because cardiorespiratory fitness is closely related to cardiovascular health and may contribute to blood pressure control through improved vascular function, enhanced autonomic regulation, and reduced myocardial workload [4, 44, 45, 51]. Thus, the improvement in physical fitness should not be viewed as an isolated outcome. Instead, it may represent one of the pathways through which the intervention contributed to improvements in blood pressure, vascular function, and autonomic regulation [44, 45, 51].

Taken together, the present findings suggest that circuit-structured mat Pilates may influence cardiometabolic health through interconnected mechanisms. Repeated moderate-intensity movement may increase muscular work and energy expenditure, contributing to reductions in body weight and fat mass [42, 43]. These body composition changes may reduce obesity-related sympathetic activation, vascular load, and neurohormonal stress [46, 47]. Simultaneously, repeated dynamic contractions may enhance endothelial shear stress and vascular responsiveness, while controlled breathing and focused movement may support parasympathetic modulation [44, 50, 52]. Improvements in cardiorespiratory fitness may further reinforce these adaptations by supporting vascular and autonomic regulation [44, 45, 51]. Therefore, the benefits observed in this study likely reflect an integrated response involving body composition, hemodynamic regulation, vascular function, autonomic balance, and physical fitness.

Despite these encouraging outcomes, several limitations should be acknowledged. First, the sample size was small (n = 20), with only 10 participants per group completing the study, and was slightly below the a priori target sample size, potentially reducing statistical power for detecting smaller effects and limiting the generalizability of the findings. Second, participants were all obese men with elevated or stage 1 hypertension, which limits the generalizability of the findings to women, older adults, individuals with normal blood pressure, or patients with more severe hypertension. Third, because body weight, BMI, and fat mass improved in the exercise group, this study cannot determine whether the improvements in blood pressure, vascular function, and autonomic regulation were caused by the Pilates program itself, by body composition changes, or by their combined effects. This limitation should be considered when interpreting the cardiovascular and autonomic outcomes. Fourth, although participants were instructed to maintain their usual dietary intake and habitual physical activity during the study period, these factors were not strictly controlled or objectively monitored, which could have influenced body composition and cardiometabolic outcomes. Fifth, VO₂peak was estimated using an indirect method rather than measured directly with gas analysis, potentially affecting the accuracy of cardiorespiratory fitness assessment. Finally, the short 8-week intervention period and absence of follow-up preclude conclusions regarding long-term sustainability of the observed effects.

In conclusion, an 8-week circuit-structured mat Pilates exercise program was associated with improvements in body composition, blood pressure and vascular function, autonomic nervous system regulation, and health-related physical fitness in obese men with elevated or stage 1 hypertension. These findings suggest that mat Pilates may be a feasible low-impact exercise strategy for improving cardiometabolic health in this population. However, because the intervention also produced meaningful changes in body composition, the cardiovascular and autonomic improvements should be interpreted as potentially resulting from both the exercise stimulus and concurrent reductions in body weight and fat mass. Future studies with larger samples, both sexes, longer follow-up periods, and stricter control of diet and habitual physical activity are needed to clarify the independent and combined effects of Pilates training and body composition changes on vascular-autonomic adaptation and blood pressure regulation.