Exercise and
adult women’s health
Amos Pines
Be fit – be healthy
Ways to measure fitness:
• Ordinary exercise testing
• Walk test
Parameters used to measure the intensity
of exercise:
• Heart rate
• Oxygen consumption (VO2)
• Energy expenditure (METs or k/cal spent
during a time unit)
Measuring energy expenditure
1 Metabolic Equivalent Task (MET) = calories
spent while resting
(the individual basal metabolic rate (BMR) is
adjusted for body size)
The intensity of physical activity is measured by
METs per time unit: 2 METs/h means spending
twice the calories needed at rest during 1 hour
Exercise improves
cardiovascular risk profile
• Body mass index
• Total, abdominal (subcutaneous and
•
•
•
•
•
visceral) fat
Waist circumference
Glucose metabolism/insulin resistance
Blood pressure
Lipids
Endothelial function/intima-media
thickness
IMPROVED
Benefits of exercise in
postmenopausal women
70% maximal heart rate; 45 minutes;
3-4 times weekly for 6 months
Control (n = 13)
Pre
Age (years)
Body weight (kg)
Lean body mass (kg)
Fat mass (kg)
% Body fat
BMI (kg/m2)
Waist-hip ratio
˙ -max (ml/kg/min)
VO
2
MHR (bpm)
MRQ
Exercise (n = 10)
Post
Pre
59.1 ± 1.5
73.7 ± 4.07
41.7 ± 1.4
30.0 ± 3.1
42.3 ± 2.2
27.1 ± 1.4
0.84 ± 0.03
26.5 ± 1.4
165 ± 3.7
1.19 ± 0.03
Post
58.0 ± 1.8
73.7 ± 4.30
41.8 ± 1.6
30.0 ± 3.2
41.2 ± 1.9
27.1 ± 1.4
0.83 ± 0.03
26.4 ± 1.4
163 ± 4.0
1.20 ± 0.02
67.4 ± 2.76
40.6 ± 1.6
26.9 ± 3.4
39.3 ± 1.2
24.6 ± 1.1
0.77 ± 0.03
28.7 ± 1.9
162 ± 4.2
1.21 ± 0.04
64.4 ± 2.83*
40.7 ± 1.7
23.6 ± 3.5*
36.1 ± 2.0*
23.6 ± 1.4*
0.77 ± 0.02
34.9 ± 2.8*
166 ± 3.7
1.25 ± 0.03
Values are mean ± SE. MRQ, maximal respiratory quotient; MHR, maximal heart rate
*p < 0.05 (significant changes with exercise and significantly different from the control group)
Santa-Clara H, et al. Metabolism 2006;55:1358–64
Exercise and CHD morbidity
The Nurses’ Health Study data:
the more active, the less CHD morbidity
Multivariate
relative risk
Without BMI
With BMI
Physical activity (hours/week)
≥ 3.5
1–3.49
<1
p
1.00 1.43 (1.27, 1.61) 1.58 (1.39, 1.80) < 0.001
1.00 1.34 (1.18, 1.51) 1.43 (1.26, 1.63) < 0.001
Li TY, et al. Circulation 2006;113:499
Exercise and
cardiovascular morbidity
The WHI observational trial data:
• Up to 45% decreased risk for
cardiovascular events,
correlated with the degree of
energy expenditure (MET)
1.2
1.00
1.0
0.8
0.85
0.70
0.66
0.55
0.6
0.4
0.2
0.0
1
2
3
4
5
Lowest
Highest
Quintile of total MET score
White women (n = 61,574)
p < 0.001
Manson JE, et al. N Engl J Med 2002;347:716
Relative risk of casrdiovascular disease
WHI observational study: CV events
inversely correlated with walking pace
1.1
1.0
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0.0
1.00 1.00
1.07 1.06
Adjusted for age and walking time (p < 0.001)
Multivariate (p = 0.002)
0.86
0.76
0.73
0.58
0.57
0.40
Rarely or
never walk
(n = 10,896)
< 2 mph
(easy casual)
(n = 10,690)
2–3 mph
(average)
(n = 30,523)
3–4 mph
(brisk)
(n = 17,555)
> 4 mph
(very brisk)
(n = 990)
Walking pace (mph) among walkers
Manson JE, et al. NEJM 2002;347:716
Exercise and mortality
The Nurses’ Health Study data:
the more active, the better prognosis
(mean age at baseline 48 years)
Relative risk (95% confidence interval)
Physical activity
(hours/week)
Cardiovascular
deaths
(n = 923)
Cancer
deaths
(n = 2727)
Non-cancer,
non-cardiovascular,
non-diabetes
causes of death
(n = 1040)
<1
2–3.9
≥7
1.0
0.74 (0.62–0.88)
0.69 (0.49–0.97)
1.0
0.85 (0.76–0.94)
0.87 (0.72–1.04)
1.0
0.57 (0.48–0.67)
0.46 (0.33–0.64)
Respiratory
deaths
(n = 181)
1.0
0.46 (0.34–0.63)
0.23 (0.11–0.50)
Rockhill B, et al. Am J Public Health 2001;91:578
Fitness and mortality
The Lipid Research Clinics Study
Fitness
Time to max. heart rate
(min)
All cause death
1.3–5.6
7.1–8.0
9.3–13.0
CVD death
1.3–5.6
7.1–8.0
9.3–13.0
Number of
deaths
Age-adjusted death rate
(per 100,000 person-years)
208
80
33
7.6
6.0
4.8
89
30
7
2.8
2.2
0.9
n = 2506; age 30-75; > 20 years follow-up
Fitness measured by the time to produce a predicted maximal heart rate. The shorter, the better prognosis
Method of testing: Bruce protocol
Stevens J, et al. Am J Epidemiol 2002;156:832
Fitness and mortality
in healthy women > 70 years old
Prognosis is associated with ability to perform
and speed during a 400-m corridor walk:
Better survival for those who walk faster
70
Mortality (%)
60
Excluded
Stopped
Quartile 1
Quartile 2
Quartile 3
Quartile 4
Quartile 1- the best performers
50
Quartile 4 – the worst performers
40
30
20
10
0
0
0.5
p < 0.001
1.0
1.5
2.0
2.5
3.0
3.5
4.0
4.5
5.0
5.5
Years
Newman AB, et al. JAMA 2006;295:2018
Relative risks of death from any cause
among participants with various risk factors
who achieved an exercise capacity of less than 5 METs
(metabolic equivalents) or 5–8 METs, as compared with
participants whose exercise capacity was more than 8 METs
4.0
> 8 METs (n = 2743)
5–8 METs (n= 1885)
< 5 METs (n = 1585)
Relative risk of death
3.5
3.0
2.5
2.0
1.5
1.0
0.5
0.0
Hypertension
COPD
Diabetes
Smoking
BMI
TC
Warburton DER, et al. CMAJ 2006;174:961
Exercise and BMD:
conflicting results
• 4 years of progressive strength training showed a positive correlation
with BMD changes
Osteoporosis Int 2005;16:2129
• 3 years of low-volume, high-resistance strength training and highimpact aerobics maintained BMD at the spine, hip and calcaneus,
but not at the forearm
Osteoporosis Int 2006;17:133
• 1-year program showed site-specific responses to upper and lower
body exercise training
Bone 2006;July, available online
• “The exercise protocols that were used in this individual patient data
meta-analysis do not improve femoral neck BMD”
Am J Obstet Gynecol 2006;194:760
Exercise and
fracture risk
• 12-year follow-up from the
1.2
Relative risk (95% CI)
•
Nurses’ Health Study
61,200 healthy women;
415 incidental hip
fractures
Risk lowered by 6% for
each increase in activity
equivalent to 1 hour of
walking/week at an
average pace, compared
to sedentary women
BMI
< 25
> 25
1.0
0.8
0.6
0.4
0.2
0
<3
3–8.9
9–14.9
15–23.9
>24
Activity, MET hours/week
Feskanich D, et al. JAMA 2002;288:2300
Exercise and
fracture risk
• 672 healthy women (mean age 59);
•
mean follow-up 5.3 years; annual incidence of
osteoporotic fractures 21/1000 women/year
Odds ratio for fracture was doubled in women
with low physical activity
Variable
Personal history of fragility fracture after 45 years
BMD total hip < 0.736 g/cm2
Physical activity score < 14
Left grip strength < 0.60 bar
Age > 65 years
Maternal history of fragility fracture
Past falls
OR
95% CI
p
3.33
3.15
2.08
2.05
1.90
1.77
1.76
1.42–7.79
1.75–5.66
1.17–3.69
1.15–3.64
1.04–3.47
1.01–3.09
1.00–3.09
0.006
0.001
0.01
0.01
0.04
0.04
0.05
Albrand G, et al. Bone 2003;32:78
Exercise prevents falls
•
•
•
•
•
150 participants
Mean age 75, 70% women
Intervention: weekly exercise classes and home training
Results: better performance in balance tests
40% less falls during 12 months
Intervention
(n = 76)
Control
(n = 74)
Risk
(95% CI)
Falls
Rate
One or more
Two or more
0.605
35.5%
10.8%
0.946
50.0%
24.3%
0.60 (0.36–0.99)
0.71 (0.49–1.04)
0.44 (0.21–0.96)
Falls injuries
Rate
One or more
Two or more
0.395
28.9%
7.9%
0.541
37.8%
13.5%
0.66 (0.38–1.15)
0.77 (0.48–1.21)
0.58 (0.22–1.52)
Barnett A, et al. Age Aging 2003;32:407
Exercise decreases
breast cancer risk
• Numerous studies showed an inverse modest
•
correlation (15–20% decrease) between physical
activity and postmenopausal breast cancer risk
A trend analysis indicated a 6% decrease in
breast cancer risk for each additional hour of
physical activity per week
Monninkhof EM, et al. Epidemiology 2007;18:137
Exercise and breast cancer risk
• High calorie intake and high BMI are known risk
factors for breast cancer in postmenopausal women
• 38,660 women (age 55–74); 10-year follow-up
• > 4 hours/week of vigorous physical activity resulted
in 22% reduced risk for breast cancer as compared
to non-actives
• Women with the most unfavorable energy balance
(high energy intake, high BMI, physically inactive)
demonstrated a two-fold risk versus those with most
favorable data
Chang SC, et al. Cancer Epidemiol Biomarkers Prev 2006;15:334
Depression and mortality
• WHI observational study (93,676 women, followed 4.1 years).
Depression was measured by a short form of the Center for
Epidemiological Studies Depression Scale
• Depression was associated with higher mortality
Exercise (episodes/week of moderate
or strenuous activity ≥ 20 min)
None
Some
2–4
>4
Number
of women
Relative risk
(95% CI)
12,637
35,648
17,093
27,251
1.00
0.78 (0.74–0.82)
0.67 (0.62–0.71)
0.56 (0.53–0.59)
Wassertheil-Smoller S, et al. Arch Intern Med 2004;164:289
Exercise and depression
• WHI observational study (93,676 women, followed 4.1 years).
Depression was measured by a short form of the Center for
Epidemiological Studies Depression Scale
• Exercise reduces the risk of depression
Stroke
Cardiovascular disease
All-cause mortality
1.00
Depressed
Not depressed
Proportion
0.99
0.98
0.97
0.96
0.95
0
1 2
3 4 5
0
1 2 3 4 5
Time (years)
0
1 2
3 4 5
Wassertheil-Smoller S, et al. Arch Int Med 2004;164:289
Exercise and dementia
Incidence of dementia – 13/1000 person-years for those who exercised
3+ times/week vs. 19.7 for those engaged in physical activity < 3 times/week
• 1740 participants
• Mean age 74, 60%
Dementia-free
women
• Mean follow-up 6.2 years
• Comparing those
exercising < 3 vs. 3+
times weekly (defined as
> 15 min of any sort of
activity)
≥ 3 times per week
< 3 times per week
1.00
0.75
0.50
0.25
0.00
65 70 75 80
85 90 95 100
Age during the study (years)
Larson EB, et al. Ann Intern Med 2006;144:73
Exercise improves quality of life
• 60 women, mean age 54
• Low active vs. moderate active vs. high active
Total frequency of symptoms (score)
Psychological
Vasosomatic
General somatic
Total severity (score)
103 vs. 90 vs. 76
43 vs. 38 vs. 32
32 vs. 25 vs. 21
29 vs. 27 vs. 23
105 vs. 87 vs. 73
Elavsky S, McAuley E. Maturitas 2005;52:374
Exercise is associated
with better sleep
• Overweight, sedentary, non-users of HRT,
•
•
•
aged 50–75
A year-long study comparing moderateintensity exercise to low-intensity stretching
Morning exercisers, > 225 minutes/week,
had 3-fold less trouble of falling asleep and
longer sleep duration vs. those stretching
Evening exercisers had more trouble falling
asleep!!!
Tworoger SS, et al. Sleep 2003;26:830
Exercise affects
sex hormone levels
• Data from the Women's Health Initiative Dietary
Modification
• Trial: BMI was positively associated with estrone,
estradiol, free estradiol, free testosterone, prolactin,
but was negatively associated with SHBG
• Total physical activity (METs per week) was
negatively associated with concentrations of
estrone, estradiol, and androstenedione
• Lowest hormonal levels recorded in women with
low BMI/high physical activity
McTiernan A, et al. Obesity 2006;14:1662
Counseling on exercise
• Mean age 57 years; 67% women; 12 months
follow-up
Conclusion: counselling patients in general
practice on exercise is effective in increasing
physical activity and improving quality of life
over 12 months
Raina Elley C, et al. BMJ 2003;326:793
How much exercise
is needed?
• The specific dose of physical activity, in terms
•
of frequency, intensity, and duration, and the
related volume of energy expenditure that is
effective in achieving specific biological or
clinical outcomes are still partially understood
Recommendations for women are usually
defined as at least three 30-min sessions/week
of moderate intensity physical activity, which
corresponds to expending about 600 kcal/week
(7–10 METs/week)
Blair SN. Arch Intern Med 2005;165:2324
Recommended levels of exercise required
to improve physical activity
and fitness levels for health benefits
• Moderate-intensity aerobic exercise
–
–
–
–
•
40–59% of heart rate reserve, or about 4–6 METs
20–60 min per day
3–5 days per week
Examples: brisk walking (15–20 min per mile),
dancing
Detailed prescription for recommended levels of
aerobic, resistance and flexibility exercise may be
found in CMAJ 2006;174:961–74
Warburton DER, et al. CMAJ 2006;174:961–74
Adverse consequences of exercise
• Even moderate exercise may be harmful
•
•
•
to the musculo-skeletal-articular system
Strenuous exercise may be dangerous to
the cardiovascular system
Too much exercise may be addictive
Exercise may lead to hormonal changes
with a decrease in free estradiol and
worsening of hot flushes
Exercise in the
menopause: conclusions
• Any physical activity is better than being sedentary
• Regular exercise reduces total and cardiovascular
•
•
•
mortality
Better metabolic profile, balance, muscle strength,
cognition and quality of life are observed in physically
active persons
Heart events, stroke, fractures and breast cancer are
significantly less frequent
Benefits far overweigh possible adverse
consequences: the more – the better, but too much
may cause harm
Exercise in the
menopause: conclusions
• Optimal exercise prescription: at least
•
•
30 minutes of moderate-intensity
exercise, at least 3 times weekly
Two additional weekly training sessions
of resistance exercise may provide
further benefit
Injury to the musculo-skeletal-articular
system should be avoided