Exercise and Exercise and adult women’s healthadult women’s health

Amos Pines

Be fit – be healthyBe fit – be healthy

• Ordinary exercise testing

•Walk test

Ways to measure fitness:

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 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 improvesExercise improvescardiovascular risk profilecardiovascular 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

Control (n = 13) Exercise (n = 10)

Pre Post Pre Post

Body weight (kg) 73.7 ± 4.07 73.7 ± 4.30 67.4 ± 2.76 64.4 ± 2.83*

Lean body mass (kg) 41.7 ± 1.4 41.8 ± 1.6 40.6 ± 1.6 40.7 ± 1.7

Fat mass (kg) 30.0 ± 3.1 30.0 ± 3.2 26.9 ± 3.4 23.6 ± 3.5*

% Body fat 42.3 ± 2.2 41.2 ± 1.9 39.3 ± 1.2 36.1 ± 2.0*

BMI (kg/m2) 27.1 ± 1.4 27.1 ± 1.4 24.6 ± 1.1 23.6 ± 1.4*

Waist-hip ratio 0.84 ± 0.03 0.83 ± 0.03 0.77 ± 0.03 0.77 ± 0.02

VO2-max (ml/kg/min) 26.5 ± 1.4 26.4 ± 1.4 28.7 ± 1.9 34.9 ± 2.8*

MHR (bpm) 165 ± 3.7 163 ± 4.0 162 ± 4.2 166 ± 3.7

MRQ 1.19 ± 0.03 1.20 ± 0.02 1.21 ± 0.04 1.25 ± 0.03

Benefits of exercise in Benefits of exercise in postmenopausal womenpostmenopausal women

70% maximal heart rate; 45 minutes; 70% maximal heart rate; 45 minutes;3-4 times weekly for 6 months3-4 times weekly for 6 months

Santa-Clara H, et al. Metabolism 2006;55:1358–64

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)

Age (years) 59.1 ± 1.5 58.0 ± 1.8

˙

Exercise and CHD morbidityExercise and CHD morbidity

The Nurses’ Health Study data:

the more active, the less CHD morbidity

Li TY, et al. Circulation 2006;113:499

Multivariate Physical activity (hours/week)relative risk

≥ 3.5 1–3.49 < 1 p

Without BMI 1.00 1.43 (1.27, 1.61) 1.58 (1.39, 1.80) < 0.001

With BMI 1.00 1.34 (1.18, 1.51) 1.43 (1.26, 1.63) < 0.001

Exercise and Exercise and cardiovascular morbiditycardiovascular morbidity

The WHI observational trial data:

• Up to 45% decreased risk for cardiovascular events, correlated with the degree of energy expenditure (MET)

Manson JE, et al. N Engl J Med 2002;347:716

p < 0.001

White women (n = 61,574)

Lowest HighestQuintile of total MET score

1.00

0.85

0.70 0.660.55

1.2

1.0

0.8

0.6

0.4

0.2

0.01 2 3 4 5

WHI observational study: CV events WHI observational study: CV events inversely correlated with walking paceinversely correlated with walking pace

Manson JE, et al. NEJM 2002;347:716

Adjusted for age and walking time (p < 0.001)Multivariate (p = 0.002)

Walking pace (mph) among walkers

Rarely ornever 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)

Rel

ativ

e ri

sk o

f ca

srdi

ova

scul

ar d

isea

se 1.11.00.90.80.70.60.50.40.30.20.10.0

1.00 1.00

1.07 1.06

0.73

0.86

0.57

0.76

0.40

0.58

Exercise and mortalityExercise and mortalityThe Nurses’ Health Study data:

the more active, the better prognosis(mean age at baseline 48 years)

Rockhill B, et al. Am J Public Health 2001;91:578

Relative risk (95% confidence interval)

Non-cancer,non-cardiovascular,

Cardiovascular Cancer non-diabetes RespiratoryPhysical activity deaths deaths causes of death deaths(hours/week) (n = 923) (n = 2727) (n = 1040) (n = 181)

< 1 1.0 1.0 1.0 1.0

2–3.9 0.74 (0.62–0.88) 0.85 (0.76–0.94) 0.57 (0.48–0.67) 0.46 (0.34–0.63)

≥ 7 0.69 (0.49–0.97) 0.87 (0.72–1.04) 0.46 (0.33–0.64) 0.23 (0.11–0.50)

Fitness and mortalityFitness and mortalityThe Lipid Research Clinics StudyThe Lipid Research Clinics Study

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 protocolStevens J, et al. Am J Epidemiol 2002;156:832

Fitness

Time to max. heart rate Number of Age-adjusted death rate(min) deaths (per 100,000 person-years)All cause death1.3–5.6 208 7.67.1–8.0 80 6.09.3–13.0 33 4.8CVD death1.3–5.6 89 2.87.1–8.0 30 2.29.3–13.0 7 0.9

Fitness and mortalityFitness and mortalityin healthy women > 70 years oldin healthy women > 70 years old

Prognosis is associated with ability to performand speed during a 400-m corridor walk: Better survival for those who walk faster

Newman AB, et al. JAMA 2006;295:2018

Mor

talit

y (%

)

Years

0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0 4.5 5.0 5.5

70

60

50

40

30

20

10

0

p < 0.001

Quartile 1- the best performers

Quartile 4 – the worst performers

ExcludedStoppedQuartile 1Quartile 2Quartile 3Quartile 4

Relative risks of death from any causeRelative risks of death from any causeamong participants with various risk factorsamong participants with various risk factors

who achieved an exercise capacity of less than 5 METs who achieved an exercise capacity of less than 5 METs (metabolic equivalents) or 5–8 METs, as compared with (metabolic equivalents) or 5–8 METs, as compared with

participants whose exercise capacity was more than 8 METsparticipants whose exercise capacity was more than 8 METs

Warburton DER, et al. CMAJ 2006;174:961

Hypertension COPD Diabetes Smoking BMI TC

> 8 METs (n = 2743)

5–8 METs (n= 1885)

< 5 METs (n = 1585)

Rel

ativ

e ri

sk o

f d

eath

4.0

3.5

3.0

2.5

2.0

1.5

1.0

0.5

0.0

Exercise and BMD:Exercise and BMD:conflicting results 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 high-impact 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 andExercise andfracture riskfracture risk

• 12-year follow-up from the 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

Feskanich D, et al. JAMA 2002;288:2300

1.2

1.0

0.8

0.6

0.4

0.2

0

Rel

ativ

e ri

sk (

95%

CI)

Activity, MET hours/week

< 3 3–8.9 9–14.9 15–23.9 >24

BMI

< 25

> 25

Exercise andExercise andfracture riskfracture 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

Albrand G, et al. Bone 2003;32:78

Variable OR 95% CI p

Personal history of fragility fracture after 45 years 3.33 1.42–7.790.006

BMD total hip < 0.736 g/cm2 3.15 1.75–5.660.001

Physical activity score < 14 2.08 1.17–3.69 0.01

Left grip strength < 0.60 bar 2.05 1.15–3.64 0.01

Age > 65 years 1.90 1.04–3.47 0.04

Maternal history of fragility fracture 1.77 1.01–3.09 0.04

Past falls 1.76 1.00–3.09 0.05

Exercise prevents fallsExercise 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

Barnett A, et al. Age Aging 2003;32:407

Intervention Control Risk(n = 76) (n = 74) (95% CI)

FallsRate 0.605 0.946 0.60 (0.36–0.99)One or more 35.5% 50.0% 0.71 (0.49–1.04)Two or more 10.8% 24.3% 0.44 (0.21–0.96)

Falls injuriesRate 0.395 0.541 0.66 (0.38–1.15)One or more 28.9% 37.8% 0.77 (0.48–1.21)Two or more 7.9% 13.5% 0.58 (0.22–1.52)

Exercise decreasesExercise decreasesbreast cancer riskbreast 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 riskExercise 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 mortalityDepression 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

Wassertheil-Smoller S, et al. Arch Intern Med 2004;164:289

Exercise (episodes/week of moderate Number Relative riskor strenuous activity ≥ 20 min) of women (95% CI)

None 12,637 1.00

Some 35,648 0.78 (0.74–0.82)

2–4 17,093 0.67 (0.62–0.71)

> 4 27,251 0.56 (0.53–0.59)

Exercise and depressionExercise 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

Wassertheil-Smoller S, et al. Arch Int Med 2004;164:289

Stroke Cardiovascular disease All-cause mortality

Time (years)

0 1 2 3 4 5

1.00

0.99

0.98

0.97

0.96

0.95

Pro

po

rtio

n

DepressedNot depressed

0 1 2 3 4 5 0 1 2 3 4 5

Exercise and dementiaExercise and dementia

• 1740 participants

• Mean age 74, 60% women

• Mean follow-up 6.2 years

• Comparing those exercising < 3 vs. 3+ times weekly (defined as > 15 min of any sort of activity)

Incidence of dementia – 13/1000 person-years for those who exercised3+ times/week vs. 19.7 for those engaged in physical activity < 3 times/week

Larson EB, et al. Ann Intern Med 2006;144:73

Age during the study (years)

Dem

ent

ia-f

ree

1.00

0.75

0.50

0.25

0.00

65 70 75 80 85 90 95 100

≥ 3 times per week< 3 times per week

Exercise improves quality of lifeExercise improves quality of life

• 60 women, mean age 54

• Low active vs. moderate active vs. high active

Elavsky S, McAuley E. Maturitas 2005;52:374

Total frequency of symptoms (score) 103 vs. 90 vs. 76

Psychological 43 vs. 38 vs. 32

Vasosomatic 32 vs. 25 vs. 21

General somatic 29 vs. 27 vs. 23

Total severity (score) 105 vs. 87 vs. 73

Exercise is associatedExercise is associatedwith better sleepwith better sleep

• Overweight, sedentary, non-users of HRT, aged 50–75

• A year-long study comparing moderate-intensity 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 affectsExercise affectssex hormone levelssex 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 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 exerciseHow much exerciseis needed?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 Recommended levels of exercise required to improve physical activityto improve physical activity

and fitness levels for health benefitsand 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 Adverse consequences of exerciseexercise

• 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 theExercise in themenopause: conclusions 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 theExercise in themenopause: conclusions 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