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2012 Women's Health Research Review
Afton Cazares, M.A. and Len Kravitz, Ph.D.

Improving the health of female (and male) clients is a concerted effort every exercise professional seeks with enthusiasm and sincerity. However, navigating through all of the information on the Internet and other sources can be overwhelming, and often contradictory. In this research review on women's health a concerted attempt has been taken to focus on some central women's health topics of interest. For each health issue a key question was initially asked, which directed our research review. Next, we analyzed the existing research on the topic and selected a contemporary research article that answered or addressed this area. For each topic practical guidance and application recommendations for exercise professionals are offered in the 'Take Home Message'. Women's health topics in this review include stroke and physical activity, breast cancer prevention update, metabolic syndrome and occupational physical activity, physical activity during pregnancy and postpartum, weight gain during menopause, adherence to strength training programs and a question and answer side bar on women's health.

Stroke and Physical Activity
Key Question: What role does physical activity play in the lowered risk of stroke in women?
Sattelmair, J.R., Kurth, T., Buring, J.E., and Lee, I-Min. (2010). Physical Activity and Risk of Stroke in Women. Stroke, 41(6) 1243-1250.
Stroke by definition is the decrease of blood flow to the brain, thereby depriving the brain of oxygen and foodstuffs. It is considered a major threat to both women and men and is one of the leading causes of disability and death in the United States. Although strokes are one of the leading causes of death and disability, there is a way to modify their occurrence. According to Sattelmair and colleagues (2010), physical activity has been shown to reduce the risk of stroke by 25 to 30 percent. The Sattelmair research team investigated the risk of stroke in 39,315 healthy women approximately 45 years of age. The participants were required to report their physical activity during various follow-ups, which occurred at months 36, 72, 96, 125, and 149 of this study.

The study by Sattelmair et al. entailed an assessment of the impact of physical activity and other variables such as height, weight, age, diet, history of hypertension, elevated cholesterol levels, diabetes mellitus, use of postmenopausal hormones, occurrence of migraine headaches, and parental history of myocardial infarction to the occurrence of stroke. The occurrence of stroke was recorded during follow-ups, which were confirmed through medical records. Additionally each participant was classified according to BMI: healthy weight=BMI <25 kg/m2, overweight=BMI 25-25.9 kg/m2, or obese=BMI>30 kg/m2.

The assessment of physical activity commenced by estimating the time each participant spent engaging in eight different types of activities. These included walking, jogging, hiking, group-led aerobics, swimming, yoga, stretching, and the utilization of machines such as stationary bikes and treadmills. The kilocalories from exercise were calculated in order to determine the estimated weekly expenditure; this was done in order to place the participants in the appropriate categories which were based on the following quartiles of energy expended: <200, 200-599, 600 -1499, or > 1500kcal/week, respectively.

The study by Sattelmair and colleagues concluded that fast-paced walking on a regular basis significantly reduces the risk of any type of stroke. Women who were the most active in this study were 17% less likely to have a stroke than the women who were the least active. The study also found that women who walked two or more hours a week at a brisk (somewhat hard) pace had a 30 percent less chance of having a stroke.
TAKE HOME MESSAGE: Stroke is the third leading cause of death and disability in the U.S. Encouraging women to do daily physical activity that progressive develops into a brisk intensity (somewhat hard) yields the greatest protection from stroke, from the exercise participation perspective.

Breast Cancer Prevention Update
Is lifestyle an effective intervention for breast cancer prevention?
Magne, N., Melis, A., Chargari, A., Castadot, P., Guichard, J. B. et al. (2011). Recommendations for a lifestyle which could help prevent breast cancer and its relapse: Physical activity and dietetic Aspects. Critical Reviews in Oncology/ Hematology, 80, 450-459.
Breast cancer is considered a major health risk in women. By definition, it is a cancer that is formed in the tissues of the breast. There are two main types of breast cancer: ductile carcinoma (the more common type), which occurs in the ducts that allow the milk to travel from the breast to the nipple, and lobular carcinoma, which takes place in the lobules, where milk is produced. There appears to be a link between breast cancer and healthy lifestyle habits such as proper diet and exercise. According to Magne and colleagues (2011), a healthy diet (i.e., low in saturated and trans fats and low in simple sugars) as well as light to moderate intensity exercise may aid in the prevention of breast cancer among pre-menopausal women. Both dietary and physical activity interventions may also increase the quality of life in post-menopausal women with breast cancer. The authors review several studies, which suggest that early intervention of healthy eating, and consistent physical activity can be meaningful in breast cancer prevention. The authors state, “the link between dietary habits and breast cancer appears potentially very early, between the ages of 3-5 years.” Key et al. (2004) continue the overweight/obesity are very related to breast cancer (and other cancers) and suggest patients should strive to attain a healthy BMI (<25 kg/m2). In addition, Magne et al cite research suggesting that alcohol intake (&Mac179;7 alcoholic beverages a week) is associated with increased risk of breast cancer. The authors explain that the dietary and activity lifestyle interventions modify breast cancer risk through their varying effects on hormone metabolism (e.g., estrogen, progesterone, and IGF receptor). From their research review the authors recommend women engage in exercise 3 to 5 hours of moderate intensity physical activity each week.
TAKE HOME MESSAGE: Current research confirms that physical activity definitely plays a major role in the reduced risk of breast cancer. Unfortunately, a great majority of women are quite sedentary in their daily lives. A major breast prevention goal of personal trainers is to encourage and educate female clients of all ages to engage in physical activity while designing satisfactory workout programs that are complimentary to their work schedule. Children and teens are no exception to this goal. In fact, Magne et al. (2011) cite research that suggests a healthy lifestyle and physical activity that begins in childhood transfers those health benefits into adulthood.

Metabolic Syndrome and Occupational Physical Activity
What role does occupational physical activity play in the reduced risk of metabolic syndrome in women?
Mozumdar, A. and Liguori, G. (2011). Occupational Physical Activity and the Metabolic Syndrome Among Working Women: A Go Red North Dakota Study. Journal of Physical Activity and Health, 8, 321-331.
Metabolic syndrome is becoming increasingly prevalent in women. To be diagnosed with metabolic syndrome a woman must have at least 3 or more risk categories of the following: hypertension (&Mac179;130/85 mmHg or on a blood pressure lowering medicine), blood triglycerides (&Mac179;150 mg/dL), fasting glucose (&Mac179;100 mg/dL), waist circumference (>35 inches), and HDL cholesterol (&Mac178;50 mg/dL) (National Cholesterol Education Program, 2001). Physical activity plays a major role in the prevention of metabolic syndrome. According to the study done by Mozumdar and Liguori, occupational physical activity may help decrease the risk of metabolic syndrome in working women. The study included 642 women aged from 35 to 55 years of age. They were asked to complete a survey pertaining to personal lifestyle habits including the amount of leisure time physical activity they complete. Subjects also participated in a biometric assessment, which included measuring their blood pressure, cholesterol, height, weight, body mass index, fasting blood glucose and blood lipids. During the study, the women were placed into three separate categories. The first was for women who maintained a sedentary occupation, defined as working in a sitting position for an entire day. The second was for women who maintained a moderately active occupation, which was described as standing and walking during work throughout the day. The third was for women who maintain a heavy working occupation, which was identified as being highly active throughout the working day. All women were identified with or without metabolic syndrome. The study results indicate that women in moderate to heavy working occupations may actually acquire sufficient amounts of physical activity to ward off getting metabolic syndrome. Secondly, the more active women are during their leisure time, the less likely they will have metabolic syndrome. By contrast, the least active women who also have sedentary jobs are the most likely to have metabolic syndrome.
TAKE AWAY MESSAGE: In today's technological society most working women's occupations involve sustained sitting at a desktop computer workstation. Thus, leisure time physical activity is essential in reducing the risk of metabolic syndrome. Women who are highly active in their occupation are able to decrease the risk of metabolic syndrome because of the demands of their job.

Physical Activity During Pregnancy and Postpardum
How much exercise is recommended during and postpardum?
Doran, F. and Davis, K. (2011). Factors that influence physical activity for pregnant and postpartum women and implications for primary care. Australian Journal of Primary Health 17, 79-85.
According to the old school of thought, exercise during pregnancy would not only put the mother at risk, but it would also put the unborn child at risk. Many studies have shown that exercise has a profound and positive effect on both the mother and baby (Doran and Davis, 2011). It is highly recommended for women to engage in 30 minutes of moderate intensity exercise on most, if not all of the days of the week before, during and after pregnancy (Doran and Davis). Benefits include weight management, prevention of gestational diabetes mellitus (and thus type 2 diabetes) and better overall physiological readiness for the demands of childbirth, and the energy and ability to properly care for a newborn baby. Alas, in spite of these benefits, most women do not engage in the recommended amount of physical activity.

Doran and Davis sought to determine the factors that affect both pregnant and postpartum women (currently pregnant or who experienced gestational diabetes within previous 18 months) from engaging in physical activity. Of the seventy-two women (18-45 yrs) who completed the survey in their study, 37 had gestational diabetes mellitus and 34 women were pregnant when they participated in the survey. The results in this study confirmed that there are several factors that influence physical activity (positively and negatively) in pregnant and postpartum women. Unfortunately, close to 72% stated they had not been given guidance from their health care provider of the benefits to engaging in moderate levels of physical activity, either during or after pregnancy. Table 1 is a helpful table for exercise professionals to use as a checklist when working with clients during and after pregnancy. It summarizes the barriers to exercise and enabling factors that encourage exercise participation from Doran and Davis (2011).

Table 1. Barriers and Enabling Factors to Physical activity During and After Pregnancy
Barriers Enabling Factors
Lack of child care Feel better when exercise
No time Exercise helps manage weight
Lack of money Look healthier
Caring for others Enjoy exercise
Nowhere to exercise/ Lack of facilities Will prevent future health problems
Being overweight Helps manage stress
Exercise is too hard Support from family and friends
Feeling uncomfortable during pregnancy Support from doctor and diabetes educator
Feeling unwell Fearful of getting type 2 diabetes
Do not enjoy physical activity Having a workout partner
Family is not supportive Having a place to exercise
Note: Table adapted from Doran and Davis (2011).
TAKE AWAY MESSAGE: Exercise during and after pregnancy may be decisive in the prevention or management of gestational diabetes mellitus and type 2 diabetes as well as other health consequences. There are many ways that exercise professionals can help encourage pregnant and postpardum women to regularly engage in 30 minutes of moderate intensity exercise on most if not all days of the week before, during and after pregnancy (see Table 1).

Weight Gain During Menopause
What is the best intervention to minimize and/or prevent this from happening?
Al-Zadjali, M., Keller, C., Larkey, L.K., Albertini, L. (2010). Evaluation of intervention research in weight reduction in post menopausal women. Geriatric Nursing, 31(6), 419-434.
Weight gain during menopause is of great concern to exercise professionals working with female clients 50 years of age and older. The prevalence of obesity has increased significantly over the past few decades with a very steep increase in women before, during and after menopause. In fact, cross-sectional examination of overweight data shows higher obesity rates for women during the postmenopausal years (Al-Zadjali et al. 2010).
The authors add that as women age overweight and obesity are a serious risk factor for heart disease and diabetes. Al-Zadjali et al. (2010) proceeded to assess the pros and cons of weight loss interventions in postmenopausal women. From an exhaustive research evaluation of 120 articles the research teach found 15 that met their strict inclusion criteria.

Overall, the research shows that a dietary intervention of meal replacements, reduced fat intake, reduced saturated fat and cholesterol consumption and lower daily caloric consumption when combined with increased physical activity produces the most beneficial health results. The combined interventions result in lowered BMI, fat mass, waist circumference, systolic blood pressure, triglycerides, glucose, leptin and cortisol, triglyceride, and glucose and low-density lipoprotein (LDL) cholesterol. Body weight reduction also reduced plasma C-reactive protein, which is a strong marker for cardiovascular disease.

The authors report that weight-bearing exercise produces positive weight loss while also maintaining and/or increasing bone mineral density in postmenopausal women. They note that even low-intensity exercise results in an improvement in cardiorespiratory fitness and reduction in body weight in obese postmenopausal women. Also, progressively increasing to a moderate-intensity exercise is the eventual goal for optimal management of metabolic risk variables (i.e., insulin resistance) during menopause.
TAKE AWAY MESSAGE: This research review confirms to exercise professionals that a combination of varying levels of cardiovascular exercise intensity, weight bearing exercise (resistance training or cardiovascular) and dietary interventions of meal replacement, lower caloric consumption and reduced saturated fat and cholesterol leads to the most beneficial health and weight management results for women during menopause. ACSM recommends 250 to 300 minutes/week (~2000 kilocalories/week) of moderate intensity exercise for greater weight loss and prevention of weight gain (Donnelly et al. 2009).

Strength Training Adherence
Adhering to a strength training routine: are there factors preventing older women from getting the exercise they need?
Arikawa, A.Y., O'Dougherty M., Schmitz K.H. (2011). Adherence to a Strength Training Intervention in Adult Women. Journal of Physical Activity Health, 8(1):111-118
Strength training plays an essential role in maintaining a healthy lifestyle. The evidence is clear that resistance training may enhance musculoskeletal fitness resulting in prominent gains in health status while reducing the risk of chronic disease and disability (Warburton, Nicol, & Bredin 2006). Warburton and colleagues continue stating that longitudinal investigations have revealed that women (and men) with high levels of muscular strength have fewer functional limitations, and lower incidences of chronic diseases such as coronary artery disease, diabetes, stroke, arthritis, and pulmonary disorders. Although it holds many potential benefits, adhering to a strength training routine is one of the many difficulties women seem to face these days. According to a Arikawa, O'Dougherty and Schmitz (2011) only 17.5 percent of females engage in a strength training routine two or more days per week, which is the recommended minimum of suggested by the American College of Sports Medicine (Garber et al., 2011). Arikawa, O'Dougherty and Schmitz continue that very little is known about what motivates premenopausal women to adhere to resistance training the studies. The researchers therefore sought to answer this question in a two-year twice-weekly weight training intervention with 164 sedentary overweight and obese premenopausal women (25 to 44 yrs of age) who underwent a program that consisted of supervised and unsupervised exercise instruction. During the first four months the participants engaged in a supervised program provided by certified fitness trainers. They met twice a week for 60-90 minutes each session. The beginning of their workout regiment included cardiorespiratory exercises and exercises for the abdominals and lower back. The women then started their strength training workout, which included 3 sets of 8-10 repetitions of their one repetition max for 9 different body exercises. The next phase of the study (months 5-24) was unsupervised. The women continued the workout regiment but on their own or with a friend. During this time, the women could decrease their sets to 2 per exercise. During this unsupervised period the researchers “booster sessions” every 12 weeks where groups of 2-6 women subjects met with personal trainers to learn new exercises and ensured they were performing all exercises correctly. These sessions were also held to provide encouragement to the women. Each subject could schedule an independent booster session once a week with a trainer if they so desired as well. The results for this study show that the women adhered to the supervised (95.4% adherence) workout program much better than the unsupervised (64.5% adherence) workout program. The findings also revealed that married women had better adherence (75.4%) then unmarried women (36.35) to the exercise program. However, parental females noted that being a parent is a challenge to scheduling exercise time. Unforeseen to the researchers was the finding that women with a college degree had a lower adherence (90.8%) than women with less than a college degree (97.9%) during the supervised exercise period of the study. No significant effects were observed with race, age, or work status on exercise adherence.
TAKE HOME MESSAGE: This study very objectively shows the value of exercise professionals in their role of educating and motivating female clients to adhere to resistance training exercise. In many ways it should encourage personal trainers to enhance their business by providing other options for exercise participation, such as small group training to involve more women in supervised exercise.
Side Bar 1: Twelve Women's Health Questions and Answers
1) Why are check-ups important?
Check-ups are important in the prevention and early detection of health problems. Receiving proper treatments and screenings will hopefully lead a woman along the right path to a long and healthy life. The frequency of visits depends on important lifestyle factors such as diet, activity level, smoking habits and current health conditions. Retrieved 8/26/2012

2) How often does a woman in the United States suffer from a heart attack?
Every 90 seconds. Retrieved 8/26/2012

3) What are the symptoms of a heart attack?
The symptoms of a heart attack include: pressure or pain in the center or left side of the body, unusual discomfort in the upper body, shortness of breath, breaking into a cold sweat, unusual or unexplained fatigue, light headedness or sudden dizziness, and nausea. Retrieved 8/26/2012

4) How much physical activity should young girls be getting daily?
Girls (and boys) need 60 minutes of play at a moderate to vigorous activity level every day. Only one-third of high school students get the recommended levels of physical activity. Retrieved August 26, 2012

5) What are five tips to help encourage female clients to be more physical active in their life?
a. Chose physical activities they enjoy doing.
b. Use stairs instead of an elevator and always walk up and down the escalator.
c. Create movement opportunities during the waking day, such as parking the car at a distance from the destination (i.e., back of parking lot at store), walking around the mall before beginning to shop, taking a walk break with every water, coffee and restroom break, and standing up every 30 minutes and moving when in a seated behavior (i.e. when watching TV).
d. If you have children or pets, make time to play with them
e. Be physically active (such as taking a walk) after lunch with coworkers, family or friends.

6) How often should you receive a breast cancer screening?
The recommendations are every three years for women in their 20's and 30's and every year for women 40 and over. Retrieved 8/26/2012

7) What are a few ways to reduce the risk of breast cancer in women?.
a. Control weight through diet and exercise
b. Know your family history of breast cancer
c. Limit alcohol intake to no more than one drink/day
d. Discuss the risks and benefits of hormone replacement therapy with your health practitioner Retrieved 8/26/2012

8) What are the symptoms of menopause?
These include night sweats, fatigue, hot flashes, vaginal changes and thinning of bones. While some women may experience all of the above symptoms, others may only experience some. It is recommended that women consult their doctors to determine treatment options. Retrieved 8/26/2012

9) Why is osteoporosis more common in women?
Osteoporosis is more common in women because they tend to have less bone density than men. They also tend to lose bone density earlier, which puts them at a higher risk for osteoporosis. One of every two women is likely to experience an osteoporosis-related fracture in their lifetime. Retrieved 8/26/2012

10) What is the prevalence of type 2 diabetes developing from gestational diabetes in the U.S.?
Approximately 5-10% of women are diagnosed with type 2 diabetes soon after pregnancy. In addition, 20%-50% of women will be diagnosed with type 2 diabetes in the next 5-10 years. Retrieved 8/26/2012

11) What are the current recommendations for women to increase bone mineral density and prevent fractures?
The key interventions include resistance exercise or weight bearing exercise, balance exercises and adequate calcium consumption. The National Osteoporosis Foundation estimates that more than 10 million people over the age of 50 in the U.S. have osteoporosis and another 34 million are at risk for the disease. Retrieved 8/26/2012

12) What is the major cause of death in women?
According to the American Heart Association (AHA), more women die of cardiovascular disease than from the next four causes of death combined, including all forms of cancer. The AHA also suggests that 80% of cardiac events in women could be prevented if women made the right choices for their hearts involving diet, exercise and abstinence from smoking. The AHA recommends at least 150 minutes of moderate-intensity or 75 minutes of vigorous-intensity aerobic physical activity each week, which can be accumulated in 10-minute intervals. Retrieved 8/26/2012 Retrieved 8/26/2012

Afton Cazares, MA, is a doctoral student in Exercise Science at the University of New Mexico, Albuquerque. She holds a masters in Human Performance and Sport, with a concentration in Exercise Science from New Mexico Highlands University, Las Vegas, New Mexico. Her research interests are in women's health, exercise testing and training and tactical strength and conditioning.
@bio:Len Kravitz, PhD, is the program coordinator of exercise science and a researcher at the University of New Mexico, where he won the Outstanding Teacher of the Year award. He has received the prestigious Can-Fit-Pro Lifetime Achievement Award and was chosen as the American Council on Exercise 2006 Fitness Educator of the Year.
Additional References:
Donnelly, J.E., Blair, S.N., Jakicic, J.M., Manore, M.M., Rankin, J.W., & Smith, B.K. (2009). Appropriate physical activity intervention strategies for weight loss and prevention of weight regain for adults. Medicine & Science in Sports & Exercise, 41(2), 459-471.

Garber, C.E., Blissmer, B., Deschenes, M.R., Franklin, B.A, et al. (2011). Quantity and quality of exercise for developing and maintaining cardiorespiratory, musculoskeletal, and neuromotor fitness in apparently healthy adults: Guidance for prescribing exercise. Medicine & Science in Sports & Exercise, 43 (7), 1334-1349., August 22, 2012
Retrieved August 26, 2012

Key, T.J., Schatzkin, A., Willett, W.C., Allen, N.E., Spencer, E.A., & Travis, RC. (2004). Diet, nutrition and the prevention of cancer. Public Health Nutrition, 7(1A), 187-200.

National Cholesterol Education Program, 2001. NCEP ATP III. Executive summary of the third report of the National Cholesterol Education Program (NCEP) Expert Panel on detection, evaluation and treatment of high blood cholesterol in adults (Adult Treatment Panel III). Journal of the American Medical Association, 285(19), 2486-2497.

Warburton, D.E.R., Nicol, C.W.N., & Bredin, S.S.D. (2006). Health benefits of physical activity: the evidence. Canadian Medical Association Journal, 174(6), 801-809.