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Research Update: Explore the Value of Exercise for Women's Health
By Tori Lau, Bryanne Bellovary, M.S. and Len Kravitz, PhD

Fitness pros have a unique opportunity to take a leadership role in training and educating their female clients toward a healthier, movement-oriented lifestyle. This women's health research update discusses contemporary scientific findings on five top health conditions for women, and how exercise may help reduce associated disease outcomes. The health topics reviewed in this article include type 2 diabetes, cardiovascular disease, osteoporosis, anxiety disorders and menopause. With each health issue, practical application training guidelines and suggestions are provided.

Diabetes and Exercise
Diabetes is a disease in which the body's ability to produce (type 1 diabetes) or respond (type 2 diabetes) to the hormone insulin is impaired. This leads to an undesirably altered metabolism of carbohydrates and elevated levels of glucose in the blood. Of the estimated 30.3 million adult cases of diabetes in the United States, 90 - 95% are persons with type 2 diabetes (National Diabetes Statistics Report, 2017). Approximately 14.9 million U.S. women, 18 years of age and older, have diabetes. Of that number, 11.7 million (9.2%) have diagnosed diabetes and the other 3.2 million women have undiagnosed diabetes (National Diabetes Statistics Report, 2017). A woman's risk of being diagnosed with diabetes increases if she smokes, is overweight or obese, has high blood pressure, is physically inactive, and has high cholesterol and high blood sugar (National Diabetes Statistics Report, 2017).

The American Diabetes Association (ADA) Position Stand (2016) states that regular exercise improves blood glucose in type 2 diabetes, helps promote weight loss, reduces cardiovascular risk factors (which are associated with type 2 diabetes) and improves well-being. The position paper further states that since blood glucose management varies with diabetes type and the presence of diabetes-related complications, exercise recommendations should be tailored to meet the specific needs of each individual

Exercise Guidelines
The ADA (2016) exercise guidelines for persons with diabetics includes the following two overarching recommendations:
1) Daily exercise, or at least not allowing more than 2 days between exercise sessions. This recommendation is focused to increase insulin sensitivity. A person who is insulin sensitive will require smaller amounts of insulin to lower blood glucose levels.
2) Adult females with type 2 diabetes should do both aerobic exercise and resistance training for optimal blood glucose control and health. When completing aerobic and resistance training in one session, the ADA recommends that doing the resistance training first, because it results in more stable blood glucose control. Female clients with type 1 diabetes are recommended to do aerobic exercise. However, the effects of resistance training and type 1 diabetes are currently unclear. So, although resistance training for persons with type 1 diabetes is encouraged, there currently are no specific ADA recommendations.
Primary Aerobic Exercise Guidelines
In females with diabetes, at least 150 minutes of moderate to high volumes of aerobic activity are recommended on 3-7 days of the week. This is associated with a substantially lower cardiovascular disease risk and mortality (ADA, 2016). In addition, high-intensity interval training has been shown to improve insulin sensitivity and cardiorespiratory fitness in persons with diabetes. The ADA (2016) suggests that a training emphasis should be placed on progressing female clients to vigorous intensity aerobic exercise as long as there are no complications for the female clients with diabetes.

Primary Resistance Training Guidelines
The ADA (2016) recommends a minimum of 2 nonconsecutive days/week of resistance training leading to an eventual 3 days/week. Exercise programs should include 8-10 exercises to target the major muscle groups of the body. Recommendations advise fitness pros to start clients with single set training and progress to 3 sets per exercise. Intensity should begin at a moderate intensity of 10-15 repetitions with each set and then progress to an 8-10 repetitions per set intensity and eventual 6-8 repetitions per set. All sets should be performed to near fatigue of the female exerciser.

Balance and Flexibility Exercise Guidelines
The ADA position paper (2016) recommends that females with diabetes should do flexibility and balance training on 2-3 days per week. Have female clients stretch to the point of mild discomfort and hold the stretch for 10-30 seconds, repeating stretches 2-4 times. The balance training, which can reduce fall risk, may be of any length, primarily focusing on the balance goals and needs of each client.

Special Research Findings with Diabetes and Exercise
In a randomized controlled 16-week study by Alvarez et al. (2016), 23 women (BMI = 30.5 kg/m2, 44 yrs) with type 2 diabetes were assigned to at HIIT group (n = 13) or control (n = 10). The HIIT group participated in a running based interval program where 30-second work interval intensity was 90-100% of heart rate reserve (HRR), which is a ratings of perceived exertion equivalent to hard to all-out intensity, alternating with 120-second relief intervals at 70% or less HRR (i.e., light intensity). Total exercise time for the HIIT group progressed from 22 to 37 min per session over the course of the 16-weeks study. Results showed significant improvements in both fasting glucose and HbA1c levels from the HIIT training.

Cardiovascular Disease and Exercise
Cardiovascular disease (CVD), the leading cause of death in women, is a class of diseases that involve the heart and blood vessels. It is estimated that approximately 1 out of every 3 women in the U.S. will die from CVD, killing one woman every 80 seconds (American Heart Association, 2018). Some common types of CVD include coronary artery disease, stroke, peripheral artery disease, congestive heart failure, arrhythmias and congenital heart disease. The underlying mechanisms vary depending on the disease, however coronary artery disease, stroke, and peripheral artery disease involve atherosclerosis, a disease characterized by narrowing and hardening of the arteries due to fatty plaque build up on the inner artery wall. Over time, the artery can be completely blocked and two main events can occur: a heart attack or stroke. Garcia et al. (2016) highlight women are at increased risk of CVD due to some sex-specific risk conditions and diseases including preterm delivery, hypertensive pregnancy disorders, gestational diabetes, autoimmune diseases, breast cancer treatment and menopausal transition.

Exercise Guidelines
To improve overall cardiovascular health and function, the AHA (2017) recommends a minimum of 150 minutes per week of moderate intensity exercise or 75 minutes per week of vigorous intensity exercise (or a combination of moderate and vigorous intensity exercise). The AHA suggests that a female adult can break up her exercise into 2 to 3 segments of 10 to 15 minutes each day. In addition, AHA guidelines further recommend that adults with high blood pressure or high cholesterol aim for 40 minutes of aerobic exercise of moderate to vigorous intensity three to four times a week. It should be noted that AHA also recommends moderate-to-high-intensity muscle-strengthening exercise on at least 2 days per week for additional health benefits.

Special Research Findings with CVD and Exercise
Recent research indicates there is currently a plateau of improvement to thwart the occurrence rate of mortality of coronary heart disease in women under the age of 55 yrs (Chomistek et al. 2016). Chomistek et al. continue that women are less likely to receive preventive treatment or guidance, such as lipid-lowering therapy, therapeutic lifestyle changes, and aspirin than are men at similar risk. The researchers note that when medications are prescribed, the treatment is not rigorous enough to achieve desired results. Also, Chomistek and colleagues state that women are 55% less likely to participate in cardiac rehabilitation programs then men, due to a lack of referral from their treating physician, program structure and patient preferences. However, the research with physical activity programs to combat or treat CVD in women is promising.

Surprisingly, although CVD is more common in older adults, rather little is known about the association between physical activity and CVD in older adults. The results of the Cardiovascular Health Study by Soares-Miranda et al. (2015) provides very strong evidence that physical activity, particularly walking, is associated with lower risk of CVD later in life, even in those ages 75 years and older. In this study, 4207 U.S. women and men (73 yrs at baseline) were followed for 10 years. Study findings show that walking distance and speed are especially important activity factors, given that walking is the most common type of physical activity as people age. For example, as compared to walking 2 mph, those who walked 3 mph had a 50%, 53% and 50% lower risk of CHD, stroke, and CVD, respectively. As well, compared with individuals who walked 0 to 5 blocks per week, those who walked 49 or more blocks per week had 36%, 54% and 47% lower risk of CHD, stroke, and CVD, respectively.

A review by Cramer et al. (2014) assessed the positive influences of yoga on risk factors associated with CVD. A total of 44 clinical trials qualified for the review. Results showed that compared to no stimulus, yoga decreased both systolic and diastolic blood pressure, reduced waist circumference, bettered blood lipid levels and improved measures of insulin sensitivity. All of these positive changes contribute to reductions in CVD risk. Yoga is often practiced by many Americans and recommended by physicians and therapists as a supplement to aerobic and resistance training because of its calming effects.

Osteoporosis and Exercise
Osteoporosis is an age-related disease associated with the breakdown, thinning, and softening of bones. This change in bone structure leads to decreased bone strength and low bone density, increasing the risk of bone breaks and fractures. According to the U.S. Department of Health and Human Services (HHS) Office of Women's Health (OWH) (2017), of the 10 million people in the United States with osteoporosis, 8 million are female. Factors that increase a woman's risk for developing osteoporosis are summarized in Table 1.

Ultimately 1 out of 2 women in the United States will experience an osteoporosis-related fracture over her lifetime (Xu et al, 2016). It is imperative that fitness pros educate their female clients on proper care and prevention of this disease that claims lives and disables so many women every year.

Table 1: Factors that Increase a Woman's Risk to Osteoporosis
1. Post-menopause: A decrease in the hormone estrogen can cause rapid bone loss
2. Mexican-American, Asian-American, and White women: Women (>50 yrs) of these races/ethnicity have an increased risk.
3. Small body frame: Petite stature women (under 127 lbs) have a higher risk of developing bone loss.
4. Family history: If a female's mother or grandmother had osteoporosis, she has a higher chance as well.
5. Sedentary lifestyle: Physical inactivity does not allow bones to naturally strengthen and grow. Physical activity, implementing weight-bearing activity is important for all females starting at youth and continuing throughout adulthood.
6. Low calcium and vitamin D intake: Both calcium and vitamin D work together to build and maintain strong bones.
7. Eating disorders: due to low body weight, poor diet or restricted diet, eating disorders such as anorexia nervosa and bulimia nervosa lead to weakened bones
8. Amenorrhea: No menstrual cycle for &Mac179;3 months or more: this suggests women are lacking estrogen production.
9. Smoking: frequent and large amounts of smoking can diminish bone mass and lead to an increase in bone breaks. Chronic smokers display lower bone density and reach menopause earlier when compared to non-smokers.
10. Excessive alcohol consumption: Recommended daily alcohol intake is 1 drink per day for females. Over consumption of alcohol has been shown to increase bone mineral loss and increase risk of falling, leading to bone breaks.
11. Certain medications: Medicines to treat chronic health problems, such as arthritis, asthma, lupus, or thyroid disease.
Source: Adapted from US Department of Health and Human Services, Office of Women's Health (2017). Osteoporosis

Exercise Guidelines
According to the HHS-OWH (2017), weight-bearing physical activity is particularly central to building bone and helping to prevent bone loss. From their extensive review, Xu et al (2016) propose that combined impact loading programs for 30-60 minutes on at least 3 days per week may be recommended for better health benefits for premenopausal women. If applicable and tolerable, this same recommendation has been found to preserve and maintain bone density in postmenopausal women. Fitness pros need to adapt the exercise program to the postmenopausal female clients health and fitness status. The different types of impact styles to include the following four categories:
1) High-impact loading exercises (e.g., rope jumping, fast running),
2) Odd-impact loading exercises (e.g., aerobic classes, agility exercises)
3) Low-impact loading exercises (e.g., slow jogging, brisk walking)
4) Combined impact loading exercises (e.g., impact exercises mixed with strength/resistance exercises)
Xu et al (2016) note that many comprehensive exercise programs for bone health also include balance training to promote muscle function and prevent falls. The HHS-OWH (2017) suggests starting osteoporosis prevention training with teenage females, because girls develop 90% of their bone mass by the age 18.

Special Research Findings with Osteoporosis and Exercise
The LIFTMOR study by Watson et al. (2017) implemented high-intensity resistance and impact training (called HiRIT) to postmenopausal women with low bone mass. The researchers describe HiRIT as large multi-joint compound exercises such as the squat and deadlift that are conducted in weight-bearing positions that involve substantial muscle recruitment The study aimed to determine if high vs. low intensity exercise was safe and effective to increase bone mineral density in post-menopausal women (>58 yrs). One hundred and one women were randomly assigned to either an exercise control (n= 52) or exercise (n=49) group. Both groups underwent pre-and post-testing which measured functional movement (timed up and go; functional sit and reach; 5 times sit-to-stand; back and leg extensor strength; vertical jump) and bone mineral density of the femur head and lumbar spine using DEXA scanning. The exercise group (HiRT) engaged in highly-supervised exercise sessions that occurred 2x/week for 30 minutes each session for 8 months. During each session deadlifts, overhead shoulder presses and squats were performed at 80-85% of 1RM, completing 5 sets of 5 repetitions per exercise. The exercise control group (CON) performed unsupervised, low-intensity, home-based exercises. Each session was 30 minutes in length, 2x/week for 8 months. Each home session consisted of a 10-minute walk to warm up, followed by low-load resistance exercises using body weight and working up to 6.6 lb hand weights. Stretching exercises were followed by a 5-minute cool down period.

The results from the LIFTMOR study indicate that in properly supervised sessions, HiRT exercises are safe, beneficial, and effective for increasing bone strength and improving functional movement in post-menopausal women with low bone mass. The HiRT group was superior to the control group in every measured parameter of the study. Also, of worthiness to the results was program participation and compliance. The HiRT group had a 92% rate of adherence, displaying a tolerance and enjoyment to the HiRT exercise format. Under proper supervision and correct teaching of technique, HiRT is safe and highly effective exercise program for postmenopausal women who need to adhere to an exercise program for overall health as well as to increase or maintain bone strength.

Anxiety Disorders and Exercise
Intermittent worry is a normal part of life for many women. Deadlines at work or school, paying all the bills on time, or making life-changing decisions are events that may present themselves with some added stress and apprehension and then cease as the situation is resolved. In contrast, for a person with an anxiety disorder, the anxiety does not readily go away and may get worse over time. There are several different types of anxiety disorders including generalized anxiety disorder, social anxiety disorder, panic disorder, obsessive-compulsive disorder and posttraumatic stress disorder. It is estimated that 28.8% of individuals experience an anxiety disorder over their lifetime (Kessler et al, 2005). Women with a generalized anxiety disorder have excessive worry that may last for months. General anxiety disorder symptoms include irritability, muscle tension, difficulty controlling worry, sleep problems and fatigability (HHSa, 2016).

A social anxiety disorder is also referred to as a “social phobia" (HHSa, 2016). Women with a social anxiety disorder have a fear of social situations in which they expect to feel rejected, judged, embarrassed or fearful of offending others. Social anxiety disorder symptoms include: 1) worrying for days or weeks before an event where other people will be attending, 2) staying away from places where there are other people, 3) having a hard time making friends and keeping friends, and 4) feeling very self-conscious in front of other people (HHSa).
Women with panic disorder have recurrent intermittent panic attacks, which are unforeseen periods of harsh fear that may include accelerated heart rate, heart palpitations, trembling, sweating and shaking (HHSa). Some women may also have sensations of smothering or choking. During a panic attack, the person has feelings of being out of control. Women who experience panic disorders often worry when the next attack will happen. People who experience panic disorders try to avoid places where a panic attack has previously occurred.

Obsessive-compulsive disorder (OCD) is a persistent disorder in which a person has uncontrollable obsessions (i.e., repeated thoughts, urges, or mental images) and compulsions (i.e., repetitive behaviors that a person with OCD feels the urge to do) that can interfere with aspects of a woman's life (HHSb, 2016). Common symptoms include aggressive thoughts towards others or oneself, having things in perfect order, fear of germs, and forbidden thoughts involving religion, harm or sex. A woman with OCD may be excessive at cleaning, hand-washing and arranging things in a particular way. Some individuals with OCD also have a tic disorder. With tic disorders a woman will do repetitive movements, such as eye blinking, shoulder shrugging, facial grimacing, throat-clearing, sniffing and head or shoulder jerking.

Post-traumatic stress disorder (PTSD) is a disorder that some women may develop after experiencing a dangerous or shocking event (HHSc, 2016). There is fear during and after the traumatic situation. This fear triggers changes in the body to react with the 'flight-or-flight' response. Women who have PTSD may feel stressed or frightened even when they are no longer in danger. It should be noted that any person may potentially get PTSD at any age (HHSc, 2016). This includes survivors of physical and sexual assault, abuse, car accidents, war veterans, disasters, and terror attacks. Symptoms include bad dreams, frightening thoughts, and flashbacks-reliving the trauma over and over. The assessment of any anxiety disorder should first start with a visit to a qualified care provider, who has experience helping people with the particular disorder. Anxiety disorders are typically treated with medication, psychotherapy or both.

Exercise Guidelines
The research on the effects of exercise for the treatment of anxiety disorders is relatively new and somewhat limited. More research on the effects of exercise on anxiety disorders will eventually and hopefully lead to guidelines for mode, intensity, duration and frequency.

Special Research Findings with Anxiety Disorders and Exercise
A study by LeBouthillier and Asmundson (2017) investigated the effectiveness of aerobic and resistance exercise in treating anxiety-related symptoms. In this randomized control trial, 48 participants (females and males between ages of 18-65 yrs), all of who were diagnosed with an anxiety-related disorder, participate in either an aerobic exercise (AE), resistance training (RT) or waitlist group. Participants were doing less than 150 minutes of exercise a week, but were screened (using the Canadian PAR-Q+) to safely engage in exercise. All exercise was supervised by a personal trainer and participants met 3 times per week for 1 month. The aerobic-trained (AT) group cycled for 40 minutes at 60-80% maximal heart rate reserve. The resistance trained (RT) group performed 7 exercises (machine leg press, machine chest press, machine hamstring curl, dumbbell single arm row, machine shoulder press, machine triceps extension, and machine biceps curl) completing 2-3 sets of 10-12 repetitions. Study results indicate that both aerobic exercise and resistance training were successful in favorably influencing improvements in anxiety-related disorder symptoms and related factors.

Menopause and Exercise
Fitness pros will most likely have a female client who is approaching or well into her menopause phase of life. Women who are entering menopause are in perimenopause. These women will still have a menstrual cycle, but the hormone estrogen is beginning to decline. The average age for a woman to enter perimenopause is mid-40's, but it can occur earlier or later (HHS-OWH, 2018).

Menopause occurs naturally, between the ages 45-55, but can occur earlier or later. Some women experience unnatural menopause due to surgery (i.e., hysterectomy) or damage to the ovaries (i.e., cancer) (Cleveland Clinic, 2017). Natural menopause is defined as the termination of menstruation not brought upon by medical treatment (Cleveland Clinic). It is a time when the ovaries no longer release eggs and estrogen is no longer produced. Menopause is officially diagnosed when a woman does not menstruate for 12 months (Cleveland Clinic). When estrogen is no longer produced, a women's risk of developing other health-related diseases such as osteoporosis, heart attack, and stroke increases (HHS-OWH, 2018). Other health issues include physical inactivity leading to weight gain, losses in muscular strength and cardiovascular fitness (Shaw et al., 2016). Symptoms that are bothersome and can cause distress in a women's life are hot flashes, sleep complications, variations in mood, anxiety and depression. Shaw et al. note that postmenopausal women have been found have a greater prevalence of abdominal obesity, hypertension, and elevated fasting glucose concentrations during the 10 to 14 years after menopause. The researchers submit that these changes suggest that menopause is an independent risk factor for developing a multitude of chronic diseases, such as type 2 diabetes and high cholesterol.

Exercise Guidelines
According to the American College of Obstetricians and Gynecologists Exercise (2015) regular exercise improves a woman's overall health and slows down the loss of bone. Weight-bearing exercise (such as walking) is encouraged to maintain bone strength. Strength training is recommended for muscle strength and bone health. Balance training is also recommended to help a woman avoid falls, which could lead to broken bones.

Special Research Findings with Menopause and Exercise
Shaw et al. (2016) sought to determine how resistance training (RT) with would affect various physiological parameters in 37 postmenopausal women (age range 50-79 yrs; body weight = 150 lbs, BMI = 25.3 kg/m2). For 6 weeks, 19 women completed two 40-minute RT sessions per week. Another group of 18 women were the control group, who did not engage in organized exercise, but were told to maintain their regular routines. The exercise group did 3 sets of 10 repetitions (30-90 seconds rest between sets) performed at 67-85% of the participant's one repetition max (1RM) on the following exercises: dumbbell shoulder presses, machine rows, machine latissimus dorsi pulldowns, machine leg presses, barbell squats, machine hip adduction exercises and machine standing calf raises. Participants also did dumbbell 3 sets of 10 repetitions of dumbbell loaded pelvic lifts and abdominal curls. The resistance group showed significant improvements in upper and lower body strength, blood glucose concentrations, systolic and diastolic blood pressure, fat mass, percent body fat and waist circumference.

Women's Health Research Update Final Thoughts
It is hoped this women's health research update will empower and inspire fitness pros to guide female clients to happier, healthier and physically active lifestyles. The road to optimal health and fitness has no finish line.

Side Bar 1. Key Takeaway Messages from All of Health Topics Reviewed
Both cardiovascular training and resistance training are recommended for females with diabetes. Progressively increasing intensities in both modes appear to deliver the more optimal health outcomes.
Cardiovascular Disease (CVD): Fitness pros should regularly educate female clients, particularly those who may be at high risk or who currently have, on the importance of doing regular cardiovascular exercise and resistance training to combat CVD, the #1 disease killer of women.

Osteoporosis: The framework exercise program design for female clients is to increase and maintain bone health needs with combined impact loading exercise programs. Women should also include balance training with their regular workouts during the week to promote proper muscle function and limit falls.

Anxiety Disorders: Research results highlight the efficacy of employing different exercise modalities (i.e., aerobics and resistance training) in managing anxiety-related disorder symptoms. Design the exercise interventions to each client's interest, as this may increase the likelihood for exercise adherence.

Menopause: Weight bearing exercise (such as walking), resistance training and balance training are key components of an exercise program for a woman going through menopause. To help prevent weight gain, study results indicate 30-45 minutes of moderate intensity exercise on most days of the week in addition to a dietary food consumption plan of 1300 -1500 kcals per day (Simkin-Silverman et al., 2003).

Side Bar 2: What is the Truth About Weight Gain During Menopause
Weight gain during menopause is largely due to aging, sedentary behavior, hormonal changes, and physical inactivity. All of these factors will vary between women. Results of a 5-year randomized study with over 500 menopausal women showed that in healthy women, weight gain and increased waist circumference during the peri- to post-menopause can be prevented with a long-term life-style dietary and physical activity intervention (Simkin-Silverman et al., 2003). Simkin and colleagues note that to achieve this goal, women need to complete 30-45 minutes of moderate intensity exercise on most days of the week in addition to a dietary food consumption plan of 1300 -1500 kcals per day.

Tori Lau is an Exercise Science masters student at the University of New Mexico, Albuquerque. Her specific interests include clinical populations, disease prevention, risk factor modification, and exercise for older populations.

Bryanne N. Bellovary M.S., CSCS, NSCA-CPT is an Exercise Physiology doctoral student at the University of New Mexico, Albuquerque. Her specific interests include fitness project testing and environmental physiology concerning exercise and altitude.

Len Kravitz, PhD, CSCS, is the program coordinator of exercise science at the University of New Mexico, where he received the Outstanding Teacher of the Year and Presidential Award of Distinction. In addition to being a 2016 inductee into the National Fitness Hall of Fame, Len was awarded the 2016 CanFitPro Specialty Presenter Award.

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