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Women's Health Research Update
Len Kravitz, Ph.D.

Research on women's health is surging with health discoveries, medical developments and research findings on exercise, cardiovascular disease, fat metabolism, exercise behaviors, hypertension, metabolic syndrome, musculoskeletal problems and longevity. As fitness professionals and personal trainers, our vocation steers us to combine modern-day science with newer, safer and more effective forms of exercise. Although many consumers seek out the guidance of 'medicine makers', it is becoming more apparent from the research of the important role of fitness professionals and personal trainers in guiding clients to sensible solutions with their health. Although an eclectic group of studies was selected for this review, the driving theme was to choose studies where fitness professionals could use the research to immediately and positively impact their students.

What Health Message are Young Women Getting?
Turner, M.B., Vader, A.M., & Walters. S.T. (2008). An analysis of cardiovascular health information in popular young women's magazines: what messages are women receiving?
American Journal of Health Promotion, 22(3), 183-186.
Cardiovascular disease (CVD) is the number one killer of women in America with greater than 450,000 deaths each year (American Heart Association {AHA}, 2009). Nearly 39 percent of all female deaths in America occur from CVD, which includes coronary heart disease (CHD), stroke and other cardiovascular diseases (AHA, 2009a). According to the AHA, the majority of women are very unaware of this serious threat to their health. Low-to-moderate intensity exercise (e.g. walking, yard work, dancing and gardening) for up to 30 minutes daily will help combat the onset of this disease. More vigorous aerobic activities (e.g. swimming, bicycling, roller skating, and running) adds even greater cardiovascular health benefits. In addition, nutrient-rich foods such as vegetables, fruits, whole-grain products and low-fat (or fat free) dairy products have vitamins, minerals, fiber and other nutrients for a healthy diet, optimal weight management and cardiovascular disease prevention. It is also important to note that cigarette smokers are 2-3 times more likely to die of heart disease (AHA, 2009b)

This study assessed the uniformity of cardiovascular health information in six issues (spanning 6 months) of four popular women's magazines (Cosmopolitan, Glamour, Vogue, and Shape) with the American Heart Association's guidelines for physical activity, nutrition, weight management, and smoking. The authors report that these magazines represent 10 millions readers of which the majority are aged 18 to 34 years. The most common topic covered in these magazines was physical activity followed by nutrition, weight management, and cigarette smoking. The subject area most consistent with AHA guidelines was nutrition (78%), followed by content on smoking (68%), physical activity (66%) and weight management (19%). The researchers note that weight management had a low association with the AHA guidelines due to a lack of specific information on weight management and CVD (i.e., information on body mass index and waist circumference assessment, etc.). The authors identify and acknowledge that a limitation of this 6-month analysis of these magazines is it may not adequately depict a full year of article content.

TAKE AWAY MESSAGE: It appears that some of the popular young women's magazines are providing truthful and helpful content in regards to cardiovascular health information, but more specific information about weight management and its association to CVD is recommended.

Is Hypertension Inevitable for Women as they Age?
Coylewright, M., Reckelhoff, J.F., and Ouyang, P. (2008). Menopause and hypertension: An age-old debate. Hypertension, 51, pp. 952-959.
According to ACSM (2006), hypertension is defined as an elevation in arterial blood pressure equal to or exceeding a systolic blood pressure of 140 mmHg and/or a diastolic blood pressure of 90 mmHg. Pre-hypertension is the classification of persons with systolic blood pressure of 120 to 139 mmHg and/or diastolic blood pressure of 80 to 89 mmHg. The risk of many diseases (e.g., stroke, congestive heart failure, kidney failure, and peripheral vascular disease) is increased with the prevalence of hypertension. Most women will develop hypertension during their lifetime, and Coylewright and colleagues (2008) report that women who develop hypertension at a younger age are at higher risk of adverse cardiovascular events. The authors assert that several studies propose the onset of hypertension in women is a result of the onset of menopause, while other conflicting research suggests hypertension is more related to age. In their review, the researchers propose this conflicting research-based evidence is most likely due to numerous methodological differences in research designs of the published research.
Several factors contribute to hypertension in postmenopausal women (Coylewright, Reckelhoff and Ouyang, 2009). Estrogen deficiency may lead to endothelial (layer of cells that line the interior surface of blood vessels) dysfunction, thus reducing the effectiveness of the vasodilators (chemicals that relax the smooth muscle in blood vessels) that modulate blood vessel vascular tone (muscle tone of the walls within blood vessels). Increased artery stiffness also appears to coincide with menopause. As well, estradiol appears to provide cardioprotection by controlling mechanisms of the renin-angiotensin system (which is a regulator of blood pressure, blood fluids and electrolytes). Salt sensitivity has also been shown to increase with women (and men) with chronological age. Yet, post-menopausal women are known to be more salt sensitive then pre-menopausal women. The onset of obesity, which occurs with some women during menopause, is shown to have a strong correlation to hypertension.
From the exercise perspective, ACSM (2006) recommends the following for persons with hypertension. The primary exercise mode should be aerobic activities performed at 40% to 70% of heart rate reserve. The frequency should be 3 to 7 days per week, emphasizing that daily exercise may be more beneficial in controlling hypertension due to the positive acute effects of aerobic exercise lowering blood pressure (in hypertensives) for several hours after a exercise. Duration should be from 30 to 60 minutes. Resistance exercise (lower resistances with higher repetitions) is not recommended as the primary form of exercise, but should be combined with aerobic training.

TAKE AWAY MESSAGE: The association of hypertension and menopause with women is a multifactorial phenomenon, with many proposed factors and unanswered questions. Yet, the participation in regular aerobic exercise is a critically important lifestyle modification which has been shown to lower systolic (-7.4 mmHg) and diastolic (-5.8 mmHg) blood pressure in hypertensive persons (ACSM, 2006).

Physical Activity and Breast Cancer: New Update
Friedenreich, C.M. & Cust, A.E. (2008). Physical activity and breast cancer risk: impact of timing, type and dose of activity and population subgroup effects. British Journal of Sports Medicine, 42, pp 636-647.
According to the American Cancer Society (2008), breast cancer is the most common malignancy among women in the U.S. with 26% of the cancer cases totally 182,460 new cases in 2008. Lung and bronchus cancer (14%) are second followed by colon and rectum cancer (10%) in women. The American Cancer Society advises that to reduce the risk of developing breast cancer, women should adopt lifestyle behaviors such as reducing alcohol use, engaging in physical activity, maintaining a healthy weight, eating a balanced diet (with at least 5 servings of fruits and vegetables a day) and breast feeding. Well over 80 studies now convincingly suggest that there is an inverse relation with physical activity to breast cancer (i.e., exercise reduces the risk of breast cancer) (Friedenreich and Cust, 2008). In this recent review by Friedenreich and Cust, the authors found a decrease in the risk of breast cancer by approximately 25% among the most physically active women as compared to the least active females. Both moderate and vigorous exercise exhibited nearly equal benefits for a decrease in breast cancer risk. As well, physical activity through a woman's lifetime conferred the highest risk prevention benefits. The authors note that physical activity reduced the risk of breast cancer in all groups of females except obese (as determined by BMI &Mac179; 30 kg/m2 {weight in kg/height in meter squared}). The greatest risk reduction was with lean females who had a BMI of < 22 kg/m2. The authors summarize that the positive influence of physical activity to reduced cancer risk may be due to a modulation of inflammation and immune function. It appears that exercise may favorably change the balance of pro- and anti-inflammatory cytokines (signaling molecules that, like hormones and neurotransmitters, are used extensively in cellular communication) thus lessoning the negative effects of chronic inflammation in the circulatory system.

TAKE AWAY MESSAGE: The evidence is very persuasive that moderate to vigorous exercise reduces the risk of breast cancer. Those females who do regular physical activity during their lifetime have an even lesser risk. These risks are more noticeable in non-obese female populations.

Exercise Metabolism in Women: New Insights and Implications
Tarnopolosky, M.A. (2008). Sex differences in exercise metabolism and the role of 17-beta estradiol. Medicine & Science in Sports & Exercise, 40(4), 648-654.
It has generally been assumed that men and women have similar muscle fiber types and thus metabolize fats, carbohydrates and proteins similarly. Indeed, the majority the studies on metabolism have been done with male populations, assuming this similarity. However, in a review of all substrate (fat, carbohydrate and protein breakdown for energy) oxidation (loss of a electrons and thus the substrate is being broken apart) studies during endurance exercise (>60 minutes), Tarnopolosky (2008) summarizes that it is clear that women have a higher fat utilization and lower carbohydrate energy expenditure. This elevated fat utilization during endurance exercise is seen with women before and after training, thus suggesting that the underlying mechanism is due to a sex difference between men and women, and not a training effect. As well, Tarnopolosky notes that women have been shown to have a slightly higher percent of Type I or slow twitch (oxidative) fiber type, which may partially contribute to the increased fat metabolism during endurance-type activities. More profoundly, it appears that higher levels of the major estrogen seen in women, 17-beta estradiol (which men also have in low levels in the body) is the mediating hormone that enhances fat oxidation (thus sparing carbohydrates) pathways during endurance exercise.

TAKE AWAY MESSAGE: Since women are metabolizing fat more effectively during endurance exercise > 60 minutes, an exercise program that includes sustained aerobic exercise bouts is encouraged for those female students and clients wishing to optimize fat metabolism through exercise.

Are Pregnant Women Getting Enough Physical Activity?
Borodulin, K.M., Evenson, K.R., Wen, F., Herring, A.H., and Benson, A.M. (2008). Physical activity patterns during pregnancy. Medicine & Science in Sports & Exercise, 40(11), 1901-1908.
The health benefits of being physically active during and immediately after pregnancy include potential deterrence of preeclampsia (abnormal state of pregnancy characterized by hypertension and fluid retention), gestational diabetes and chronic musculoskeletal complications (e.g., pelvic pain, back pain, lower extremity weakness). Additional benefits of habitual exercise include improved mental well-being and promotion of a healthy body weight. The inclusion of consistent cardiovascular exercise can also assist with the postpartum recovery. Borodulin et al. (2008) highlight that the American College of Obstetricians and Gynecologists (ACOG) recommends that pregnant women engage in moderate-intensity exercise for at least 30 min on most, if not all days of the week. In this study of 1,482 women (71.6% white, 17.3% African American, 11.1% other, pre-pregnancy BMI was 23.4 kg/m2), the majority of the women self-reported some physical activity during the second (96.5%) and third (93.9%) trimester. The reported level of intensity and total volume of exercise decreased between the second and third trimester. The authors detail that the physical activity consisted of household related indoor activities, care-related responsibilities and recreational activities. However, the majority of women did not reach the activity guidelines as recommended by ACOG. The authors note that this current data from study is in agreement with numerous other previous studies showing a decrease in intensity and duration of physical activity during pregnancy.

TAKE AWAY MESSAGE: Fitness professionals and personal trainers can serve their pregnant students and clients beneficially through proper education of the health benefits of remaining physical activity during pregnancy.

Love Helps and Hurts: Social Relations and Exercise
Cotter, K.A. & Sherman, A.M. (2008). Love Hurts: The Influence of Social Relations on Exercise Self-Efficacy for Older Adults With Osteoarthritis. Journal of Aging and Physical Activity, 16, 465-483.
One of the benefits of exercise, especially for older adults, is that it helps decrease musculoskeletal pain and improve joint mobility and function, especially for person's with osteoarthritis. One of the most effective strategies to promote regular exercise is through positive self-efficacy. Self-efficacy is the belief that a person is capable of performing in a certain approach that will lead to the attainment of specific goals. So, using self-efficacy as a teaching aid, a fitness professional would help a client attain a regular exercise program and educate the client that this will lead to a healthier, more active lifestyle. Eventually the client believes this herself, which encourages this optimistic outcome. Cotter and Sherman (2008) report that research promoting exercise self-efficacy has been shown to improve exercise adherence in older adults, because it instills a sense of self-confidence in a woman's ability to be regularly active. However, many older individuals may experience what is referred to as 'social strain', which is negative feedback from others in their life trying to dissuade them from exercise. Statements such as 'you are always exercising and never have time to be with me' provide social strain, which may then begin to stifle a woman's motivation to want to continue to exercise. In Cotter and Sherman's recent study with older adults (77% women) with osteoarthritis, the researchers found that social support was a positive predictor of exercise self-efficacy but that social strain influences are very potent and power distracters to exercise self-efficacy, and are prevalent in the lives of many older women.

TAKE AWAY MESSAGE: Fitness professionals must be on the alert with their older female clients about the influence of social strain on the client's present and future success for exercise adherence. Help a client realize early on that others may find her dedication to a healthy lifestyle a distraction or detour from a relation. She needs to address and explain these issues with her significant others in her life and seek their support. Ideally friends and family will learn to be supportive and play a constructive role in the client's long term exercise adherence. See the research on women's exercise behaviors below for even more extensive research relating to this topic.

Exercise Intensity and Metabolic Syndrome: Is Harder Better?
Irving, B.A., Davis, C.K., Brock, D.W., Weltman, J.Y., Swift, D., Barrett, E.J., Gaesser, G.A, and Weltman, A. (2008). Effect of exercise training intensity on abdominal visceral fat and body composition. Medicine & Science in Sports & Exercise, 40(11), 1863-1872.
Central obesity is a risk factor of metabolic syndrome. Metabolic syndrome is a cluster of cardiovascular disease risk factors that are associated with elevated blood triglycerides, hypertension, and insulin resistance (see Table 1 for risk factors).
Table 1. Risk Factors for Metabolic Syndrome: Defined as Having 3 or more Risk Factors
Risk Factor Risk Criteria
HDL-C <50 mg/dL for women, <40 mg/dL for men
Blood pressure &Mac179;130 mmHG (systolic) And/Or &Mac179;85 mmHG (diastolic)
Waist circumference >35 inches (88 cm) for women , >40 inches (102 cm) for men
Fasting blood glucose &Mac179;100 mg/dL
Triglycerides &Mac179;150 mg/dL
Adapted from Heyward, V. (2006). Advanced fitness assessment and exercise prescription. Champaign, Ill., Human Kinetics
Cardiovascular exercise has been shown to be an effective strategy for decreasing visceral abdominal fat. However, there is no widespread consensus as to what dose of exercise will obtain the most healthful effect. In this 16-week study by Irving et al. (2008), 27 moderately obese (BMI 34 kg/m2), sedentary (reporting less than 2 days/week of exercise) middle-aged women (51 years of age) with metabolic syndrome were randomly assigned to one of three different 16-week interventions: 1) 7 subjects maintained their current level of activity (<2 days/week) or inactivity, thus serving as the control group) 2) 11 subjects exercised 5 days/week at an intensity &Mac178; lactate threshold (point in exercise where lactate accumulates in a non-linear manner; which is approximately a RPE of 10-12); expending 400 kilocalories each session, 3) and a high intensity group (9 participants) exercised 3 days/week > lactate threshold (RPE 15-17) with 2 days/week &Mac178; lactate threshold (RPE 10-12) equaling 400 kilocalories per session. Subjects in groups 2 and 3 did a walk/run exercise program that totaled 2000 kilocalories per week. The diet of all subjects was not altered during the length of this study.

Only the high intensity exercise group had a significant reduction in body weight, BMI, %body fat, fat mass and waist circumference as compared to the control and moderate intensity group. Improvement was also seen in the high intensity group's high-density lipoprotein cholesterol (the healthy cholesterol) as well as a decrease in triglycerides. Although the kilocalorie expenditure was matched for the two exercise groups, the researchers suggest that the post-exercise oxygen consumption (exercise after burn) was likely higher in the high intensity group as this is very common from previous research.

TAKE AWAY MESSAGE: This study adds to an increasing number of investigations that suggests for optimal health benefits in females (and reduction in metabolic syndrome), clients should follow a progressively increasing training continuum. Initially and very importantly, get clients and students regularly exercising and physically active on most if not all days of the week (expending around 2,000 kilocalories per week). Then, progressively provide the exercise direction for them to get 'fitter' with gradual increases in exercise intensity in their cardiovascular workouts.

How Can We Get More Women Exercising?
Vrazel, J., Saunders, R.P., & Wilcox, S. (2008). An overview and proposed framework of social-environmental influences on physical-activity behavior of women. The American Journal of Health Promotion, 23(1), 2-12.
The health benefits for women exercising include reduced risk of type 2 diabetes, coronary heart disease, stroke, some cancers, and other leading causes of disability (Vrazel et al., 2008). Physically active women have a much lower mortality risk then their inactive counterparts. Yet, Vrazel and colleagues note that despite the meaningful health benefits of exercise, females are regularly shown to be less active then men, and that their physical activity decreases considerably as they age. Understanding and changing the causes for this inactivity is of great concern to fitness professionals and researchers, and was the motivation of this research review.
In their attempt to identify and understand the factors that affect women and their exercise behaviors, the authors centered their investigation on the impact of the social environment, as current research has focused its investigation in that area (Vrazel et al., 2008). Vrazel and fellow researchers began this project with an exhaustive research review in several databases. Studies, both quantitative and qualitative, with women 20 to 60 years of age were the target of this project. Physical activity was defined as any bodily movement that results in energy expenditure, such as lifestyle activity, leisure-time activity and exercise. Forty-three studies met all of the researchers inclusion criteria. Although a complex group of factors exist in the social environment that influence women's exercise behaviors, two major areas discussed in this article will be social support and cultural standards.

Social Support
Social support is the most understood and investigated area of a female's social environment. Social support is the assistance a female receives via emotional, informational, instrumental or appraisal support. One can receive social support from individuals or an organization (i.e., a 'woman in business' club that a lady is a member), which would be an example of a social network. The emotional support involves situations where a lady feels the acceptance from others, involving daily life connections with other persons, such as colleagues at work, personal friends and family members. The research is very pervasive that women want this type of support and encouragement to be physically active. Investigations reveal that women who have support from their friends and family have a much higher likelihood to be consistently physical active (Vrazel et al., 2008). Emotional support is also a major influencing factor for exercise adherence. Women who have elevated levels of assurance of the worthiness of exercise from others will be more likely to sustain the exercise. As well, the fitness professionals and personal trainer is an incredibly important provider of emotional support for the female exerciser. The data additionally illustrates that having a companion(s), workout partner, or group to exercise with is a big facilitator to exercise adherence with women.
Information support involves getting suggestions or some type of informational support, which is what magazines, television (i.e., fitness-related or health-related) and the internet provide. Information support is best if it includes specific health benefit information (i.e., the benefit of exercise in reducing cancer risk), and strategies how to 'fit' exercise into a woman's busy life. Fitness professionals can be of great assistance in providing and guiding students and clients with informational support.

Instrumental support is a tangible service, and refers to getting some type of specific aid, such as having assistance for the multiple roles a woman must do daily (e.g., someone to help with household duties; someone who can lend a hand with the care giving for the family; or a personal trainer to lead/teach an exercise program). If a woman's significant other is willing to 'partner' responsibilities with raising children, there is a greater likelihood she will have more willingness (and time) to exercise for herself.

Appraisal support involves constructive feedback and affirmations that help develop beliefs about exercise. Hearing from a medical correspondence that exercise is very beneficial and good for you can be a catalyst to begin and/or continue exercise. Thus appraisal support helps to develop core values about the worthiness of fitness.

Cultural standards
Gender-role expectations are included in cultural standards and are a complex aspect of a female's social environment. Many women feel social pressure (due to their gender-role expectations) that their family obligations are their primary focal point and must concentrate their efforts on these obligations above personal interests, such as exercise. Another chief issue with cultural standards is the acceptance of exercise as being culturally appropriate. The research suggests women perceive acceptance to exercise as an essential factor to persuade them to exercise. With some subpopulations of women, such as Hispanic females, this 'consent' to exercise from her husband is crucial for her to participate in an exercise program. Critical to personal trainers and fitness professions is the research finding that females actively seek role models to inspire and motivate them to be active. Thus explains how celebrity fitness gurus often garner so much attention. However, the research suggests that women need more role models from their community (such as personal trainers) who can show them how they can lead their life, work, care for the family and still be physically active.

TAKE AWAY MESSAGE: This study unmistakably provides evidence-based research showing that a female's social environment is critically important to her physical activity behavior. Most striking from this research is the discovery how important the personal trainer and fitness professional are in serving their clients as role models.

Final Thoughts
Women enjoy having options for health choices, but when there are dozens of options, and truly no single choice that works for all women, the education and direction of the fitness professional is paramount. The newest research suggests that the role of personal trainers is paramount to the exercise success of their clients. Take this challenge and 'Be the Example' through your own daily life as you aid lead your clients to healthy lifelong solutions.

Len Kravitz, Ph.D., is the Program Coordinator of Exercise Science and Researcher at the University of New Mexico UNM) where he won the "Outstanding Teacher of the Year" award. Len was honored with the 2006 Canadian Fitness Professional “Specialty Presenter of the Year” awards and chosen as the American Council on Exercise 2006 "Fitness Educator of the Year”. He was recently presented with the 2008 Canadian Fitness Professional “Lifetime Achievement Award”.

Special Thanks: I would like to thank Jennifer Lynne Wolfe, undergraduate student at UNM, for her help in researching this project.

Additional References:
American Cancer Society (2008). Cancer Statistics Presentation
Retrieved February 8, 2009
American College of Sports Medicine. (2006). Guidelines for Exercise Testing and Prescription 7th Edition. Philadelphia, PA: Lippincott Williams & Wilkins.
AHA. (2009) Women and Heart Disease
Retrieved February 5, 2009
AHA. (2009a). Facts about women and cardiovascular diseases
Retrieved February 5, 2009
AHA. (2009b). Smoking and Cardiovascular Disease
Retrieved February 5, 2009