Physical Activity on Cardiorespiratory Fitness and Cardiovascular Risk in Premenopausal and Postmenopausal Women

A Systematic Review of Randomized Controlled Trials

Maitane Ruiz-Rios, MS; Sara Maldonado-Martin, PhD

Menopause. 2022;29(10):1222-1229.

Abstract and Introduction

Abstract

Importance: The apparent cardioprotective effects of endogenous estrogens to prevent cardiovascular disease in premenopausal women are reduced with the loss of estrogen post-menopause. Cardiorespiratory fitness and cardiovascular risk factors are closely related to physical activity levels.

Objective: This study conducted a critical assessment of studies for health prevention that analyze the effects of physical activity programs on cardiorespiratory fitness and cardiovascular risk factors in women, comparing premenopausal and postmenopausal states, through a systematic review of randomized controlled trials.

Evidence Review: A computerized literature search was performed to include articles up until December 2021 in the following online databases: PubMed, Cochrane, Scopus, SportDiscus, and Web of Science. Regarding physical activity intervention, women of all ages were engaged. The PEDro scale and Oxford's evidence levels were used for the assessment of the risk of bias in the included articles.

Findings: Fourteen scientific articles met the inclusion criteria. Great variability was found in physical activity variables. All the studies found an improvement in at least one variable. The risk of bias was high, with all the articles obtaining a low methodological quality, except two with high methodological quality. Only one article considered the differences in the menopausal state observing the effects of physical activity intervention and highlighting the importance of physical activity in both states.

Conclusions and Relevance: To strengthen the evidence for the benefits of physical activity programs in women and to observe the effects depending on their menopausal state, there is an ongoing need for more rigorous randomized controlled trials of appropriate length and dose, with individualized exercise intensity.

Introduction

Cardiovascular disease (CVD) is a major cause of morbidity and mortality for women (35% of total deaths), and it is associated with menopause among other well-established risk factors (eg, hypertension, dyslipidemia, diabetes, obesity, poor diet, sedentary lifestyle, inactivity, and smoking).^[1] It has been hypothesized that the apparent cardioprotective effects of endogenous estrogens to prevent CVD in premenopausal women are reduced with the loss of estrogen after menopause.^[2,3] However, menopausal hormone replacement therapy is not indicated for primary or secondary prevention of CVD.^[1]

The fact that higher cardiorespiratory fitness (CRF) and physical activity (PA) patterns are inversely associated with CVD mortality is well documented.^[4] Thus, CRF is promoted as a clinical vital sign and thus the need for its assessment.^[4] This assertion highlights the potential impact on the survival of PA intervention,^[5] meeting the international guidelines on PA (ie, 150–300 min/wk of moderate intensity, or 75 to 150 min/wk of vigorous intensity, or an equivalent combination of both intensities, plus muscle-strengthening activities).^[6] It has recently been stated that regular exercise, especially at high intensity, leads to higher CRF, which is associated with a better lipoprotein particle profile in perimenopausal and late postmenopausal women.^[7] However, the effect of menopause is still understudied, underrecognized, underdiagnosed, and undertreated globally.^[1] Therefore, knowing the relevance of lowering cardiovascular risk factors (CVRFs) and increasing CRF to prevent the onset of CVD and the role of PA in this sense,^[8–12] a study is needed that analyzes the results found in studies on this issue specifically in women. In addition, it seems necessary to distinguish the menopausal state when analyzing the effects of PA due to hormonal differences.^[13] Therefore, this systematic review aimed to analyze the effects of PA programs on CRF and CVRF in women by comparing premenopausal and postmenopausal states.

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Abstract and Introduction
Methods
Results
Discussion
Conclusions
References
Sidebar

Table 1. Main characteristics of the included scientific articles that analyzed CRF and CVRF after PA intervention
Electronic database	Reference	Principal characteristics	Intervention	Main results
CENTRAL
	Andersen et al (1999)¹⁶	- Obesity, 21–60-y old women (n = 40) - From Philadelphia, USA (non-Hispanic White, non-Hispanic Black, Mexican American) - BMI = 32.9 kg/m² - MOI: in person	- 16-wk study + 1-y follow-up - Two groups: (1) diet + structured aerobic exercise (three step aerobics sessions), (2) diet + moderate lifestyle activity (increased moderate-intensity PA to 30 min/d in short bouts most days of the week)	- After 16 wk, both groups: TC↓, TG↓, LDL-C↓, HDL-C↓ - TC, HDL-C ratio > = < at 16-wk, but ↓ in lifestyle group at 1-y follow-up - Resting SBP↓ during 16 wk, remained lower than baseline in lifestyle group at 1-y follow-up - V̇o_2max↑ during the intervention, with no difference between groups - Vigorous aerobic exercise better sparing of lean tissue than did lifestyle activity
	Ibáñez et al (2010)⁸	- Sedentary, obesity, nonsmoking 40–60 y (n = 34) - BMI 30–40 kg/m² - Not on hormone therapy - MOI: in person	- 16-wk intervention (three groups): (1) control, (2) weight-loss diet, (3) weight-loss diet + RT - Dynamic resistance exercises, 2 d/wk; 45–60 min/session - First 8 wk: loads of 50%-70% 1RM - Last 8 wk: loads of 70%-80% 1RM	- Weight-loss diet group: serum adiponectin levels↑, insulin sensitivity↑, baseline insulin levels↓, with no changes in lipid profile, thigh muscle mass↓ - Weight-loss diet + RT group: insulin sensitivity↑, baseline insulin levels↓, TC↓, LDL-C↓, serum adiponectin levels↓, > = < thigh muscle mass - After 16 wk, both groups: body mass↓, abdominal SAT↓, thigh subcutaneous fat↓, visceral fat mass↓
	Lee and Kim (2006)⁹	- Overweight/obesity, sedentary, hypertriglyceridemia (TG ≥150 mg/dL), 35–50 y (n = 19) - Kyongi Province, South Korea - BMI ≥23 kg/m² - MOI: in person	- 12-wk intervention (two groups): (1) brisk walking program, (2) brisk walking program + diet - Walking program: 20–50 min/d at 40–50% HR reserve (3-6 d/wk)	- Both groups: TG↓, Apo B↓ - Exercise effects on serum TG are dependent on baseline TG levels, and ↑ when participants' initial TG concentrations are ↑
	Pribulick et al (2013)¹⁰	- Nonsmoking, 35–65 y (n = 93) - From two rural counties (New York and Virginia, USA) - MOI: in person	- 14-mo study of dietary fruit and vegetable intake, and PA level	- Higher PA level: CRP↓, CVRF↓ - A ↑BMI corresponds to ↑CRP
	Pullyblank et al (2020)¹¹	- Overweight (BMI ≥25 kg/m²), sedentary, rural, ≥40 y (n = 194) - 16 communities (12 in Montana, 4 in New York, USA) - White, non-Hispanic - MOI: in person	- 24-wk intervention (1 h, 2 d/wk) - 20–30 min of aerobic exercise + 10–15 min of progressive strength training	- Intervention group: ↑ strength and endurance (chair stand and step test; and physical function)
	Ratajczak et al (2019)¹⁷	- Obesity, 18–65 y (n = 39) - From Poland - BMI ≥30 kg/m² + WC >80 cm + body fat ≥33% - MOI: in person	- 3-mo physical training program (3 d/wk) - ET: cycle ergometer; 5-min low-intensity warm up + 45 min training 60%-80% HR_max + 5 min non–weight-bearing cycling + 5-min low-intensity cooldown - CT: 5-min low-intensity warm-up + 20-min strength exercises + 25-min endurance exercise at 60%-80% HR_max + 5 min non–weight-bearing cycling + 5-min low-intensity cooldown - Sets: 16 sets in barbell curls, 30 sets in barbell squats (10- to 15-s rest between sets)	- Postintervention, both groups: body mass↓, BMI↓, WC↓, resting HR↓, resting DBP↓, SBP↓, VEGF↑, TG↓, TAC↓, ↑V̇o_2peak - ET + CT: total-body skeletal muscle mass index↑, TC↓ - CT: VAI↓, LDL-C↓, CRP↓, atherogenic index of plasma↓ - CT: more effective visceral fat↓, > = < or ↑muscle mass than ET alone - ET: HDL-C↑, endothelial nitric oxide synthase↑, thiobarbituric acid reactive substances↓
	Wu et al (2007)¹⁸	- With at least one CVRF, 35–64 y (n = 36) - From Taiwan - All nonsmokers, except two; no drinkers, except four - Not on hormone therapy - Menopause state assessed - MOI: in person	- 8-wk intervention - Exercise group: 5-min warm-up + 30-min treadmill training + 5-min cooldown (3 d/wk) - Control group: maintain their previous lifestyle	- Exercise group: BMI↓, waist-to-hip ratio↓, resting SBP↓ and DBP↓, mood↑; ↑vigor-activity, fatigue-inertia, and total mood scores after 8 wk - TG > = < in exercise and control group - Participants with SBP >140 mm Hg: greater reduction than those with SBP <139 mm Hg
SPORTDiscus
	Álvarez et al (2019)¹⁹	- Physically inactive, hyperglycemia, overweight/obesity (26-35 kg/m² + WC >80 cm), nonsmoking 41 ± 6 y (n = 40) - From Chile - Not living in a rural area - PA levels <600 MET min/wk - Fasting glucose 100–125 mg/dL - SBP 130–139 + DBP 85–90 mm Hg - TC >200 mg/dL - MOI: online, in person	- 20-wk of CT intervention: 3 d/wk; 5-min warm-up + cooldown; 50-min RT + 30-min ET - RT: eight exercises with dumbbells at no more than 10%-20% 1RM - ET: walking or running at no more than 70% HR_max	- Body mass↓, waist-to-hip ratio↓, fat mass↓, lean mass↓, mean SBP↓, fasting glucose↓, 6MWT↑
	Domene et al (2016)²⁰	- Physically inactive (≤1 d/wk), overweight/obesity (BMI 25 kg/m²), nonsmoking 18–64 y (n = 20) - From the United Kingdom - Inexperienced at Zumba fitness - Free from musculoskeletal injury - MOI: in person	- 8-wk Zumba fitness intervention - 12 classes (1 d/wk increased progressively) - 1-h length + 48 h between classes	- Body fat↓, V̇o_2max↑, white blood cells↓ - HRQoL: physical functioning↑, emotional well-being↑, energy/fatigue↑
	Parra-Medina et al (2011)¹²	- Financially disadvantaged African American, ≥35 y, primarily HTN, diabetes (n = 266) - From South Carolina, USA - BP <160/95 mm Hg - MOI: online, in person	- Standard care (motivational, stage-based behavioral counseling) + telephone counseling intervention (12 mo)	- Comprehensive participants: ↑ in leisure time PA and dietary risk assessment total score↑, CVRF↓
	Robins et al (2016)²¹	- Nondiabetic, 35–50 y (n = 63) - From central Virginia, USA (24% African American, 76% White) - BMI >40 kg/m² - Uncontrolled HTN (BP ≥160/100 mm Hg) and increased risk for CVD - MOI: in person	- 8-wk tai chi intervention - 60-min sessions: breathing, posture, balance, movement, consciousness for relaxation - Home practice: 15 min most days of the wk	- Postintervention: ↓ fatigue, granulocyte colony-stimulating factor, proinflamamatory cytokines associated with CVD, depressive symptoms, stress ↑ mindfulness, self-compassion, spirituality
Additional articles
	Alvarez et al (2018)²²	- Sedentary, overweight/obesity, 18–59 y (n = 49) - From Chile - Fasting hyperglycemia >126 mg/dL - TC >200 mg/dL - Were not on hormone therapy - MOI: in person	- 16-wk HIIT program (3 d/wk) - Groups: T2DM, DYS, DYSHG, CON - HIIT: jogging/running (90%-100% reserve HR) interspersed with low-intensity active recovery (walking below 70% of reserve HR)	- T2DM, DYS, DYSHG: HDL-C↑, fasting glucose -DYS, DYSHG: TC↓ - DYSHG: LDL-C↓ - After intervention: TG↓, body mass↓, BMI↓, WC↓, skinfold thickness↓, endurance performance↑ - All groups: SBP↓, not DBP
	Behall et al (2003)¹³	- Premenopausal (n = 10) and postmenopausal (n = 13), nonsmoking, sedentary, 18–77 y - From the USA - BMI >25 kg/m² - Not on hormone therapy - Menopause state confirmed by blood analysis - MOI: in person	- 12-wk training intervention, 3 d/wk - Two groups of different training in each menopausal state: 1) aerobic training with 20–40 min progressively; 60%-65% HR reserve, and 2) resistance training with 14 exercises; 2 sets of 8–15 reps; 1-min rest interval; 2-min rest sets	- After aerobic exercise in both groups: percent body fat↓ - After aerobic exercise especially in postmenopausal: TG↓, cholesterol↓ - After intervention in both groups: TC↓, LDL-C↓, HDL/LDL-C ratio improved, insulin areas under the curve↓, C-peptide areas under the curve↓ - Average glucose concentrations ↓ with aerobic, ↑ with resistance exercise
	Krishnan et al (2015)²³	- Diabetic and nondiabetic sedentary, overweight/obesity (BMI 25–40 kg/m²), 18–65 y (n = 28) - From Texas, USA - MOI: online, in person	- 16-wk Zumba dance intervention, 3 d/wk	- Body weight↓, BMI↓, WC↓, hip circumference↓ - Aerobic capacity↑, flexibility↑, muscular endurance↑, % HRmax↑ - Intrinsic motivation↑, commitment↑, enjoyment↑

↓, Decreased; ↑, increased; > = <, unchanged; +, addition; Apo B, apolipoprotein B; BMI, body mass index; BP, blood pressure; CENTRAL, Cochrane Central Register of Controlled Trials; CON, healthy control; CRF, cardiorespiratory fitness; CRP, C-reactive protein; CT, concurrent training; CVD, cardiovascular disease; CVRF, cardiovascular risk factors; DBP, diastolic blood pressure; DYS, dyslipidemia; DYSHG, dyslipidemia associated with hypertriglyceridemia; ET, endurance training; HDL-C, high-density lipoprotein cholesterol; HIIT, high-intensity interval training; HR, heart rate; HRQoL, health-related quality of life; HR_max, maximum heart rate; HTN, hypertension; IL-4, interleukin-4; IL-6, interleukin-6; IL-8, interleukin-8; LDL-C, low-density lipoprotein cholesterol; 6MWT, 6-Minute Walk Test; MET, metabolic equivalent; MOI, modality of intervention; n, population size; PA, physical activity; reps, repetitions; RM, repetition maximum; RT, resistance training; SAT, subcutaneous adipose tissue; SBP, systolic blood pressure; TAC, blood total antioxidant capacity; TC, total cholesterol; T2DM, type 2 diabetes mellitus; TG, triglycerides; TNF, cytokine tumor necrosis factor; VAI, visceral adiposity index; VEGF, vascular endothelial growth factor; V̇o_2max, maximum oxygen consumption; V̇o_2peak, peak oxygen consumption; WC, waist circumference.

Table 2. Assessment of the PEDro scale and Oxford's Evidence levels of the included scientific articles that analyzed CRF and CVRF after PA intervention
References	PEDro ratings									Oxford's evidence levels
	1	2	3	4	5	6	7	8	Total
Andersen et al¹⁶	Y	Y	N	Y	N	N	Y	Y	4	2b
Ibáñez et al (2010)⁸	Y	Y	N	N	Y	Y	Y	Y	5	2b
Lee and Kim (2006)⁹	Y	N	N	Y	Y	Y	Y	Y	5	2b
Pribulick et al (2013)¹⁰	Y	Y	N	Y	Y	Y	Y	Y	6	2b
Pullyblank et al (2020)¹¹	Y	Y	N	Y	N	Y	Y	Y	5	1b
Ratajczak et al (2019)¹⁷	Y	Y	N	Y	N	Y	N	Y	4	2b
Wu et al (2007)¹⁸	Y	N	N	Y	Y	Y	Y	Y	5	1c
Álvarez et al (2019)¹⁹	Y	Y	N	Y	N	Y	Y	Y	5	1b
Domene et al (2016)²⁰	Y	Y	N	Y	Y	Y	Y	Y	6	1b
Robins et al (2016)²¹	Y	Y	N	Y	N	Y	Y	Y	5	2b
Parra-Medina et al (2011)¹²	Y	Y	N	Y	N	Y	Y	Y	5	1b
Alvarez et al (2018)²²	Y	N	N	Y	N	Y	Y	Y	4	2b
Behall et al (2003)¹³	Y	N	N	Y	N	Y	Y	Y	4	2b
Krishnan et al (2015)²³	Y	N	N	N	N	Y	Y	Y	3	2b

PEDro ratings: 1: eligibility criteria were specified; 2: participants were randomly allocated to groups; 3: allocation was concealed; 4: the groups were similar at baseline regarding the most important prognostic indicators; 5: measures of at least one key outcome were obtained from more than 85% of subjects initially allocated to groups; 6: all participants for whom outcome measures were available received the treatment or control condition as allocated or, where this was not the case, data for at least one key outcome were analyzed by "intention to treat." 7: the results of between-group statistical comparisons are reported for at least one key outcome; 8: the study provides both point measures and measures of variability for at least one key outcome.
CRF, cardiorespiratory fitness; CVRF, cardiovascular risk factor; N, no; PA, physical activity; Y, yes.

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Physical Activity on Cardiorespiratory Fitness and Cardiovascular Risk in Premenopausal and Postmenopausal Women

A Systematic Review of Randomized Controlled Trials

Abstract and Introduction

Abstract

Introduction

Tables

Tables

References

Authors and Disclosures

Authors and Disclosures

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