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ARTICLE IN PRESS
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Maturitas xxx (2015) xxx–xxx
Contents lists available at ScienceDirect
Maturitas journal homepage: www.elsevier.com/locate/maturitas
Review
The exercise prescription for enhancing overall health of midlife and older women Miriam J. Woodward a , Chi Wei Lu a , Richard Levandowski b , John Kostis c , Gloria Bachmann a,∗ a Department of Obstetrics, Gynecology and Reproductive Sciences, Rutgers Robert Wood Johnson Medical School (RRWJMS), 125 Patterson Street, New Brunswick, NJ 08901, United States b Department of Family Medicine—Section of Sports Medicine, RRWJMS, 125 Patterson Street, New Brunswick, NJ 08901, United States c Department of Cardiology, RRWJMS, 125 Patterson Street, New Brunswick, NJ 08901, United States
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Article history: Available online xxx Keywords: Activity Fitness Exercise prescription Midlife women Menopausing
a b s t r a c t Background: For midlife and older women, this period of their life is associated with an increase in risk factors for the development of chronic medical conditions. Data confirms the importance of regular exercise for both prevention and management of cardiovascular and other non-communicable diseases, unwanted weight gain, worsening metabolic profile and osteoporosis. However, in most clinical practices, midlife and older women patients are not offered specific exercise guidance. Objectives: This review assessed the current environment of what exercise advice is being offered to women at clinical encounters and suggests ways of incorporating an exercise prescription into clinical practice. Materials and Methods: A PubMed review of the literature from the past 20 years was conducted. Results: A universal template for an exercise prescription for aging women does not exist. Globally, there are scant programs that offer exercise advice and interventions to patients at the end of clinical encounters. Conclusions: Although most aging women know the benefits of engaging in a regular exercise program, many do not establish a regular routine. By the clinician offering an exercise prescription, this not only reinforces the importance of exercise but also provides simple guidelines on how women can commence an exercise routine in their life. © 2015 Published by Elsevier Ireland Ltd.
Contents 1.
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.1. Exercise and disease prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.2. Exercise and managing disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.3. Barriers to exercise . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2. Materials and methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3. Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.1. Existing prescription programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.2. Potential prescription model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.2.1. Patient Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.2.2. An exercise prescription . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Competing interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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∗ Corresponding author. Tel.: +1 732 235 7633; fax: +1 732 235 8302. E-mail address: [email protected] (G. Bachmann). http://dx.doi.org/10.1016/j.maturitas.2015.03.020 0378-5122/© 2015 Published by Elsevier Ireland Ltd.
Please cite this article in press as: Woodward MJ, et al. The exercise prescription for enhancing overall health of midlife and older women. Maturitas (2015), http://dx.doi.org/10.1016/j.maturitas.2015.03.020
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Funding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Ethics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Provenance and peer review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Acknowledgment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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1. Introduction
1.3. Barriers to exercise
Physical activity and exercise are widely recognized healthy lifestyle interventions. They are recommended for prevention and management of a number of conditions, and are known factors in improving quality of life. Unfortunately, most patients do not put enough emphasis on making adequate exercise a part of their daily routines. Physicians can proactively address this problem by providing a simple exercise prescription at the end of nonemergency encounters that would guide their midlife patients on exercise and reinforce the fact that an exercise prescription is as important as a drug prescription in contributing to overall wellbeing.
In the average US state, data shows that only 51.6% of the population engages in the recommended amount of aerobic exercise per week, and only 20.9% achieve the recommended amount of weekly aerobic and muscle-strengthening exercise [11]. In addition, only 34% of all US adults talk about exercise with their physicians [12]. Women may not independently ask their doctor about exercise and physicians do not appear to routinely discuss this aspect of the patient’s wellness. Even motivated midlife women may be reluctant to speak to their physician about exercise issues. An exercise prescription given by the woman’s clinician would verify the importance of this preventive strategy in the same manner as suggesting an adequate intake of calcium and vitamin D for maintenance of bone health.
1.1. Exercise and disease prevention Midlife women particularly benefit from an exercise prescription, since engaging in routine exercise addresses a number of issues commonly presenting during the peri- and post-menopausal years. Unwanted weight gain, decreasing muscle mass and bone density, and an increasing risk of diabetes, hypertension, cardiovascular disease, cancer and arthritis can often be ameliorated or prevented with exercise [1,2]. Exercise, specifically weight bearing exercise, increases bone density as well as muscle strength, both of which are areas many women struggle with during these years [3]. Bone density is of particular importance because it affects their likelihood of developing postmenopausal osteoporosis. Additionally, exercise is a key component in any weight maintenance or weight loss program, and so can contribute to the dramatic reduction in risk status of other medical conditions associated with obesity. The myriad benefits of physical activity also are reflected in enhanced quality of life, and decreased all-cause mortality, especially decreased cardiovascular mortality [4]. Adult cardiac health can benefit significantly from exercising even in limited amounts [5]. Furthermore, significant improvements in cardiovascular health from exercise can be seen even among women who do not experience significant weight loss or body composition changes [6]. Additionally, the health benefits of exercise have been shown to result in lowered medical expenses in those who exercise as compared to sedentary individuals [7]. 1.2. Exercise and managing disease Regular exercise cannot only contribute to disease prevention, but also can help manage existing medical conditions. Data shows that diabetes, depression, hypertension, and arthritis are better managed in those who exercise. Since women have depressive disorders significantly more often than men, methods of addressing depression, such as with exercising, are especially relevant to female patients [8]. Research suggests that exercise and physical activity can be comparable in effectiveness to anti-depressant medication use, and in some instances capable of enhancing the positive effects of this class of medications [8,9]. No matter what the midlife woman’s current capacity is for physical activity, studies have shown that low-intensity exercise can be as effective as high-intensity exercise in maintaining or increasing fitness [10].
2. Materials and methods A literature review was conducted using PubMed which examined publications from over the past 20 years. Key search words used included: exercise, physical activity, menopause, women’s health, exercise prescription, exercise program, exercise prescription review, recommendations, and aging. In addition, guidelines from professional organizations and governmental agencies were reviewed (see Fig. 1). 3. Results 3.1. Existing prescription programs Currently, there are a number of initiatives that have the goal of encouraging patients to lead more active lives. In the UK, the National Health Service’s “Exercise on Prescription” program uses a referral program in which physicians can direct patients to a discounted or free fitness program. In order to get this exercise prescription, patients usually have a condition that is known to benefit from exercise intervention—such as depression, obesity, or cardiovascular disease. One of the community activities the program encourages is walking groups, which have been shown to be a safe and effective health behavior intervention [13]. The program uses self-assessment questionnaires given to patients to rapidly assess its effectiveness, and this method has been shown to have testretest reliability, and could therefore be used to assess participants in similar exercise programs effectively [14]. New Zealand has an exercise program aimed at increasing physical activity called the “Green Prescription” (GRx ) program [15]. Unlike the “Exercise on Prescription” program, the GRx promotes exercise as a preventative measure as well as one for intervention. The GRx program’s professional staff provides advice (often via educational pamphlets) and suggests local activities which can be used by patients, such as walking groups, to get the daily amount of recommended exercise. A useful additional GRx service which could be used by other clinical offices is their follow up procedure. Those in the program have the option to receive ongoing support and encouragement through regular monthly phone calls, face to face meetings, or community support groups [16]. The American College of Sports Medicine (ACSM) has developed a basic program, referred to as the “Exercise is Medicine” program.
Please cite this article in press as: Woodward MJ, et al. The exercise prescription for enhancing overall health of midlife and older women. Maturitas (2015), http://dx.doi.org/10.1016/j.maturitas.2015.03.020
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Fig. 1. Literature review selection process.
It involves either referring women to a fitness specialist, or giving them a simple prescription that reminds them of the recommended amount of weekly exercise they should engage. Fig. 2 is a copy of the prescription form [17]. It provides the necessary information on frequency and length of time recommended for weekly exercise.
However, the form does not provide further guidance on intensity of exercise or potential activities to participate in. Patients who receive print advice from their physicians in addition to verbal advice are more likely to engage in increased physical activity than those who receive verbal advice alone [18].
Fig. 2. Exercise is medicine–prescription & referral form (adopted from ACSM.org).
Please cite this article in press as: Woodward MJ, et al. The exercise prescription for enhancing overall health of midlife and older women. Maturitas (2015), http://dx.doi.org/10.1016/j.maturitas.2015.03.020
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3.2. Potential prescription model In response to the many benefits associated with exercise, it appears that handing the patient a simple, yet descriptive exercise prescription is advisable. Although data regarding benefits of providing written exercise guidelines are limited, the low cost and limited time necessary to implement this practice makes it practical and potentially highly valuable. Informing midlife and older women of recommended activity levels and providing guidance on how they can work toward achieving that activity level is an investment that can result in lowering the patient’s risk of many chronic conditions. Chart 1 shows WHO exercise recommendations for older patients [19,20]. The basic exercise prescription can be simple: recommending to the midlife women her splitting up various specific exercises into five aerobic workouts every week that last for 15 or 30 min. The workouts should be of vigorous or moderate intensity respectively. The other two days of the week should focus on weight bearing exercises. To quantify intensity in a simple way for patient education, a relative intensity measure should be recommended, which focuses on perceived effort expended. The simplest relative intensity measure is the “talk test,” which categorizes moderate-intensity activity as activity during which “you can talk, but not sing,” and vigorous-intensity as activity during which “you will not be able to say more than a few words without pausing for a breath” [21]. Some examples of moderate-intensity activities include walking briskly, general gardening, and ballroom dancing, while examples of vigorous-intensity activities include running, jogging, swimming laps, cycling, elliptical cross training, stair master, and hiking. Cell phone apps have becoming increasingly popular among users of all ages. For every technology platform, apps for monitoring daily activity levels are readily available. Many of these include features allowing them to sync with a wearable device (fit bit, fit bands, etc) for tracking and recording activity levels. The engagement of these devices may greatly enhance the implementation of an exercise prescription. Since it may be difficult for individuals to keep track of exactly what exercise they engaged in, how long they did it for, or on what day they exercised, smart phones apps are a useful and inexpensive solution, often require no additional cost for users. It’s practical to use an already existing program to keep track of exercise. One example is MapMyFitness, a free app that is consistent across iOS and Android platforms. MapMyFitness allows users to record type, time, and date of workouts. Recording workouts may help women keep track of their exercise history and their gradual improvement as well as allowing them to self-assess their exercise adherence. For those who are not utilizing technology tools, encouraging women to exercise with an exercise partner and record daily activity in a diary or computer program also can provide a sense of accountability for the woman.
Table 1 Table for evaluation patient fitness level. Age
BMI category*
Activity level
Medical condition? Y|N
43–62
Underweight
ARTICLE IN PRESS
MAT-6377; No. of Pages 7
Maturitas xxx (2015) xxx–xxx
Contents lists available at ScienceDirect
Maturitas journal homepage: www.elsevier.com/locate/maturitas
Review
The exercise prescription for enhancing overall health of midlife and older women Miriam J. Woodward a , Chi Wei Lu a , Richard Levandowski b , John Kostis c , Gloria Bachmann a,∗ a Department of Obstetrics, Gynecology and Reproductive Sciences, Rutgers Robert Wood Johnson Medical School (RRWJMS), 125 Patterson Street, New Brunswick, NJ 08901, United States b Department of Family Medicine—Section of Sports Medicine, RRWJMS, 125 Patterson Street, New Brunswick, NJ 08901, United States c Department of Cardiology, RRWJMS, 125 Patterson Street, New Brunswick, NJ 08901, United States
a r t i c l e
i n f o
Article history: Available online xxx Keywords: Activity Fitness Exercise prescription Midlife women Menopausing
a b s t r a c t Background: For midlife and older women, this period of their life is associated with an increase in risk factors for the development of chronic medical conditions. Data confirms the importance of regular exercise for both prevention and management of cardiovascular and other non-communicable diseases, unwanted weight gain, worsening metabolic profile and osteoporosis. However, in most clinical practices, midlife and older women patients are not offered specific exercise guidance. Objectives: This review assessed the current environment of what exercise advice is being offered to women at clinical encounters and suggests ways of incorporating an exercise prescription into clinical practice. Materials and Methods: A PubMed review of the literature from the past 20 years was conducted. Results: A universal template for an exercise prescription for aging women does not exist. Globally, there are scant programs that offer exercise advice and interventions to patients at the end of clinical encounters. Conclusions: Although most aging women know the benefits of engaging in a regular exercise program, many do not establish a regular routine. By the clinician offering an exercise prescription, this not only reinforces the importance of exercise but also provides simple guidelines on how women can commence an exercise routine in their life. © 2015 Published by Elsevier Ireland Ltd.
Contents 1.
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.1. Exercise and disease prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.2. Exercise and managing disease . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.3. Barriers to exercise . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2. Materials and methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3. Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.1. Existing prescription programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.2. Potential prescription model . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.2.1. Patient Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.2.2. An exercise prescription . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Competing interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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∗ Corresponding author. Tel.: +1 732 235 7633; fax: +1 732 235 8302. E-mail address: [email protected] (G. Bachmann). http://dx.doi.org/10.1016/j.maturitas.2015.03.020 0378-5122/© 2015 Published by Elsevier Ireland Ltd.
Please cite this article in press as: Woodward MJ, et al. The exercise prescription for enhancing overall health of midlife and older women. Maturitas (2015), http://dx.doi.org/10.1016/j.maturitas.2015.03.020
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Funding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Ethics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Provenance and peer review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Acknowledgment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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1. Introduction
1.3. Barriers to exercise
Physical activity and exercise are widely recognized healthy lifestyle interventions. They are recommended for prevention and management of a number of conditions, and are known factors in improving quality of life. Unfortunately, most patients do not put enough emphasis on making adequate exercise a part of their daily routines. Physicians can proactively address this problem by providing a simple exercise prescription at the end of nonemergency encounters that would guide their midlife patients on exercise and reinforce the fact that an exercise prescription is as important as a drug prescription in contributing to overall wellbeing.
In the average US state, data shows that only 51.6% of the population engages in the recommended amount of aerobic exercise per week, and only 20.9% achieve the recommended amount of weekly aerobic and muscle-strengthening exercise [11]. In addition, only 34% of all US adults talk about exercise with their physicians [12]. Women may not independently ask their doctor about exercise and physicians do not appear to routinely discuss this aspect of the patient’s wellness. Even motivated midlife women may be reluctant to speak to their physician about exercise issues. An exercise prescription given by the woman’s clinician would verify the importance of this preventive strategy in the same manner as suggesting an adequate intake of calcium and vitamin D for maintenance of bone health.
1.1. Exercise and disease prevention Midlife women particularly benefit from an exercise prescription, since engaging in routine exercise addresses a number of issues commonly presenting during the peri- and post-menopausal years. Unwanted weight gain, decreasing muscle mass and bone density, and an increasing risk of diabetes, hypertension, cardiovascular disease, cancer and arthritis can often be ameliorated or prevented with exercise [1,2]. Exercise, specifically weight bearing exercise, increases bone density as well as muscle strength, both of which are areas many women struggle with during these years [3]. Bone density is of particular importance because it affects their likelihood of developing postmenopausal osteoporosis. Additionally, exercise is a key component in any weight maintenance or weight loss program, and so can contribute to the dramatic reduction in risk status of other medical conditions associated with obesity. The myriad benefits of physical activity also are reflected in enhanced quality of life, and decreased all-cause mortality, especially decreased cardiovascular mortality [4]. Adult cardiac health can benefit significantly from exercising even in limited amounts [5]. Furthermore, significant improvements in cardiovascular health from exercise can be seen even among women who do not experience significant weight loss or body composition changes [6]. Additionally, the health benefits of exercise have been shown to result in lowered medical expenses in those who exercise as compared to sedentary individuals [7]. 1.2. Exercise and managing disease Regular exercise cannot only contribute to disease prevention, but also can help manage existing medical conditions. Data shows that diabetes, depression, hypertension, and arthritis are better managed in those who exercise. Since women have depressive disorders significantly more often than men, methods of addressing depression, such as with exercising, are especially relevant to female patients [8]. Research suggests that exercise and physical activity can be comparable in effectiveness to anti-depressant medication use, and in some instances capable of enhancing the positive effects of this class of medications [8,9]. No matter what the midlife woman’s current capacity is for physical activity, studies have shown that low-intensity exercise can be as effective as high-intensity exercise in maintaining or increasing fitness [10].
2. Materials and methods A literature review was conducted using PubMed which examined publications from over the past 20 years. Key search words used included: exercise, physical activity, menopause, women’s health, exercise prescription, exercise program, exercise prescription review, recommendations, and aging. In addition, guidelines from professional organizations and governmental agencies were reviewed (see Fig. 1). 3. Results 3.1. Existing prescription programs Currently, there are a number of initiatives that have the goal of encouraging patients to lead more active lives. In the UK, the National Health Service’s “Exercise on Prescription” program uses a referral program in which physicians can direct patients to a discounted or free fitness program. In order to get this exercise prescription, patients usually have a condition that is known to benefit from exercise intervention—such as depression, obesity, or cardiovascular disease. One of the community activities the program encourages is walking groups, which have been shown to be a safe and effective health behavior intervention [13]. The program uses self-assessment questionnaires given to patients to rapidly assess its effectiveness, and this method has been shown to have testretest reliability, and could therefore be used to assess participants in similar exercise programs effectively [14]. New Zealand has an exercise program aimed at increasing physical activity called the “Green Prescription” (GRx ) program [15]. Unlike the “Exercise on Prescription” program, the GRx promotes exercise as a preventative measure as well as one for intervention. The GRx program’s professional staff provides advice (often via educational pamphlets) and suggests local activities which can be used by patients, such as walking groups, to get the daily amount of recommended exercise. A useful additional GRx service which could be used by other clinical offices is their follow up procedure. Those in the program have the option to receive ongoing support and encouragement through regular monthly phone calls, face to face meetings, or community support groups [16]. The American College of Sports Medicine (ACSM) has developed a basic program, referred to as the “Exercise is Medicine” program.
Please cite this article in press as: Woodward MJ, et al. The exercise prescription for enhancing overall health of midlife and older women. Maturitas (2015), http://dx.doi.org/10.1016/j.maturitas.2015.03.020
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Fig. 1. Literature review selection process.
It involves either referring women to a fitness specialist, or giving them a simple prescription that reminds them of the recommended amount of weekly exercise they should engage. Fig. 2 is a copy of the prescription form [17]. It provides the necessary information on frequency and length of time recommended for weekly exercise.
However, the form does not provide further guidance on intensity of exercise or potential activities to participate in. Patients who receive print advice from their physicians in addition to verbal advice are more likely to engage in increased physical activity than those who receive verbal advice alone [18].
Fig. 2. Exercise is medicine–prescription & referral form (adopted from ACSM.org).
Please cite this article in press as: Woodward MJ, et al. The exercise prescription for enhancing overall health of midlife and older women. Maturitas (2015), http://dx.doi.org/10.1016/j.maturitas.2015.03.020
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3.2. Potential prescription model In response to the many benefits associated with exercise, it appears that handing the patient a simple, yet descriptive exercise prescription is advisable. Although data regarding benefits of providing written exercise guidelines are limited, the low cost and limited time necessary to implement this practice makes it practical and potentially highly valuable. Informing midlife and older women of recommended activity levels and providing guidance on how they can work toward achieving that activity level is an investment that can result in lowering the patient’s risk of many chronic conditions. Chart 1 shows WHO exercise recommendations for older patients [19,20]. The basic exercise prescription can be simple: recommending to the midlife women her splitting up various specific exercises into five aerobic workouts every week that last for 15 or 30 min. The workouts should be of vigorous or moderate intensity respectively. The other two days of the week should focus on weight bearing exercises. To quantify intensity in a simple way for patient education, a relative intensity measure should be recommended, which focuses on perceived effort expended. The simplest relative intensity measure is the “talk test,” which categorizes moderate-intensity activity as activity during which “you can talk, but not sing,” and vigorous-intensity as activity during which “you will not be able to say more than a few words without pausing for a breath” [21]. Some examples of moderate-intensity activities include walking briskly, general gardening, and ballroom dancing, while examples of vigorous-intensity activities include running, jogging, swimming laps, cycling, elliptical cross training, stair master, and hiking. Cell phone apps have becoming increasingly popular among users of all ages. For every technology platform, apps for monitoring daily activity levels are readily available. Many of these include features allowing them to sync with a wearable device (fit bit, fit bands, etc) for tracking and recording activity levels. The engagement of these devices may greatly enhance the implementation of an exercise prescription. Since it may be difficult for individuals to keep track of exactly what exercise they engaged in, how long they did it for, or on what day they exercised, smart phones apps are a useful and inexpensive solution, often require no additional cost for users. It’s practical to use an already existing program to keep track of exercise. One example is MapMyFitness, a free app that is consistent across iOS and Android platforms. MapMyFitness allows users to record type, time, and date of workouts. Recording workouts may help women keep track of their exercise history and their gradual improvement as well as allowing them to self-assess their exercise adherence. For those who are not utilizing technology tools, encouraging women to exercise with an exercise partner and record daily activity in a diary or computer program also can provide a sense of accountability for the woman.
Table 1 Table for evaluation patient fitness level. Age
BMI category*
Activity level
Medical condition? Y|N
43–62
Underweight
