EDITORIAL COMMENT
Diet and exercise for perimenopausal women
Lifestyle interventions can decrease cardiovascular risk*
Nanette K. Wenger, MD, FACC ,*
Division of Cardiology, Emory University School of Medicine, Grady Memorial Hospital, and Emory Heart and Vascular Center, Atlanta, Georgia, USA
* Reprint requests and correspondence: Dr. Nanette K. Wenger, Emory University School of Medicine, 69 Jesse Hill Jr. Drive, SE, Atlanta, Georgia 30303, USA.
nwenger{at}emory.edu
Earlier this year, the American Heart Association and multiple partner professional organizations published evidence-based guidelines for the prevention of cardiovascular disease in women (1). These guidelines highlight the top priority of incorporating into clinical practice the advocacy of lifestyle modifications both for preventing the development of coronary risk factors and for decreasing the risk of coronary heart disease. Such interventions include smoking cessation, regular physical activity, a heart-healthy diet, and weight maintenance/reduction. Although coronary heart disease is the predominant cause of mortality for adult women in the U.S., screening for coronary risk factors and coronary risk reduction interventions remains underused in women. A recent survey (2) identified that most U.S. women are unaware of their cholesterol levels and that few personally perceive themselves as at risk for cardiovascular events.
In this issue of the Journal, a randomized controlled trial of a dietary and exercise intervention depicts its efficacy for perimenopausal women in slowing the progression of atherosclerosis, as ascertained by a noninvasive measurement of carotid intima-media thickness (3). These data from the Women's Healthy Lifestyle Project suggest that perimenopause offers the unique opportunity for coronary risk reduction in women. The recent persuasive evidence from randomized controlled clinical trials (4–6), that the use of menopausal hormone therapy by both healthy women and women with established heart disease failed to prevent cardiovascular events and rather entailed cardiovascular and other risks, has refocused attention on interventions of documented efficacy in preventing cardiovascular disease in women. Of note is that menopausal hormone use initiated by small numbers of women in the Women's Healthy Lifestyle Project between the baseline visit and study end did not alter the effect of the diet and exercise intervention. As appropriately cited by the authors, research is requisite to delineate whether a comparable diet and exercise intervention initiated later after menopause would provide similar benefit.
In the U.S., physical inactivity is more prevalent among women than men and is more likely to be present among older than younger women, among the less affluent, and among women of racial or ethnic minorities. Contemporary reports confirm that one third of Caucasian women are physically inactive, in contrast to more than one half of black and Hispanic women. More than half of Caucasian women are overweight or obese, compared with about three fourths of black and Mexican-American women (7).
Weight reduction is associated with an improvement in insulin resistance, in inflammatory markers such as C-reactive protein, in systolic and diastolic blood pressures, and in the lipid profile (8). Regular exercise such as 30 min of jogging, swimming, or brisk walking daily can lower levels of total cholesterol, low-density lipoprotein, and triglycerides and raise high-density lipoprotein concentrations. Exercise has been documented to decrease the risk of coronary heart disease by 40%, stroke by 30%, and the development of type II diabetes by 30% (9).
An earlier report from the Women's Healthy Lifestyle Project (10) clinical trial established that the modest and attainable dietary and physical activity intervention prevented weight gain and was associated with significant reductions in total cholesterol and triglyceride levels, waist circumference, systolic and diastolic blood pressures, and glucose levels. The intervention was designed to reduce dietary fat intake to 25% of daily calories, lower saturated fat intake to 7% of calories, and decrease dietary cholesterol to 100 mg daily. A reduction in caloric intake to 1,300 kcal daily and an increase in leisure time physical activity of 1,000 to 1,500 kcal energy expenditure weekly were used to facilitate weight loss/control. The study design involved intensive group programs for the initial 6 months and individual and group sessions during months 6 through 54. The current documentation of a favorable effect on a subclinical measure of atherosclerosis, carotid intima-media thickness, is concordant with the hypothesis that risk reduction favorably impacts the pathophysiologic alterations of atherosclerosis.
Unanswered, pivotal questions remain as to whether the physiologic changes of menopause per se trigger an increase in traditional coronary risk factors, whether menopause and/or its hormonal milieu increase concentrations of novel or as yet-unidentified risk factors that increase coronary risk, whether lifestyle attributes of menopausal women (including weight gain and physical inactivity) increase coronary risk, whether any of these represent a continuum of risk associated with aging without an abrupt increase at menopause, and/or whether these variables differ in subpopulations of women.
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Footnotes
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* Editorials published in the Journal of the American College of Cardiology reflect the views of the authors and do not necessarily represent the views of JACC or the American College of Cardiology. 
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References
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1. Mosca L, Appel LJ, Benjamin EJ, et al. AHA Scientific Statement. Evidence-based guidelines for cardiovascular disease prevention in women. Circulation. 2004;109:672–692[Free Full Text]
2. Mosca L, Ferris A, Fabunmi R, Robertson RM. Tracking women's awareness of heart disease. An American Heart Association National Study. Circulation. 2004;109:573–579[Abstract/Free Full Text]
3. Wildman RP, Schott L, Brockwell S, Kuller LH, Sutton-Tyrrell K. A dietary and exercise intervention slows menopause-associated progression of subclinical atherosclerosis as measured by intima-media thickness of the carotid arteries. J Am Coll Cardiol 2004;44:579–85.
4. HERS research groupGrady D, Herrington D, Bittner V, et al. Cardiovascular disease outcomes during 6.8 years of hormone therapy. Heart and Estrogen/progestin Replacement Study follow-up (HERS II). JAMA. 2002;288:49–57[Abstract/Free Full Text]
5. Writing Group for the Women's Health Initiative Investigators. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: Principal results from the women's health initiative randomized controlled trial. JAMA. 2002;288:321–333[Abstract/Free Full Text]
6. National Heart, Lung, and Blood Institute Advisory for Physicians on the WHI trial of Conjugated Equine Estrogens versus Placebo, March 2, 2004. Available at: http://whi.org/updates/advisory_ea_physicians.htm. Accessed May 24, 2004.
7. American Heart Association. Heart Disease and Stroke Statistics—2004 Update. Dallas, TX: American Heart Association, 2003. Available at: http://www.americanheart.org/downloadable/heart/1079736729696HDSStats2004UpdateREV3-19-04.pdf. Accessed May 24, 2004.
8. Noakes M, Clifton PM. Weight loss and plasma lipids. Curr Opin Lipidol. 2000;11:67–70
9. Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Executive Summary of the Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). JAMA. 2001;285:2486–2497[Free Full Text]
10. Kuller LH, Simkin-Silverman LR, Wing RR, Meilahn EN, Ives DG. Women's Healthy Lifestyle Project: A randomized clinical trial. results at 54 months. Circulation. 2001;103:32–37[Abstract/Free Full Text]
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