Exercise for women:
Reshaping attitudes

by Jolie Glass, MS

 The first question asked by most women who join our exercise program is, "How much weight will I lose and how fast?" Most women don't realize that age, genetics, metabolic rate, socioeconomic status and race, most of which cannot be changed, have all been shown to affect body weight in women. Because of these factors, many women have a propensity for weight gain that cannot be overcome. So it is apparent that no prediction can be made to determine change in body weight with or without treatment for any particular woman. 
 Since for some, the predisposition for heavier body weight exists, and it remains unclear whether various treatments will have a meaningful long-term effect on body weight, it seems more appropriate to shift the intervention focus to the mortality rates and diseases we hope to reduce or prevent, and remain less concerned with weight loss itself. We have done this at our Women's Exercise Research Center (WERC) by helping women change their attitudes about the relationships among exercise, body weight, and health. As a result, exercise adherence at the WERC is extremely high. Only 15 percent of the women who enter the basic 14-week program drop out, while over 50 percent maintain their exercise for months and years afterward. 
 Research supports our need to reshape attitudes about exercise, body weight, and health, in that studies have shown that there is a negative association between fitness levels and death rates for women.1-2 Blair and associates calculated the age-adjusted, all-cause death rates across low, moderate and high physical fitness categories in 3,120 women who were apparently healthy at baseline.1 Women with moderate and high physical fitness had nearly a 60 percent to over 80 percent reduction in death rates compared to women with low physical fitness.1 When only the heavier women (BMI>25) were considered, these rates across fitness level were similar; which indicates that overweight women who are physically fit will have lower morbidity and mortality rates than their sedentary peers.2
 Diabetes mellitus and poor lipid profiles are often associated with excess body weight. In a study by Tremblay et al., obese women started exercising for 15 months without changing current dietary habits.3 Exercise training included four to five 90-minute sessions of low to moderate intensity exercise per week, with an estimated energy cost of 350 to 600 kcal per session. Then these women continued to exercise for another 14 months while reducing caloric intake by about 300 kcal per day, primarily through decreased lipid intake. The exercise and diet intervention caused the blood lipid profiles of the obese women to become similar to the nonobese women. Interestingly, most of the changes in blood lipid levels were observed during the first 15 months of this study, where subjects exercised, but did not change current eating behaviors. Although positive changes were seen in body weight and fat mass, these women remained obese (85.7 kg; 43 percent body fat). After 29 months, the obese women also showed a normalized glucose and insulin response to an oral glucose challenge. These results indicate that the exercise treatment produced substantial improvements, or even normalized the level of risk for diabetes and cardiovascular disease in obese women, despite the persistence of an obese state. While the duration of exercise training sessions in this study was long, the intensity was low enough to where an obese woman would find it tolerable and more comfortable than high intensity exercise. 
 While excess body weight is associated with higher bone mineral density (BMD), low body weight and amenorrhea, as seen often in anorectics, is associated with lower BMD and greater risk for osteoporosis. Inactivity for either overweight or underweight women can promote bone loss throughout life, particularly following menopause when estrogen is reduced. Although the effect of exercise on bone loss in postmenopausal women is unclear, there is an indication that weight bearing modes of exercise emphasizing high load and encouraging muscular development of strength, such as walking, jogging and strength training, may be effective in halting bone loss. 
 It appears that regular exercise training can effectively reduce obesity-related diseases while preventing premature death in women. Regular exercise training should be encouraged for women who have diseases, conditions and disorders under control and have not been told by a physician to abstain from exercise. 
 Exercise programs should consist of an aerobic component (walking, cycling, etc.) that is weight-bearing when possible. While 20 to 60 minutes of exercise 3 to 6 times per week is necessary to achieve improvement in fitness level, many unfit and/or overweight women will find this amount of exercise difficult initially. Professionals should encourage women to develop the habit by participating in a type of exercise that is enjoyable for a short duration of 5 to 10 minutes several times per week, adding minutes to this duration slowly so that discouragement and injury can be avoided. Although, heart rate is often used to prescribe exercise intensity, rating of one's perceived exertion can be very accurate and easy to understand. A general recommendation should be to exercise at a rate that feels moderate to somewhat hard where one can carry on a conversation without feeling breathless. Strength training should include about 10 exercises, one per major muscle group, and should be recommended for a frequency of two to three times per week. Flexibility training is low risk and may be beneficial for improving joint mobility, reducing muscle soreness and injury while preventing or reducing low back pain.

Avoiding risks
 While the benefits of exercise are numerous, there are minimal risks. Exercise may cause muscle soreness, musculoskeletal injury, heat or cold illness, lightheadedness, fainting, cardiovascular problems and in rare cases death. To avoid soreness and injury, each exercise session should be preceded by a short low-intensity aerobic warm-up, and stretching. When exercising outdoors, dress appropriately for the weather. Drink plenty of fluids and wear layers of clothing that can be easily removed as body temperature rises. Cover skin as much as possible including face and hands in cold weather. To avoid lightheadedness and fainting, one should never stop exercising suddenly but should cool-down slowly by decreasing intensity and staying in motion for a few minutes. Also, exercise progression should be slow. An increase of more than 10% per week in duration or intensity should be strongly discouraged. To avoid major complications, patients should consult a physician before beginning an exercise program.
 

Tips to Encourage Exercise Safety for Overweight Women l  Begin with a 3-5 minute warmup and slow stretching  l  Start with a short duration of aerobic exercise and progress slowly l  End with a 3-5 minute cool-down and stretching for all muscle groups, particularly lower back l  Invest in 1-2 sessions with an educated and qualified exercise specialist to learn how to train properly l  Keep strict records of exercise activities – records are a great way to track progress, work as a motivator, and can reveal an activity disorder  l  Monitor medical conditions if they exist (e.g., blood pressure, heart rate, blood glucose)

Tips to Encourage Exercise Compliance l  Choose an emotionally safe environment.  The atmosphere should be comfortable and encouraging and not intimidating or competitive.  l  Find an exercise specialist that is sensitive to women's weight and body issues.  Specialists should show true concern for the whole woman, not just the physical woman.  l  Plan for exercise.  Schedule sessions and pack apparel in advance.  l  Minimize the effort required to prepare for exercise.  Choose a place that is easily accessible and exercise during a convenient time.  l  Make exercise fun.  Choose a mode of exercise that is enjoyable and find an exercise partner or group.

 Exercise training can also be beneficial to women with eating disorders who are amenorrheic and at risk for osteoporosis. However, one must be cautious when prescribing exercise training for a woman with an eating disorder so that the exercise does not push the woman deeper into the eating disorder and jeopardize her health. When this occurs, the exercise is no longer a healthful intervention, but becomes an activity disorder.4
 Activity disorder can be defined as excessive, purposeless, physical activity which goes beyond any usual training regimen and ends up being a detriment rather than an asset to health and well-being.4 One must monitor patients closely for signs of overtraining, such as fatigue, injury, loss of emotional vigor, and increased compulsivity.4Exercise can be detrimental to women if severe calorie restriction is combined with excessive exercise. These women will likely need intensive treatment to manage emotional issues leading to these excessive behaviors and exercise should not be recommended until eating behaviors are more steady and balanced. For patients with relatively stable eating behaviors, professionals should prescribe low intensity, low duration aerobic exercise as well as strength training to increase strength, muscle mass and possibly prevent bone loss.
 

Recommendations for Patients with a History of Eating or Activity Disorders l  Educate the patient concerning the potential health benefits and risks of exercise l  Create a written agreement with the patient that specifically details the exercise program and eating plan  l  Require the patient to keep exercise records and review these regularly for signs of activity disorder l  Require the patient to consume a calorie-containing sport drink during the exercise session l  Monitor body weight and reduce exercise activities if weight begins to drop

Feeling emotionally safe
 These guidelines will allow a woman to initiate and participate in an exercise program with minimal medical risk. However, experience has taught us that most overweight women will drop out of an exercise regimen because of psychological or emotional reasons, even though their medical health status is improving.5
 As mentioned earlier, exercise adherence at our Women's Exercise Research Center is extremely high. These women have expressed several reasons why they have been able to maintain their exercise programs. Number one on their list of importance is a safe environment.  Surprisingly, they don't mean physically safe, they mean emotionally safe. These women love to come to a place where there are no men, where the "health club atmosphere and attitude" is absent, and where they can exercise at their own level without feeling intimidated. The women expect a well-educated staff, but admire a staff that is knowledgeable and sensitive to women's issues around body size and acceptance. The women also rank a caring atmosphere high on their priority of needs. These women can easily discern between a staff member who cares about them versus one who cares only about their program. Many of our women need to talk about how their exercise is affecting them emotionally, spiritually, and psychologically; in addition to how it is affecting them physiologically. These factors along with the social aspects many women desire help them change their attitude from an angry and determined "I can exercise" to a pleasant and satisfying "I like to exercise".
 In summary, it is important to convey to your patients that not all overweight women will significantly reduce body weight in response to an exercise training program. Emphasize the potential health benefits of exercise training regardless of weight reduction, which include improvement in aerobic fitness, strength and flexibility, blood pressure and cholesterol profile, and reduction in risk for diabetes, cardiovascular disease, osteoporosis and premature death.  Provide an emotionally safe environment where a women can relate all the aspects of self to her exercise behavior. 

Jolie Glass, MS, is Director of the Women's Exercise Research Center, Exercise Science Programs, School of Public Health and Health Services, and the George Washington University Medical Center, Washington, DC.
 

References
1.  Blair SN, Kohl HW, Barlow CE.  Physical activity, physical fitness, and all-cause mortality in women: do women need to be active?  J Am Coll Nutr 1993; 12(4): 368-371. 
2.  Blair SN.  Evidence for success of exercise in weight loss and control.  Ann Int Med 1993.  119 (7 pt 2): 702-706. 
3.  Tremblay A, Despres J-P, Maheux J et al.  Med Sci Sports Exerc 1991; 23 (12): 1326-1331.
4.  Costin C.  The Eating Disorder Handbook. Los Angeles, CA:  RGA Publishing Group, 1997, 28-44. 
5.   Miller, W.C.  Negotiated Peace: How to End the War Over Weight.  Boston, MA: Allyn and Bacon, 1998, 55-132.