Effects of lifestyle intervention improve cardiovascular disease risk factors in community-based menopausal transition and early postmenopausal women in China.

Menopause: The Journal of The North American Menopause Society Vol. 21, No. 12, pp. 1263/1268 DOI: 10.1097/gme.0000000000000248 * 2014 by The North American Menopause Society

Effects of lifestyle intervention improve cardiovascular disease risk factors in community-based menopausal transition and early postmenopausal women in China Liping Wu, PhD, RN,1 Rong Chen, MD,2 Di Ma, MS,1 Sijia Zhang, MS,1 Benita Walton-Moss, PhD,3 and Zhong He, PhD, RN 4 Abstract Objective: The aim of this study was to test the efficacy of a 12-month lifestyle intervention in improving cardiovascular disease risk factors in community-based menopausal transition and early postmenopausal women in China. Methods: One hundred healthy menopausal transition and early postmenopausal women aged 40 to 60 years were randomly assigned to receive either lifestyle change intervention (n = 53) or usual care (n = 47). Menopause status was defined by the menstrual change criteria of the Stages of Reproductive Aging Workshop + 10 based on prospective menstrual calendars. Women in the intervention group were provided with a colorful booklet that included dietary and physical activity recommendations, were individually interviewed, and completed biophysical cardiovascular risk assessments at the Women’s Health Center (Beijing, China). Women were encouraged to follow a healthy eating pattern and to increase their aerobic activity (moderate level, 3 d/wk, 40 min/d). Women in the control group continued their usual eating patterns and activities. Weight, body mass index (BMI), waist circumferenceYtoYhip circumference ratio (WHR), waist circumference (WC), body composition, blood pressure (BP), blood glucose, and serum lipids were assessed at baseline, 3 months, 6 months, and 12 months in both groups. Results: Women in the intervention group were observed to have significant decreases in weight, BMI, WC, WHR, systolic BP, total cholesterol, and low-density lipoprotein cholesterol compared with women in the control group. At 3 months, there were significant decreases in weight (j0.28 vs 0.68 kg, P = 0.002), BMI (j0.06 vs 0.44 kg/m2, P = 0.003), WC (j0.28 vs 1.43 cm, P = 0.001), and WHR (j0.01 vs 0.01, P = 0.045) in the intervention group compared with the control group. At 6 months, there were significant decreases in WC (j0.73 vs 1.02 cm, P = 0.012), WHR (j0.02 vs j0.003, P = 0.020), and systolic BP (j7.52 vs j0.63 mm Hg, P = 0.012) favoring the intervention group over the control group. At 12 months, there were significant decreases in total cholesterol (j0.07 vs 0.03 mmol/L, P = 0.045) and low-density lipoprotein cholesterol (j0.13 vs 0.01 mmol/L, P = 0.022) in the intervention group versus the control group. Conclusions: Lifestyle intervention may be an effective means for reducing cardiovascular disease risk factors in menopausal transition and early postmenopausal women in China. Key Words: Lifestyle intervention Y Cardiovascular disease Y Menopausal transition Y Early postmenopause.

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ardiovascular diseases (CVDs) are major threats to women’s health, particularly after the menopausal transition. In 2009, CVDs accounted for 32.3% of all deaths in the United States; the rates of death attributable to

Received January 15, 2014; revised and accepted March 5, 2014. From the 1School of Nursing, Peking Union Medical College, Chinese Academy of Medical Science, Dongcheng District, Beijing, PR China; 2 Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Beijing, PR China; 3School of Nursing, Johns Hopkins University, Baltimore, MD; and 4School of Continuing Education, Peking Union Medical College, Chinese Academy of Medical Science, Dongcheng District, Beijing, PR China. Funding/support: None. Financial disclosure/conflicts of interest: None reported. Address correspondence to: Zhong He, PhD, RN, School of Continuing Education, Peking Union Medical College, Chinese Academy of Medical Science, No. 9 Dongdansantiao, Dongcheng District, Beijing 100730, PR China. E-mail: [email protected]

CVDs were 190.4/100,000 for white women and 267.9/ 100,000 for black women.1 The challenge of CVDs in women is not limited to the United States, as heart disease is the leading cause of death among women worldwide.2 Based on European CVD statistics for 2008, CVDs were responsible for 42% of all deaths in European women younger than 75 years.3 In the last 20 years, CVD morbidity and mortality in China were projected to increase both in absolute number and as a proportion of total disease burden.4 In urban China, CVDs became the number one cause of death in women from 2000 to 2010.5 Epidemiological studies suggest that menopause is associated with increases in CVD risk factors. Women are about 10 years older than men when they develop CVDs.6 Although cardiovascular events are rare occurrences in premenopausal women, their incidence markedly increases after the ages of 45 to 54 years (ie, at the time of menopause).7 Mounting evidence indicates that, as women age and enter menopause, Menopause, Vol. 21, No. 12, 2014

Copyright © 2014 The North American Menopause Society. Unauthorized reproduction of this article is prohibited.

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they undergo significant changes in cardiovascular risk factors, including adverse alterations in lipids, blood pressure (BP), body fat distribution, and cardiometabolic parameters.8 With the rise of CVDs, substantial progress has been made in the awareness, treatment, and prevention of CVDs in women. For example, the rate of US women’s awareness of CVDs as the leading cause of death has almost doubled from 30% in 1997 to 54% in 2009.9 Furthermore, this awareness is significantly associated with taking action to reduce CVD risk.10 There are several approaches to decreasing CVD risk. The World Health Organization stated that more than three quarters of CVD-related deaths may be prevented with adequate changes in lifestyle.3 According to evidence-based guidelines from the American Heart Association, lifestyle intervention is the first and most important approach to preventing CVDs in women.11 In the Women’s Healthy Lifestyle Project, 6-month results suggested that participants were receptive to CVD risk reduction and successful in making initial positive lifestyle changes.12 In addition, weight gain and increased waist circumference (WC) from perimenopause to postmenopause were prevented with a long-term lifestyle dietary and physical activity intervention.13 At the 54-month assessment of the Women’s Healthy Lifestyle Project, decreased caloric and fat intake and increased physical exercise successfully reduced the rise in low-density lipoprotein cholesterol (LDL-C) from perimenopause to postmenopause and prevented weight gain from premenopause to perimenopause to postmenopause.14 As an integrated physical activity and nutrition intervention, lifestyle intervention effectively addressed some of the CVD risk factors to prevent CVDs among disadvantaged lowincome women in the Illinois WISEWOMAN Program.15 Furthermore, lifestyle intervention may also be an effective means for reducing cardiovascular risk in obese, sedentary, postmenopausal women16,17 and in postmenopausal women with type 2 diabetes.18 However, few published lifestyle intervention studies have focused on healthy Chinese women. Some lifestyle change studies focused on women with dyslipidemia, diabetes mellitus, or impaired glucose regulation. We do not know whether such data may also apply to healthy Chinese women. Consequently, the main objective of the present study was to test the efficacy of a 12-month lifestyle intervention in improving CVD risk factors in community-based menopausal transition and early postmenopausal women in China.

METHODS Participants Participants were 100 healthy menopausal transition and early postmenopausal women enrolled in the Ovary Aging Study who completed follow-up assessments from December 2011 to May 2012. The Ovary Aging Study was conducted from June to December 2005, and from April to July 2007.19 Healthy women aged between 30 and 54 years who were living in community settings in Beijing, China, were eligible for the study. The participants were recruited through flyers

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and bulletin board postings based on residency lists from the residency committee. Assessments included anthropometric measurements, BP, blood glucose, serum lipids, and body composition determined annually at the Women’s Health Center (Beijing, China). The participants were required to record their menstruation on menstrual calendars every month. Menopause status was defined by the menstrual change criteria from the Stages of Reproductive Aging Workshop + 1020 based on prospective menstrual calendars. Early menopausal transition is characterized by cycle length variability, qualified as a difference of at least 7 days, in consecutive cycles. This variability must recur within 10 cycles of the first variable length cycle. Late menopausal transition is defined as amenorrhea of at least 60 days. Postmenopause was defined as 12 consecutive months of amenorrhea with no other causes. Folliclestimulating hormone and estradiol levels are variable during early postmenopauseVa period estimated to last about 5 to 8 years and ending when these hormone levels have stabilized. The inclusion criteria for this study were as follows: (1) between 40 and 60 years of age; (2) in the menopausal transition or early postmenopause; (3) had regular menstrual patterns when she was aged 20 to 30 years, with menstrual periods occurring every 21 to 35 days; and (4) with an intact uterus and at least one intact ovary. The exclusion criteria were as follows: (1) with cardiovascular disease, peripheral vascular disease, or stroke; (2) use of hormone therapy during the previous 6 months; (3) use of medication to control blood cholesterol, blood glucose, and hypertension; and (4) inability to perform moderate physical activity. All participants signed an informed consent form approved by the Ethics Committee of the Peking Union Medical College. Procedures The participants were randomly assigned to receive either lifestyle change (intervention group, n = 53) or usual care (control group, n = 47). Both groups underwent biophysical cardiovascular risk measurements at the Women’s Health Center. Women in the intervention group received lifestyle intervention. Women in the control group continued their usual eating patterns and activities. Lifestyle intervention Women in the intervention group were individually interviewed and provided with a colorful booklet on menopause and CVD risk factors, dietary recommendations, and physical activity recommendations. After receiving the booklet, every participant engaged in a face-to-face interview about healthy dietary habits and physical activity. Dietary recommendations focused on reduction of salt, total fat, and saturated fat intake and increase in fruit, vegetable, and fiber intake. Physical activity goals targeted moderate-intensity aerobic or endurance-type activities, such as pulse-controlled brisk walking, jogging, dancing, etc. Women were encouraged to perform physical activity more than 3 days/week at 40 to 60 minutes/day. Women were asked to record their diet and activity 3 days/week. Every participant received a telephone * 2014 The North American Menopause Society


LIFESTYLE INTERVENTION IN WOMEN

call from a research staffVtwice in the first month and then monthly for 12 monthsVreminding her to remain on healthy diet and exercise. Adherence was evaluated by reviewing participants’ records. Adherence was good, as participants completed more than 80% of the diet and physical activity logs. Measurements Data on age, sociodemographic background (education, income, etc), reproductive history (age at menarche, age at menopause, use of oral contraceptives), smoking, alcohol use, physical activity, and others were obtained with a standardized questionnaire through face-to-face interviews. Weight, body mass index (BMI), WC, waist circumferenceY toYhip circumference ratio (WHR), body composition, BP, blood glucose, and serum lipids were assessed at baseline and 12 months. At 3 months, weight, BMI, WC, WHR, and BP were assessed. At 6 months, weight, BMI, WC, WHR, BP, blood glucose, and serum lipids were assessed. Physical measurements were obtained based on a standardized protocol. Height was measured to the nearest 0.1 cm, with the participant wearing no shoes. Weight was measured to the nearest 0.1 kg, with the participant wearing only light clothing. WC was measured to the nearest 0.1 cm at the midpoint between the lower edge of the costal arch and the upper edge of the anterior superior iliac spine. Hip circumference was measured to the nearest 0.1 cm at the maximal circumference around the buttocks posteriorly and anteriorly at the symphysis pubis. BMI was calculated as body weight (in kg) divided by height (in m) squared. WHR was calculated as WC divided by hip circumference. BP was measured in the right arm three times with the participant in sitting position and with at least 5-minute rest between measurements, using a standard mercury sphygmomanometer. Korotkoff phase I and phase V sounds were recorded for systolic BP and diastolic BP, respectively. Venous blood samples were collected after a 12-hour overnight fast. On the day of collection, plasma was analyzed for total cholesterol (TC), high-density lipoprotein cholesterol

(HDL-C), triglycerides (TG), and glucose levels. Analyses of TC, HDL-C, and TG levels were performed using an Olympus AU5400 analyzer. Friedewald formula was used to calculate LDL-C levels.21 Plasma glucose concentrations were measured using the hexokinase-glucose-6-phosphate dehydrogenase method.22 All laboratory analyses were performed at the biochemistry laboratory of Peking Union Medical College Hospital. Body composition was measured by dual-energy x-ray absorptiometry (software version 11.40.004; GE-Lunar Prodigy, Madison, WI). In this study, we measured androidto-gynoid fat mass ratio, trunk-to-leg fat mass ratio, and fat mass. All measurements were performed by a trained technician who was blinded to group assignment. Statistical analyses Normality of distribution for each variable was tested using Shapiro-Wilk test. Consequently, nonparametric and parametric analyses were used according to the variable’s distribution. Changes in variables across time are expressed as the difference in values between baseline and follow-up. Depending on normality of distribution, we used group t test or Mann-Whitney U test to compare continuous variables at baseline and follow-up and changes in risk factors. Preanalyses and postanalyses were performed using paired-samples t tests. Mann-Whitney U test was used for nonparametric analyses. SPSS software (version 17.0) was used for all calculations. All P values were two-sided, and P G 0.05 was considered statistically significant.

RESULTS Baseline characteristics At baseline, no differences in characteristics, including age, weight, BMI, WC, WHR, body composition, BP, blood glucose, and serum lipids, were observed between the two groups (P 9 0.05; Table 1). The mean (SD) age of participants was 49.89 (4.16) years. Most of them were married (92%), had middle-level education (88%), and had middle-level income

TABLE 1. Comparison of baseline characteristics between the intervention group and the control group Characteristics

Intervention group (n = 53)

Control group (n = 47)

T

Age, y 50.62 (3.92) 49.06 (4.30) 1.894 Weight, kg 61.02 (7.47) 62.51 (9.47) 0.879 2 24.14 (2.70) 24.33 (3.24) 0.320 Body mass index, kg/m Waist circumference, cm 77.48 (5.99) 78.11 (7.66) 0.457 WHR 0.83 (0.04) 0.82 (0.04) 0.875 Systolic blood pressure, mm Hg 117.04 (14.77) 115.87 (13.67) 0.408 Diastolic blood pressure, mm Hg 71.58 (9.30) 70.89 (9.83) 0.361 Glucose, mmol/L 5.24 (0.52) 5.35 (0.84) 0.733 Total cholesterol, mmol/L 5.39 (0.82) 5.31 (1.05) 0.465 Triglycerides, mmol/L 1.34 (0.69) 1.38 (0.88) 0.192 HDL-C, mmol/L 1.44 (0.29) 1.50 (0.46) 0.767 LDL-C, mmol/L 3.35 (0.77) 3.18 (0.97) 0.910 Android-to-gynoid fat mass ratio 1.00 (0.11) 1.02 (0.12) 0.707 Trunk-to-leg fat mass ratio 1.07 (0.11) 1.09 (0.12) 0.889 Fat mass, kg 21.43 (4.62) 22.80 (6.02) 1.294 Values are presented as mean (SD). WHR, waist circumferenceYtoYhip circumference ratio; HDL-C, high-density lipoprotein cholesterol; LDL-C, low-density lipoprotein cholesterol. Menopause, Vol. 21, No. 12, 2014


P 0.061 0.382 0.749 0.648 0.384 0.684 0.719 0.465 0.643 0.848 0.445 0.365 0.481 0.376 0.199

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(64%). Thirty-four women were on early menopausal transition, 32 women were on late menopausal transition, and 34 women were on early postmenopause. At 3, 6, and 12 months, 89, 85, and 82 women, respectively, had completed follow-up. Primary reasons for dropout included Blosing interest in the study[ and Bmoving to another community.[ Participant dropout (n = 18) was not associated with adverse effects or adverse events. The total study dropout rate was 18% for the 12-month period, similar to other studies of this duration. No statistical differences in sociodemographic characteristics, menopause status, dietary habits, or exercise activity were found between those remaining in the study and those discontinuing from the study. The dropout rates in the intervention and control groups were, respectively, 17% and 19% for the 12-month period. There were no significant differences in dropout rates between the two groups. Changes in risk factors between baseline and 12 months At 12 months, there were no significant changes in the intervention group, but WC significantly increased in the control group (P G 0.05; Table 2). Furthermore, there were significant decreases in TC (j0.07 vs 0.03 mmol/L, P = 0.045) and LDL-C (j0.13 vs 0.01 mmol/L, P = 0.022) in the intervention group compared with the control group. However, there were no significant decreases in android-to-gynoid fat mass ratio, trunk-to-leg fat mass ratio, and fat mass between the two groups. Changes in risk factors between baseline and 3 months At 3 months, systolic BP significantly decreased in the intervention group, whereas body weight, BMI, WC, and WHR significantly increased in the control group (P G 0.05; Table 3). Systolic BP decreased by approximately 6.59 mm Hg in the intervention group. Body weight, BMI, WC, and WHR increased

by 0.68 kg, 0.44 kg/m2, 1.43 cm, and 0.01, respectively, in the control group at 3 months. There were significant reductions in body weight (j0.28 vs 0.68 kg, P = 0.002), BMI (j0.06 vs 0.44 kg/m2, P = 0.003), WC (j0.28 vs 1.43 cm, P = 0.001), and WHR (j0.01 vs 0.01, P = 0.045) favoring the intervention group over the control group. Changes in risk factors between baseline and 6 months At 6 months, body weight, WHR, systolic BP, TC, and LDL-C significantly decreased in the intervention group (P G 0.05; Table 4). Weight, WHR, systolic BP, TC, and LDL-C decreased by 0.73 kg, 0.02, 7.52 mm Hg, 0.19 mmol/L, and 0.17 mmol/L, respectively, in the intervention group. However, there were no significant changes in the control group between baseline and 6 months. Compared with the control group, there were significant decreases in WC (j0.73 vs 1.02 cm, P = 0.012), WHR (j0.02 vs j0.003, P = 0.020), and systolic BP (j7.52 vs j0.63 mm Hg, P = 0.012) in the intervention group. DISCUSSION This study was a randomized controlled trial of a 12-month lifestyle intervention (using a booklet and interviews) to improve CVD risk factors in community-based menopausal transition and early postmenopausal women in China. The lifestyle intervention was observed to be an effective strategy for significantly decreasing women’s body weight, BMI, WC, WHR, systolic BP, TC, and LDL-C compared with women in the control group. However, there were no significant between-group differences or within-group changes in diastolic BP, TG, HDL-C, and body composition. The broad improvement resulting from the combination of booklet and individual interviews (focusing on diet and exercise instructions) suggests that lifestyle intervention warrants

TABLE 2. Changes in CVD risk factors between baseline and 12 months Intervention group (n = 44) Risk factors

Baseline

12 mo

Control group (n = 38) Baseline

12 mo

Changes at 12 mo Intervention group

Control group

P for change

Weight, kg 60.67 (7.72) 60.38 (7.80) 62.63 (9.86) 63.06 (10.37) j0.28 (2.08) 0.43 (2.34) 0.133a 2 Body mass index, kg/m 24.05 (2.77) 24.01 (2.79) 24.48 (3.38) 24.84 (3.53) j0.04 (0.84) 0.36 (1.40) 0.172a Waist circumference, cm 77.42 (6.35) 77.56 (6.59) 78.03 (7.79) 79.76 (8.61)b 0.15 (3.85) 1.74 (4.55) 0.180a WHR 0.8296 (0.04) 0.8216 (0.05) 0.8175 (0.04) 0.8247 (0.05) j0.008 (0.04) 0.007 (0.45) 0.125c Systolic blood pressure, 117.34 (14.59) 114.41 (15.09) 114.63 (13.66) 112.58 (12.65) j2.93 (12.99) j2.05 (9.85) 0.959a mm Hg Diastolic blood pressure, 71.57 (9.59) 72.75 (9.78) 69.50 (10.02) 69.55 (8.28) 1.18 (9.28) 0.05 (7.79) 0.556c mm Hg Glucose, mmol/L 5.23 (0.53) 5.20 (0.61) 5.34 (0.91) 5.18 (0.59) j0.03 (0.58) j0.16 (0.68) 0.709a Total cholesterol, mmol/L 5.35 (0.73) 5.28 (0.65) 5.35 (1.05) 5.38 (1.03) j0.07 (0.56) 0.03 (1.13) 0.045a Triglycerides, mmol/L 1.35 (0.72) 1.49 (0.80) 1.38 (0.83) 1.46 (0.71) 0.15 (0.53) 0.08 (0.50) 0.552c HDL-C, mmol/L 1.44 (0.29) 1.43 (0.28) 1.50 (0.48) 1.45 (0.32) j0.02 (0.15) j0.06 (0.36) 0.495c LDL-C, mmol/L 3.30 (0.71) 3.18 (0.66) 3.23 (1.04) 3.24 (0.75) j0.13 (0.50) 0.01 (1.07) 0.022a Android-to-gynoid fat 1.02 (0.11) 1.03 (0.10) 1.02 (0.12) 1.02 (0.14) 0.01 (0.06) 0.004 (0.05) 0.124c mass ratio Trunk-to-leg fat mass ratio 1.08 (0.11) 1.09 (0.11) 1.10 (0.12) 1.09 (0.14) 0.01 (0.05) j0.009 (0.05) 0.067c Fat mass, kg 21.18 (4.78) 21.44 (4.89) 22.96 (6.21) 23.22 (6.70) 0.25 (1.68) 0.26 (1.99) 0.974c Values are presented as mean (SD). CVD, cardiovascular disease; WHR, waist circumferenceYtoYhip circumference ratio; HDL-C, high-density lipoprotein cholesterol; LDL-C, low-density lipoprotein cholesterol. a Mann-Whitney U test. b Significant preintervention-postintervention difference within the group. c Group t test.

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LIFESTYLE INTERVENTION IN WOMEN TABLE 3. Changes in CVD risk factors between baseline and 3 months Intervention group (n = 47) Risk factors

Baseline

3 mo


Changes at 3 mo

3 mo a

Weight, kg 60.52 (7.71) 60.24 (7.61) 62.56 (9.69) 63.24 (9.95) Body mass index, kg/m2 24.02 (2.83) 23.96 (2.84) 24.46 (3.30) 24.89 (3.40)a Waist circumference, cm 77.24 (6.23) 76.97 (5.84) 78.12 (7.76) 79.54 (7.99)a WHR 0.83 (0.05) 0.82 (0.05) 0.82 (0.04) 0.83 (0.05)a Systolic blood pressure, 117.64 (14.50) 111.04 (13.26)a 114.88 (13.47) 112.07 (13.36) mm Hg Diastolic blood pressure, 71.47 (9.37) 69.83 (9.05) 70.21 (10.10) 67.64 (8.57) mm Hg Values are presented as mean (SD). CVD, cardiovascular disease; WHR, waist circumferenceYtoYhip circumference ratio. a Significant preintervention-postintervention difference within the group. b Mann-Whitney U test. c Group t test.

further study to help women decrease their cardiovascular risk factors. Results show that biophysical and blood outcome measures support the efficacy of the intervention, with significant decreases in women’s weight, BMI, WHR, BP, TC, and LDL-C. A few studies seemed to indicate that lifestyle intervention can improve women’s biophysical outcomes. In a 5-year randomized controlled trial by Kuller et al,14 premenopausal women were assigned to a lifestyle intervention program aimed at preventing increases in LDL-C and weight and at increasing leisure physical activity. The lifestyle intervention was a cognitive-behavioral therapy focusing on decreasing dietary fat, cholesterol, and calories, and on improving fitness habits, whereas the control group received no intervention. At 54 months, women in the intervention group weighed significantly less, had smaller WC, and had smaller increases in LDL-C, supportive of our results. Haruyama et al23 developed a large-scale, communitybased, nonrandomized 15-month lifestyle intervention program in Japan that also focused on diet and physical activity. Women in the intervention group reported less animal fat intake and significantly more exercise and were observed to have significantly reduced body weight, BMI, systolic BP,

Intervention group

Control group

P for change

j0.28 (1.33) j0.06 (0.59) j0.28 (2.43) j0.01 (0.04) j6.59 (12.38)

0.68 (1.48) 0.44 (1.15) 1.43 (2.66) 0.01 (0.03) j2.81 (11.99)

0.002b 0.003b 0.001b 0.045b 0.147c

j1.64 (9.06)

j2.57 (7.07)

0.593c

and TC. Notably, eligible participants had to have at least one cardiovascular risk factor, such as a BP of at least 130/85 mm Hg; they differed from the participants in our sample, who were required to be healthy to enroll in this study. In a randomized controlled trial of premenopausal, perimenopausal, and postmenopausal women, Anderson et al24 found significant decreases in the participants’ WHR, BMI, diastolic BP, and weight after a 12-week multimodal intervention (Women’s Wellness Program), which also support our results. Furthermore, the Sustainability Study found that the lifestyle intervention (Women’s Wellness Program) was effective in decreasing cardiovascular risk factors in postmenopausal women and that these decreases persisted 5 years after program completion.25 Deibert et al26 used a one-group pre-post group design to implement a 6-month lifestyle intervention that also focused on dietary and exercise modifications in overweight and obese but otherwise healthy premenopausal and postmenopausal women. They noted significant reductions in weight, systolic BP, WC, hip circumference, TC, and LDL-C. This study did not demonstrate significant effects on body composition, in contrast to studies by Simkin-Silverman et al,13

TABLE 4. Changes in CVD risk factors between baseline and 6 months Intervention group (n = 44) Risk factors

Baseline

6 mo


6 mo

Changes at 6 mo Intervention group

Control group

P for change

Weight, kg 61.07 (7.55) 60.34 (7.57)a 62.59 (9.81) 62.52 (10.06) j0.73 (2.04) 0.07 (2.17) 0.163b 2 Body mass index, kg/m 24.19 (2.83) 23.96 (2.87) 24.49 (3.34) 24.63 (3.43) j0.23 (0.79) 0.14 (1.39) 0.209b Waist circumference, cm 77.55 (6.26) 76.83 (6.53) 78.07 (7.86) 79.10 (7.76) j0.73 (3.39) 1.02 (3.50) 0.012b WHR 0.83 (0.05) 0.81 (0.05)a 0.82 (0.04) 0.82 (0.05) j0.02 (0.04) j0.003 (0.04) 0.020c Systolic blood pressure, 117.98 (14.07) 110.45 (12.72)a 115.05 (13.59) 114.41 (14.57) j7.52 (13.00) j0.63 (11.69) 0.012c mm Hg Diastolic blood pressure, 71.61 (9.46) 70.41 (10.57) 69.86 (10.08) 69.47 (8.99) j1.21 (9.97) j0.54 (9.32) 0.751c mm Hg Glucose, mmol/L 5.24 (0.51) 5.19 (0.50) 5.36 (0.89) 5.39 (1.36) j0.05 (0.39) 0.03 (0.67) 0.599b a Total cholesterol, mmol/L 5.29 (0.75) 5.09 (0.76) 5.37 (1.07) 5.43 (0.97) j0.19 (0.62) 0.06 (0.72) 0.083c Triglycerides, mmol/L 1.36 (0.72) 1.35 (0.75) 1.34 (0.81) 1.47 (1.06) j0.01 (0.73) 0.13 (0.83) 0.871b HDL-C, mmol/L 1.44 (0.30) 1.42 (0.31) 1.52 (0.48) 1.49 (0.35) j0.01 (0.15) j0.03 (0.37) 0.273b LDL-C, mmol/L 3.23 (0.69) 3.06 (0.74)a 3.24 (1.02) 3.27 (0.88) j0.17 (0.57) 0.03 (0.85) 0.235b Values are presented as mean (SD). CVD, cardiovascular disease; WHR, waist circumferenceYtoYhip circumference ratio; HDL-C, high-density lipoprotein cholesterol; LDL-C, low-density lipoprotein cholesterol. a Significant preintervention-postintervention difference within the group. b Mann-Whitney U test. c Group t test. Menopause, Vol. 21, No. 12, 2014


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Carels et al,16 Haruyama et al,23 and Deibert et al.26 With the exception of Simkin-Silverman et al,13 all authors used body fat measurement different from what we used in this study. Simkin-Silverman et al13 also used dual-energy x-ray absorptiometry. Notably, their entire sample was composed of premenopausal women, whereas our sample included only perimenopausal or postmenopausal women. Miller et al17 reported that a 2-year education program for premenopausal women did not reduce body fat, BMI, or WHR despite significant dietary reductions in fat and significant increases in physical activity. More studies are needed to determine the effects of lifestyle intervention on body composition, including differentiation of the effects on women in premenopause, postmenopause, and the menopausal transition. The current study had some limitations. First, we did not record the control group’s eating habits and activity and did not evaluate changes in their diet and exercise. Second, more than one third of the women had normal biophysical measurements or blood lipids at baseline; thus, there was a possible floor effect compared with other studies.27 Finally, the intervention’s effects decreased from 6 months to 12 months, suggesting that community intervention could have been successful if personal contact and follow-up were maintained. The sample size may not be large enough to detect clinically relevant differences. Further studies with expanded sample sizes and prolonged follow-up periods are needed to confirm these findings. CONCLUSIONS This study shows that lifestyle intervention may be an effective means for reducing cardiovascular risk in menopausal transition and early postmenopausal women in China. Further studies are needed to validate our results and to quantify possible impact on body composition. Acknowledgments: We thank Qun Xu (Department of Epidemiology, Institute of Basic Medical Sciences, Peking Union Medical College) for her assistance with statistical analysis. We also thank Dr. Tang Gao for her valuable help with the English-language presentation of this manuscript. We thank the Women’s Health Center at Peking Union Medical College Hospital for helping with data collection and all women who participated in this study.

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