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UNIVERSITI PUTRA MALAYSIA
PARVIN ABEDI
FPSK(p) 2009 10
EFFECTIVENESS OF DIET AND EXERCISE INTERVENTION PROGRAMMS ON CARDIOVASCULAR DISEASE RISK FACTORS AMONG
POSTMENOPAUSAL IRANIAN WOMEN
EFFECTIVENESS OF DIET AND EXERCISE INTERVENTION PROGRAMMS
ON CARDIOVASCULAR DISEASE RISK FACTORS AMONG
POSTMENOPAUSAL IRANIAN WOMEN
By
PARVIN ABEDI
Thesis submitted to the School of Graduate Studies, Universiti Putra Malaysia, in
Fulfilment of the Requirements for the Degree of Doctor of Philosophy
November 2009
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Dedicated
To
This thesis is dedicated to my lovely children Mahdis, Pardis and Sepideh, my dear
husband Abbas, and my father Alireza that I owe them all of success in my life.
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Abstract of thesis Presented to the Senate of Universiti Putra Malaysia in Fulfillment of
the Requirement for the degree of Doctor of Philosophy
EFFECTIVENESS OF DIET AND EXERCISE INTERVENTION PROGRAMS
ON CARDIOVASCULAR DISEASE RISK FACTORS AMONG
POSTMENOPAUSAL IRANIAN WOMEN
By
PARVIN ABEDI
November 2009
Chairman: Dr Mary Huang Soo Lee, PhD
Faculty: Medicine and Health Sciences
Cardiovascular disease (CVD) is one of the major complications in menopausal women
internationally. CVD, including heart diseases and stroke, are the leading causes of
death, and is now a leading cause of death and disability in Iran.
The aim of this study was to evaluate the effect of diet and exercise educational
intervention on improving cardiovascular risk factors among postmenopausal Iranian
women.
This study started on June 2007 and was completed on May 2008. The study was carried
out with participants recruited in a Health clinic in Ahvaz Iran. A total of 136
postmenopausal women were randomly assigned to four groups namely; exercise (38),
diet (35), diet+ exercise (34) and control groups (29). The anthropometric, biochemical,
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health beliefs, physical activity and dietary intake of participants were measured at
baseline and after six months.
Over the six months intervention period, the three intervention groups received a multi-
component educational intervention consisting of one face-to-face education, three
lecture discussion sessions and group counseling sessions (every week in the first
month). They were also received three booklets about menopause, CVD, healthy diet
and exercise with emphasis on components of Health Belief Model (HBM), monthly
telephone reminders (each month after the first month) and individual counseling
midway at the 3rd
month. The control group received booklets only. Baseline and 6th
month assessments were conducted by using the same questionnaires (interview-
administered format).
After six months intervention there was a significant positive change (P<0.05) in the
physical activity level in the exercise group, perception of participants about
seriousness, vulnerability, benefits, cues to action and barriers toward CVD in all three
intervention groups. Also the dietary fiber, vitamin C and E intakes and distribution of
participants who consumed ≥5 servings fruit and vegetable in the diet and diet + exercise
group increased significantly. The intervention improved some CVD risk factors
significantly within groups in the following areas: Weight and BMI was reduced in the
diet group, hip circumference decreased in the exercise and diet groups. The level of
LDL decreased in the exercise group, VLDL and FBS decreased in the exercise and diet
groups. The intake of protein increased in the diet + exercise group. Intake of
monounsaturated fat increased in the exercise, diet and diet +exercise groups. Poly
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unsaturated fat and saturated fat intake decreased in the exercise group. The intake of
vitamin A increased in the diet + exercise group and intake of calcium increased in the
diet and diet + exercise groups.
In conclusion the results of this study showed that six months of educational intervention
on physical activity and diet could improve some risk factors of CVD in postmenopausal
women. The diet and diet + exercise groups could reduce CVD risks more than the
group that only exercised. Therefore, the implementation of healthy diets for
postmenopausal women should be encouraged.
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Abstrak tesis yang dikemukakan kepada Senat Universiti Putra Malaysia sebagai
memenuhi keperluan untuk ijazah Doktor Falsafah
KEBERKESANAN PROGRAM PENDIDIKAN DIET DAN SENAMAN
TERHADAP FAKTOR-FAKTOR RISIKO PENYAKIT KARDIOVASKULAR DI
KALANGAN WANITA IRAN YANG PUTUS-HAID
Oleh
PARVIN ABEDI
November 2009
Pengerusi: Dr Mary Huang Soo Lee, PhD
Fakulti: Perubatan Dan Sains Kesihatan
Penyakit kardiovaskular (CVD) adalah salah satu masalah besar di kalangan wanita
putus-haid di seluruh dunia. Penyakit kardiovaskular termasuk penyakit jantung dan
strok adalah punca utama kematian dan juga merupakan punca utama kemation dan
kecacatan di Iran.
Tujuan kajian ini adalah untuk menilai kesan pendidikan diet dan senaman dalam
memperbaiki factor-faktor risiko kardiovaskular di kalangan wanita Iran yang putus-
haid.
Kajian ini bermula pada bulan Jun tahun 2007 dan telah diselesaikan pada bulan Mei
tahun 2008. Kajian ini telah dijalankan dangan peserta yang di jemput dari sebuah klinik
kesihatan di Ahvaz, Iran. Seramai 136 wanita pusca haid telah dipilih dan dibahagikan
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kepada empat kumpulan yang dinamakan kumpulan senaman, diet, senaman diet, dan
kawalan (n=38, n=35, n=34 and n=29 mengikut kumpulan yang tertera).
Sepanjang tempoh kajian selama enam bulan, tiga kumpulan kajian telah didedahkan
kepada kaedah bersemuka, sesi kuliah dan perbincangan, sesi kaunseling berkumpulan,
(setiap minggu poda bulan pertama) peringatan melalui panggilan telefon. Tiga buku
berkaitan putus haid dan CVD, serta diet sihat bersama senaman dangan penekanan
terhadap Health Belief Model (HBM), telah diedarkan kepada peserta dan kaunseling
secara individu diadakan pada bulan ketiga kajan tersebut. Kumpulan kawalan hanya
menerima buku panduan sahaja. Penilaian pada peringkat awal dan selepas enam bulan
dijalankan menggunakan borang soal selidik yang sama iaitu melalui kaedah temubual.
Selepas kajian selama enam bulan, intervensi terdaput perubahan positif yang signifikan
(P<0.05) pada tahap aktiviti fizikal dalam kumpulan senaman, persepsi kumpulan kajian
terhadap kesungguhan, kebarangkalian mendapat penyakit CVD, kebaikan, arahan
bertindak dan halangan terhadap CVD dalam semua kumpulan kajian. Pengambilan
fiber, vitamin C dan E dan distribusi peserta yang mengambil ≥ 5 hidangan sayor dan
buah-buahan di dalam kumpulan diet dan diet + senaman meningkat secara signifikan.
Kajian ini memperbaiki sesetengah risiko CVD secara signifiken di dalam kumpulan
kajian seperti yang berikut: berat badan dan BMI menerum di dalam kumpulan diet,
ukar lilitan pinggang menurun di dalam kumpulan senaman + diet, paras LDL menurun
kumpulan senaman manakala VLDL dan FBS menurun dengan kumpulan. Pengambilan
protein meningkat dalam kumpulan diet+senaman. Pengambilan lemak-mono-tak tepu
meningkat dalam kumpulan senaman, diet, dan diet + senaman. Pengambilan lemak-
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poli-taktepu dan lemak tepu menurun dalam kumpulan senaman. Pergambilan vitamin A
meningkat di dalam kumpulan diet dan senaman dan pengambilan kalsium meningkat di
dalam kumpulan diet serta di dalam kumplan diet + senaman.
Secara kesimpulannya, keputusan kajian ini menunjukkan bahawa kajian selama enam
bulan aktiviti fizikal dan diet telah dapat mengubah sebahagian daripada faktor risiko
CVD di kalangan wanita putus haid. Kumpulan diet dan kumpulan diet dan senaman
dapat mergurang kan risiko CVD lebih daripada kumpulan yang hanya bersenam. Oleh
itu, pendekatan pemakanan yang sihat untuk wanita putus haid haruslah digalakkan.
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ACKNOWLEDGEMENTS
I wish to express my sincere appreciation and gratitude to my supervisor, Assoc.
Professor Dr. Mary Huang Soo Lee for her supervision, constructive suggestions and
immense amount of guidance throughout this study. Appreciation is extended to the
members of my supervisory committee, Assoc. Professor Dr. Zaitun Yassin, Assoc.
Professor Dr. Mirnalini Kandiah and Professor Dr. Davood Shojaeezadeh for their
guidance during this study. Thanks also to the Medical University of Gondi-Shapor in
Ahvaz-Iran for their cooperation during the data collection.
I wish to convey my gratitude to my parents for their encouragement and spiritual
support during the whole of my life. And last but certainly not least, I wish to express
my deep gratitude and heartfelt appreciation to my husband, my children especially
Mahdis and my sister Shahla for their immense support, understanding and sacrifices
that have made the task of completing this project possible. Thanks also to my friends
Firoozeh and Sahar that helped during my study in Malaysia.
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I certify that an Examination Committee met on 20/11/2009 to conduct the final
examination of Parvin Abedi on her Doctor of Philosophy thesis entitled “Effectiveness
of diet and exercise intervention programmes on cardiovascular disease risk factors
among postmenopausal Iranian women” in accordance with Universiti Pertanian
Malaysia (Higher Degree) Act 1980 and Universiti Pertanian Malaysia (Higher Degree)
Regulations 1981. The committee recommends that the candidate be awarded the
relevant degree.
Members of the Examination Committee are as follows:
Name of Chairperson, PhD
Title: Associate Prof. Dr Mohd Nasir bin Mohd Taaib
Name of Faculty: Perubatan dan Sains Kesihatan
University Putra Malaysia
(Chairman)
Name of Examiner 1, PhD
Title: Associate Prof. Dr Zalilah Mohd. Shariff
Name of Faculty: Perubatan dan Sains Kesihatan
University Putra Malaysia
(Internal Examiner)
Name of Examiner 2, PhD
Title: Associate Prof. Dr Hejar Abd.Rahman
Name of Faculty: Perubatan dan Sains Kesihatan
University Putra Malaysia
(Internal Examiner)
Name of External Examiner, PhD
Title: Prof. Dr. Fatimah Arshad
Name of Department and/ or Faculty: Jabatan Permakanan dan Dietetik
Name of Organization (University / Institute): Perubatan Antarabangsa
Country: Malaysia, Kualalumpur
(External Examiner)
-------------------------------------------
HUJANG BIN KIM HUAT, PhD
Professor and Dean
School of Graduate Studies
Universiti Putra Malaysia
Date: 15 January 2010
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This thesis submitted to the Senate of Universiti Putra Malaysia and has been accepted
as fulfillment of the requirement for the degree of Doctor of Philosophy. The members
of the Supervisory Committee were as follows:
Mary Huang Soo Lee
Associate Professor, PhD.
Faculty of Medicine and Health Sciences
Universiti Putra Malaysia
(Chairperson)
Zaitun Yassin
Associate Professor, PhD.
Faculty of Medicine and Health Sciences
Universiti Putra Malaysia
(Member)
Mirnalini Kandiah
Associate Professor, PhD.
Faculty of Medicine and Health Sciences
Universiti Putra Malaysia
(Member)
Davood Shojaeezadeh
Professor
Faculty of Public Health
University of Tehran (Iran)
(Member)
--------------------------------------------------
HASANAH MOHD. GHAZALI, PhD
Professor and Dean of
School of Graduate Studies
Universiti Putra Malaysia
Date: 20/11/2009
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DECLARATION
I hereby declare that the thesis is based on my original work except for quotation and
citations which have been duly acknowledged. I also declare that it has not been
previously or concurrently submitted for any other degree at UPM or other institution.
Parvin Abedi
PARVIN ABEDI
Date: 16/6/2009
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TABLE OF CONTENT
Page
ABSTRACT iii
ABSTRAK vi
ACKNOWLEDGEMENTS ix
APPROVAL x
DECLARATION xii
LIST OF TABLES xviii
LIST OF FIGURES xxi CHAPTER
1 INTRODUCTION
1.1 Background 1
1.2 Problem Statement 3
1.3 Conceptual Framework of the Study 7
1.4 Importance of the Study 9
1.5 Objectives of the Study 10
1.6 Null Hypotheses 12
2 LITRATURE REVIEW
2.1 Introduction 15 2.2 Menopause 15
2.2.1 Population of Menopause Women 15
2.2.2 Age of Menopause 16
2.2.3 Menopause Changes and CVD 17
2.2.4 Menopause and Lipid Profile Changes 18
2.2.5 Effect of Menopause on Blood Pressure 20
2.2.6 Effect of Menopause on Weight Status 21
2.3 Cardiovascular Disease 22
2.3.1 Prevalence of CVD 23
2.3.2 Pathophysiology of CVD 24
2.3.3 Risk Factors for CVD 26
2.3.4 Obesity and CVD 27
2.3.5 Plasma Triglyceride and CVD 30
2.3.6 C Reactive Protein (CRP) and CVD 31
2.3.7 Lipoprotein (a) and CVD 31
2.3.8 Insulin Resistance and CVD 32
2.3.9 Metabolic Syndrome and CVD 32
2.3.10 Hypercholestromia and CVD 34
2.3.11 Hypertension and CVD 35
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2.4 Prevention of CVD 37
2.4.1 Exercise 38
2.4.2 Aerobic and Anaerobic Exercise 39
2.4.3 Lack of Exercise 40
2.4.4 Benefits of Regular Exercise on CVD Risk Factors 42
2.5 Health Behavior Models 45
2.5.1 Transtheoretical Model 45
2.5.2 Social Learning Theory 46
2.5.3 Health Promotion Model 48
2.5.4 Reasoned Action Theory 48
2.5.5 Health Belief Model 49
2.6 Exercise and CVD 55
2.6.1 Determinants of Physical Activity and Benefits 56
2.7 Diet intervention and CVD Risk Factors 58
2.8 Combination of diet plus Exercise Intervention and CVD 62
2.9 Summary 65
3 METHODOLOGY 67
3.1 Ethical Consideration 67
3.2 Location of the Study 67
3.3 Sample Size Calculation 68
3.4 Study Design 69
3.5 Screening and Recruitment of Participants 70
3.6 Recruitment and Retention 72
3.7 Randomization 75
3.8 Instruments 75
3.8.1 Questionnaire 75
3.8.2 Development of questionnaire 75
3.9 Measurements 77
3.9.1 Anthropometry 77
3.9.2 Biochemical Tests 78
3.9.3 Physical Activity 80
3.9.4 Dietary Intake 83
3.9.5 The Health Belief Model 85
3.10 Intervention 86
3.10.1 Development of Educational Material 86
3.10.2 Content of Educational Materials 87
3.10.3 Diet 87
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3.10.4 Exercise 88
3.10.5 Diet Plus Exercise 89
3.10.6 Control Group 89
3.11 Data Collection 89
3.12 Implementation of Intervention 90
3.13 Evaluation 95
3.14 Statistical Analysis 95
4 RESULTS AND DISCUSSION 96
4.1 Comparison at Baseline 96
4.1.1 Socio-Demographic Characteristics 96
4.2 CVD Risk Factors at Baseline 98
4.2.1 Anthropometric Measurements at baseline 98
Prevalence of Obesity Based on 99
BMI at Baseline
Prevalence of Abdominal Obesity on Waist 100
Circumference at Baseline
Prevalence of Android Obesity Based on 101
WHR at Baseline
4.2.2 Biochemical Measurements at Baseline 102
Distribution of dyslipidemia and Elevated 103
FBS at Baseline
4.2.3 Blood Pressure and Hypertension in Study Groups at 106
Baseline
4.2.4 Food Consumption Pattern 108
Macronutrient Intake at Baseline 109
Mean Percentages of Energy 112
from Macronutrient at Baseline
Micronutrient Intake at Baseline 114
Distribution of Participants According 115
To Dietary Risk Factors for CVD at
Baseline
Food Frequency Mean Scores at Baseline 117
4.2.5 Physical Activity and Energy Expenditure (MET- 118
minute/week) at Baseline
Distribution of Participants According 119
To Level of Physical Activity at Baseline
4.2.6 Health Belief Model at Baseline 120
4.3 Effect of the Intervention 121
4.3.1. Changes in Anthropometric Measurements 122
Changes in the Obesity after Intervention 124
4.3.2 Changes in Biochemical Measurements after Intervention 127
Changes in the Distribution of Participants 130
with Dyslipidemia and Elevated
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FBS after Intervention
4.3.3 Blood Pressure Measurements after Intervention 136
Changes in the Distribution of Participants 137
with Hypertension after Intervention
4.3.4 Macronutrient Intake after Intervention 140
Energy from Macronutrients after Intervention 147
4.3.5 Micronutrient Intake of Participants after Intervention 151
4.3.6 Food Frequency Mean Scores of Participants after 157
Intervention
4.3.7 Changes in Energy Expenditure (MET-minutes/week) of 158
Participants after Intervention
Distribution of Participants According to 159
Physical Activity level after Intervention
4.3.8 Changes in the Mean Scores of the Health Belief Model 162
Components after Intervention
4.3.9 Distribution of Participants According to Dietary Risk 168
Factors after Intervention
4.4 Relationship of Study Outcomes with the Health Belief 174
Model Components
5 CONCLUSION AND RECOMMENDATION 178
5.1 Conclusion 178
5.2 Strengths and Limitation of the Study 180
5.3 Recommendation 183
REFERENCES 186
APPENDICES 203
BIODATA OF THE AUTHOR 269
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LIST OF TABLE
Table Page
1.1 Glossary of terms 13
3.1 Parameters used for sample size calculation 69
3.2 Inclusion and exclusion criteria of subject selection 72
3.3 Overview of the implementation of intervention in the exercise group 92
3.4 Overview of the implementation of intervention in the diet group 93
3.5 Overview of the implementation of intervention in the diet +exercise group 94
4.1 Socio-demographic characteristics at baseline 97
4.2 Anthropometric measurements of the participants at baseline 98
4.3 Biochemical measurements of the participants at baseline 103
4.4 Dyslipidemia and elevated FBS at baseline 104
4.5 Blood pressure and distribution of participants according to hypertension 108
At baseline
4.6 Macronutrient intake at baseline 110
4.7 Mean percentages of energy from macronutrients at baseline 113
4.8 Micronutrients intakes at baseline 115
4.9 Distribution of participants according to dietary risk factors at baseline 116
4.10 Food frequency mean scores of participants at baseline 117
4.11 Energy expenditure (MET- minutes/week) at baseline 118
4.12 Knowledge and beliefs mean scores of participants based on the Health 121
Belief Model at baseline
4.13 Mean anthropometric measurements at baseline, after intervention 123
and average change over the intervention period
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4.14 Prevalence of obesity based on BMI, waist circumference and WHR 125
At baseline, after intervention and the change over the intervention period
4.15 Mean biochemical measurements at baseline, after intervention and average 129
change over the intervention period
4.16(a) Distribution of participants with dyslipidemia and elevated FBS at 131
Baseline, after intervention and change over the intervention period
4.16(b) Distribution of participants with dyslipidemia and elevated FBS at 132
Baseline, after intervention and change over the intervention period
4.17 Blood pressure measurements (mean) at baseline, after intervention and the 137
average change over the intervention period
4.18 Distribution of participants according to hypertension at baseline, after 138
intervention and change over the intervention period
4.19 Distribution of participants according to hypertension at baseline 127
After intervention and change over the intervention period
4.19(a) Macronutrient intake (mean) at baseline, after intervention and the mean 141
Change over the intervention period
4.19(b) Macronutrient intake (mean) at baseline, after intervention and the mean 142
Change over the intervention period
4.20 Percentages of energy from macronutrients at baseline, after intervention 148
And change over the intervention period
4.21 Micronutrient intake (mean) at baseline, after intervention and the change 152
Over the intervention period
4.22 Food frequency means scores of participants after intervention 157
4.23 Energy expenditure (MET-minutes/week) at baseline, after intervention 159
And the mean change over the intervention period
4.24 Distribution of participants according to physical activity level at baseline 160
And after intervention
4.25 Health Belief components (mean) at baseline, after intervention and the 163
Mean change over the intervention period
4.26 Distribution of participants according to dietary risk factors for CVD at 169
Baseline, after intervention and change over the intervention period
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LIST OF FIGURES
Figure Page
1.1 Conceptual framework of the study 8
2.1 Deaths by cause, all ages in the Islamic Republic of Iran, 2002 25
2.2 Projected prevalence of overweight, the Islamic Republic of Iran, males and 29
females aged 30 years or more, 2005 and 2015
2.3 Mean of blood pressure(mmHg) in the Islamic Republic of Iran 38
2.4 Cardiovascular mortality rate in women in the United States 42
2.5 Physical inactivity in Iran by age group 43
2.6 Conceptual frame work of the Health Belief Model 51
3.1 Location of the study 68
3.2 Study Design 71
3.3 Recruitment and retention of participants in the study 74
4.1 Distribution of the participants according to BMI categories at baseline 99
4.2 Distribution of the participants by waist circumference categories at 100
baseline
4.3 Distribution of the participants according to WHR categories at baseline 101
4.4 Distribution of the participants according to the levels of 119
physical activity at baseline
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CHAPTER 1
INTRODUCTION
1.1 Background
Menopause is a natural event in the aging process and with the cessation of cyclic
ovarian function manifested by cyclic menstruation signifies the end of a woman’s
reproductive years. The average age of menopause is 51 years, and less than 1% of
women experience it before the age of 40, while some women undergoing premature
menopause (surgery or chemotherapy) at a very early age (Burger et al., 2002). The
hormonal changes associated with menopause, for example, low plasma levels of
estrogen and marked increase in leutenizing hormone (LH) and follicle stimulating
hormone (FSH) levels, exert significant effects on the metabolism of plasma lipids and
lipoproteins (Sacks et al., 1992). Unfortunately, menopause is not just a time of dramatic
hormonal changes, but, more often, social and psychological changes accompany
menopause.
In 1960, the world population of women above 60 was less than 250 million, but it is
estimated that by 2030, 1.2 billion women will be peri- or postmenopausal, as a result of
an increase by an average of 4.7 million a year (Yong & Chang, 2003). It is also
estimated that in developed countries, women now aged 50 can be expected to live for a
further 30 years. The population of older than 60 years in Iran has also increased, due to
higher life expectancy (Massarrat et al., 2002). The World Health Organization (WHO,
2006) estimated that the population of women in Iran is 34,900,000 out of total
population 70,300,000, and 14% were above 50 years. Because of these projected
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changes in population structure, physicians are beginning to view menopause not as a
negligible natural phenomenon but as a major public health problem (Yong & Chang,
2003).
Median age of menopause has been found to be 49.9, 49.2, and 49.6 years in urban,
rural, and total population of Iran, respectively. Meanwhile, the mean age at menopause
in the total population in most countries is 50.4 years (S.D. =4.3) (Hashemi et al.,
2004).Women experience numerous changes after menopause, and about 51% of women
face excessive medical problems with these changes. Among these changes,
osteoporosis and heart disease are responsible for most problems in menopause women.
The other major complication in menopausal women is cardiovascular disease (CVD).
Globally, CVD is the number one cause of death and is projected to remain so in the
future. An estimated 17.5 million people died from CVD in 2005 alone, representing
30% of all global deaths. Around 80% of these deaths occurred in low and middle-
income countries (WHO, 2007). In countries of the Eastern Mediterranean Region
(including Iran), increasing economic wealth along with rapid population growth have
led to an increasing mortality rate from CVD (Fakhrzadeh et al., 2008). According to the
latest data from Iran, death rate of females due to CVD was 144 per 100,000 in 2002
(WHO, 2006).
It is well known that the main cause for heart disease is lipid disorders or dyslipidemia.
Part of the reasons why menopausal women are susceptible to CVD is in fact that lipid
metabolism rapidly deteriorates in women when they reach menopause. Hyperlipidemia
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and coronary heart disease rises in women of menopausal age, due to decrease in
estrogen, which has the action of controlling low density lipoprotein (LDL) production,
increasing high density lipoprotein(HDL) production and anti oxidation (Sugiura et al.,
2002). It is, therefore, not surprising that the main cause of death in developed and
developing countries is CVD.
Some risk factors for CVD, like age, sex and heredity, are unmodifiable. However, other
factors can be modified by changing lifestyles. Lifestyle consists of a broad range of
whole human activities, such as diet, physical activity, smoking and weight loss.
Therefore, in menopausal women, the key factor for reducing risk to CVD is lifestyle
change. In the present study, the researcher intends to study the effect of lifestyle
changes (physical activity and diet intervention) on CVD risk factors.
1.2 Problem Statement
In 2005, CVD was the world's leading cause of death accounting for 28% of all deaths
worldwide, with 80% of the burden experienced by low- and middle-income countries
(Abegunde, 2007). It is predicted that the leading cause of death in the world in 2030
will be ischemic heart disease (WHO, 2008). On the other hand, at least 20 million
people survive heart attacks and strokes every year, with a significant proportion of them
requiring costly clinical care, which puts a huge burden on long-term care resources.
CVD affects people in their mid-life years undermining the socioeconomic development.
In other words, it does not only affect individuals but families and nations as well.
Lower socioeconomic groups generally have a greater prevalence of risk factors to
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diseases and mortality in developed countries, and as the CVD epidemic matures in
developing countries, it will only add on to the mortality and morbidity risk factors in
these countries, many of whom can ill afford to cope with additional financial burden
(WHO, 2006).
In the 1970s, the most important causes for death in the Islamic republic of Iran were
infectious disease with 94 deaths per 100,000, followed by diarrhea and diarrhea plus
gastrointestinal disease which were responsible for 46 deaths per 100,000. The
cardiovascular disease with 42 deaths per 100,000 was the third major cause of death.
Thirty-two years later, in 2002, cardiovascular disease became the most important cause
of death in Iran with a rate of 167.7 deaths per 100,000 people, with an estimated 23.4%
wasted age (years which everybody can survive with disability), and, in the same year,
38% of all deaths were due to CVD. The mean age of death due to cardiovascular
disease in Iran was 68 years (Ministry of Health and Medical Education, Iran, 2006).
The major non- modifiable risk factors for CVD consist of increasing age, gender and
heredity factors including race. Major modifiable risk factors for CVD are smoking,
high blood cholesterol, high blood pressure, physical inactivity, obesity, diabetes type 2
and stress (Purcell et al. 2006). Among Iranians the most important risk factors for CVD
were identified as sedentary lifestyle (69%), high level of cholesterol (44%) and being
overweight (28%) (Ministry of the Health, Iran, 2005).
Menopausal women are at a greater risk of CVD. The effects of menopause transition on
metabolic and cardiovascular disease risk in women are unclear. It is unknown whether
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estrogen deficiency, aging, or a combination of both factors contributes to a worsening
health profile in women. Preliminary evidence suggests that natural menopause is
associated with reduced energy expenditure during rest and physical activity, an
accelerated loss of fat-free mass, and increased central adiposity and fasting insulin
levels (Poehlman, 2002).
Healthy lifestyle is an important strategy for the whole community, and it revolves
around a balanced diet, avoiding saturated fats, taking regular exercise, reducing weight
and not smoking. Numerous studies in people with and without documented CVD have
revealed that a low level of aerobic fitness is as an independent risk factor for all-cause
and cardiovascular mortality (Haddock et al., 2000). Regular exercise also promotes
reductions of body weight and fat stores, blood pressure (particularly in hypertensive
patients), levels of total blood cholesterol, serum triglycerides, and low-density
lipoprotein cholesterol. Exercise also increases high-density lipoprotein cholesterol, and
it may also reduce the risk of CVD by improving blood hemostatic function (Eichner,
1997). Currently it is estimated that, 60% of the world's population do not get enough
physical activity to achieve even this modest recommendation (30 to 60 minutes three or
four times a week), with adults in developed countries most likely to be inactive
(Franklin & Sanders, 2000). The risk of developing cardiovascular disease increases by
1.5 times in people who do not follow minimum physical activity recommendations
(WHO, 2006).
Education (conducted based on a standard schedule) and counseling can change
behavior. Several models of health education, for example, the Health Belief Model
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(HBM), Cognitive and Information Processing Model, Theory of Reasoned Action
(TRA) and Social Cognitive Theory (SCT) have been used in studies. In the past ten to
fifteen years, a number of conceptual models have been proposed in an attempt to
explain these individual health- related behaviors. Among these theories, the model that
has received the most direct attention and has influenced much research is the “Health
Belief Model” (Becher et al., 1977).
The Health Belief Model (HBM) posits that health behavior is a function of the
perceptions an individual has of vulnerability to an illness and the perceived potential
effectiveness of treatment with respect to deciding whether to seek medical attention. In
this model, health- related behaviors are determined by whether individuals: (1) perceive
themselves to be susceptible to a particular health problem; ( 2) see this problem as
serious; (3) are convinced that treatment or prevention activities are effective and (4) are
exposed to a cue to take a health action (Elder et al., 1999).
Due to improvements in health and nutritional status, as well as medical care in Iran,
life expectancy among women has increased to 71 years in the year 2000 (UNFPA,
2000). Therefore, with increasing the number of women who become menopause
annually, and since there are some physical and psychological problems associated with
menopause, studying menopause complications and ways to overcome these
complications in Iran is necessary.
Because CVD is the most important cause of death in Iran, and the important risk factors
for CVD are physical inactivity, high cholesterol and overweight, in the present study,
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the researcher intends to examine the effect of behavior changes (diet intervention and
exercise) on cardiovascular risk factors in postmenopausal women.
1.3 Conceptual Framework of the Study
The basic premise of the framework (Figure 1.1) was the fact that during menopause,
women go through several changes; namely, reduction and therefore a lack of estrogen,
reduction in energy expenditure due to lack of estrogen, physical inactivity and may
have unhealthy diets all of which were reflected in increased lipid profiles (box on the
far left). This put them at risk of contracting CVD. CVD risk factors included obesity,
dyslipidemia, hypertension, physical inactivity and inappropriate dietary intake (right
hand box). This study introduced an educational intervention program in order to
determine its effectiveness. The study divided the participants into three intervention
groups (exercise, diet and diet + exercise) and then determined the effects of six months
educational intervention on CVD risk factors were compared with a control group. The
box at the base of the framework spells out the changes that are expected as a result of
intervention. These include: a) biochemical changes i.e. reductions in cholesterol, TG,
FBS, LDL, VLDL CRP, increase in HDL, b) anthropometric changes like BMI, waist
circumference and WHR, c) increased physical activity, d) reduction in blood pressure,
and e) improved dietary intake.
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Figure 1.1: Conceptual Framework of the Study
Changes durig Menopause
Lack of estrogen
Reduction in energy
expenditure
Increased blood lipid
Physical inactivity
Unhealthy diet
CVD risk factors Obesity
Dyslipidemia
Diabetes
Hypertension
Physical inactivity
Unhealthy diet
Educational Intervention
Health Belief Model
Diet Exercise Diet+Exercise Control
EXPECTED CHANGES
Biochemical Changes Anthropometric Increase in physical HBM
Reduction in: Reduction in activity Increase in
Cholesterol ▪ BMI ▪ Reduction in blood ▪ Knowledge
TG ▪ Waist circumference Pressure ▪ Perception
LDL ▪ Waist hip ratio ▪ Improve dietary of Seriousness
VLDL intake ▪ Perception
Increase in HDL of vulnerability
▪ Perception of
Cues to action
▪ Perception of Benefits
▪ Reduction in
barriers
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1.4 Importance of the Study
The burden of CVD is increasing worldwide. Between 2002 and 2006, CVD has been
cited as the most important cause of death in Iran. The important modifiable risk factors
for CVD in Iran are physical inactivity, high cholesterol and being overweight. Nutrition
and dietary pattern has been known for many years to be modifiable risk factor for
chronic diseases especially CVD. Currently, interest in physical activity as a means for
primary prevention of CVD is increasing as the evidence of its protective role has
become more definitive. As the diet and physical activity are the most important aspects
of lifestyle for CVD prevention, this intervention has been developed to help women
change their dietary habits and sedentary lifestyle.
A salient characteristic of this study is that women will be encouraged to adopt healthy
diet patterns without having to make drastic diet changes (e.g. low fat or high protein,
low carbohydrate diet).
In Iran, there are not many diet and exercise intervention programs to reduce CVD risk
factors, especially among women. Therefore this study can be starting point for
menopausal women to adjust their lifestyle in order to cater to major health problems
e.g. CVD that they experience in menopause.
Therefore, this study is essential to support the importance of healthy diet and physical
activity as the primary prevention strategies for CVD. The findings and knowledge
derived from this study will be useful for the future development of diet and physical
activity programs in the society. At the present time, there is no special service devoted
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to postmenopausal women. It is also hoped that the result of this study can influence the
policy makers in Iran to pay special attention to the health needs of postmenopausal
women and, therefore, provide the appropriate health programs.
1.5 Objectives of the Study
Main objective:
The main objective of this study is to determine the effect of exercise and diet
educational intervention on modifiable CVD risk factors among postmenopausal Iranian
women.
Specific Objectives:
1- To determine the CVD risk factors in postmenopausal women:
i. Anthropometric measurements including; body mass index (BMI), waist
circumference, waist hip ratio (WHR)
ii. Lipid profile including; cholesterol, low desity lipoprotein (LDL), very low
desity lipoprotein (VLDL), high density lipoprotein (HDL), triglyceride (TG)
and C- reactive protein (CRP)
iii. Fasting blood sugar (FBS)
iv. Blood pressure
v. Physical activity
vi. Diet
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2- To determine the effects of exercise and diet educational intervention on CVD
risk factors:
i. Anthropometric measurements (BMI, waist circumference, WHR)
ii. Lipid profile (cholesterol, LDL, VLDL, HDL, TG and CRP)
iii. FBS
iv. Blood pressure
v. Physical activity
vi. Diet
3- To examine the components of the Health Belief Model at baseline and at the end
of the interventions with regards to:
i. Level of knowledge of women about the effect of exercise and diet on CVD risk
factors
ii. Perception of postmenopausal women about the seriousness of CVD
iii. Perception of postmenopausal women about the barriers and benefits of exercise and
healthy diet on CVD risk factors
iii. Perception of postmenopausal women about vulnerability to CVD
iv. Perception of postmenopausal women about cues to action to reduce CVD risk
factors
4-To examine the relationship of Health Belief Model and reduction in CVD risk
factors
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1.6 Null Hypotheses
At the end of the study, there is no significant difference in changes among groups
before and after the intervention in the following areas:
1- CVD risk Factors
i Anthropometric measurements (BMI, waist circumference, WHR)
ii. Lipid profile (cholesterol, LDL, VLDL, HDL, TG and CRP)
iii. FBS
iv. Blood pressure
v. Physical activity
vi. Diet
2- Components of the Health Belief Model
i. The level of knowledge
ii. The perception of the seriousness of CVD
iii. The perception of the benefits of intervention for CVD prevention
iv. The perception of the vulnerability to CVD
v. The perception of cues to action for CVD
vi. The perception of barriers towards CVD prevention
3- There is no significant relationship between Health Belief Model and reduction
in CVD risk factors
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Table 1.1: Glossary of terms
Terms Definition Reference
Health Belief
Model (HBM)
The HBM is an educational model for
prevention-focused programs as these
programs generally promote specific
actions, and the HBM helps
participants to take action.
Glanz, Lewia & Rimer.
(1997).
Health enhancing
physical activity
(HEPA)
An active category that computed for
people who being active at least 1.5 to
2 hours throughout the day, which
accumulate a minimum of at least
3000 MET-minutes/week
IPAQ Group, (2004)
METs Metabolic Equivalents, multiple of the
resting rates of oxygen consumption
during physical activity
Ainsworth et al., 1993
Physical activity Any body movement produced by
skeletal muscles and resulting in a
substantial increase over the resting
energy expenditure
American Heart
Association, (2001) © COPYRIG
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Cardiovascular
disease (CVD)
Cardiovascular disease is defined as a
disease in heart or blood vessel and
stroke.
American Heart
Association, (2006)
CVD risk factors
CVD risk factors include: Heredity,
being male, advancing age, cigarette
smoking, high blood pressure,
diabetes, obesity, lack of physical
activity, (abnormal blood cholesterol
and homocysteine levels).
Blair et al., 1995 & Collins,
(2006).
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