Women & Health

ISSN: 0363-0242 (Print) 1541-0331 (Online) Journal homepage: http://www.tandfonline.com/loi/wwah20

Effect of Aerobic Exercise and Nutrition Education

on Quality of Life and Early Menopause
Symptoms: A Randomized Controlled Trial

Mehrnaz Asghari MSc, Mojgan Mirghafourvand PhD, Sakineh Mohammad-

Alizadeh-Charandabi, Jamileh Malakouti MSc & Saharnaz Nedjat

To cite this article: Mehrnaz Asghari MSc, Mojgan Mirghafourvand PhD, Sakineh Mohammad-
Alizadeh-Charandabi, Jamileh Malakouti MSc & Saharnaz Nedjat (2016): Effect of Aerobic
Exercise and Nutrition Education on Quality of Life and Early Menopause Symptoms: A
Randomized Controlled Trial, Women & Health, DOI: 10.1080/03630242.2016.1157128

To link to this article: http://dx.doi.org/10.1080/03630242.2016.1157128

Accepted author version posted online: 24

Feb 2016.

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 Effect of aerobic exercise and nutrition education on quality of
life and early menopause symptoms: A randomized controlled
trial

Mehrnaz Asghari, MSca, Mojgan Mirghafourvand, PhDb, Sakineh Mohammad-Alizadeh-

Charandabic, Jamileh Malakouti, MScb, Saharnaz Nedjate

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a
Student Research Committee, Aras International Branch, Tabriz University of
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Medical Sciences, Tabriz, Iran

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b
P Nursing and Midwifery Faculty, Midwifery Department, Tabriz University of
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Medical Sciences, Tabriz, Iran

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c
P Social Determinants of Health Research Center, Nursing and Midwifery
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Faculty, Midwifery Department, Tabriz University of Medical Sciences, Tabriz,

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Iran
d

e
P Department of Epidemiology and Biostatistics, School of Public Health,
P
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Knowledge Utilization Research Center, Tehran University of Medical

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Sciences, Tehran, Iran

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The aim of this randomized controlled study was to assess the effect of exercise and nutrition
69T 69T 69T 69T 69T 69T 69T 69T 69T
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education on quality of life and early menopausal symptoms. This trial was conducted in east
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Azerbaijan province-Iran, during 2013-2014 on 108 women allocated into one of four groups
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(n = 27 in each group) by block randomization. The interventions received by the three

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intervention groups were: nutrition education, aerobic exercise, or exercise plus nutrition

education. The control group did not receive any intervention. The Greene and MENQOL

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 menopause symptom scales were completed before and at 8 and 12 weeks after the

intervention. The mean Greene score was significantly lower than the control group in the

exercise (adjusted mean difference: -5.1) and exercise plus nutrition groups (-8.0) at the end

of week 8 and in the nutrition (-4.8), exercise (-8.7) and exercise plus nutrition (-13.2)

groups at the end of week 12. Also, the mean MENQOL score was significantly

lower than the control group in the exercise (-8.3) and exercise plus nutrition groups (-

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13.8) at the end of week 8 and in the nutrition (-6.6), exercise (-13.5) and exercise plus
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nutrition (-22.1) groups at the end of week 12. Nutrition education with aerobic exercise can

improve quality of life.

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Key words: Exercise, Nutrition, Quality of life, Menopause, Education
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Received 28 Aug 2015 Revised 30 Sep 2015 Accepted 06 Oct 2015
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CONTACT Mojgan Mirghafourvand, PhD

Nursing and Midwifery Faculty, Midwifery Department, Tabriz University of Medical

Sciences, Tabriz, Iran
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Email: mirghafourvandm@tbzmed.ac.ir
e
pt

Color versions of one or more figures in this article are available online at

www.tandfonline.com/wwah.
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Introduction
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Menopause is one the most important stages of women’s life, characterized by falling

estrogen levels and symptoms such as hot flashes, sleep disturbances, and urogenital

problems, and potential long-term complications, including osteoporosis and cardiovascular

problems (Speroff and Fritz 2011). Hot flashes are an early menopause symptom with

prevalence rates ranging from 18% to 75% in different studies (75% in American women
2
 over 50 years old, 17% in Japan, 21% in China (Utian 2005) and 59.5% % in Iranian women

( Asadi et al. 2012)). Different studies conducted in Iran and other parts of the world have

revealed the negative effect of menopause symptoms on quality of life (QOL) (Fallahzade

2010; Abedzadeh et al. 2011). QOL is a subjective and multi-dimensional concept that

includes physical and psychological aspects (Mirghafourvand et al., 2015).

Although the standard treatment for early menopausal symptoms is hormone therapy,

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this approach has become less appropriate due to the serious long-term side effects of
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estrogen (Rossouw et al. 2002), and today, non-pharmacological treatments are sometimes

recommended for improving menopausal symptoms (Golian Thehrani, Ghobadzade, and

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Arastou 2007). Observational studies have shown that vasomotor and other early menopausal
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symptoms, including sleep disturbances, were improved with increased physical activity

(Elavsky and McAuley 2007; Ayati et al. 2008). Moreover, some other studies reported the
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positive effect of exercising on QOL in menopausal women (Elavsky and McAuley 2007;

Mansikkamäki et al. 2015). Another study did not show any significant correlation between a
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12-week structured exercise program and QOL, while, a significant correlation was observed
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between exercising and reduction of climacteric symptoms (Ueda 2004). However, some
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studies revealed that exercising did not have a significant effect on reducing vasomotor and
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sexual symptoms but did reduce physical and mental symptoms (Shabani Bahar and

Pooraghaei 2009). Review studies have reported insufficient evidence for the effect of
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exercising on reducing hot flashes, and clinical trials have not completely proved that

exercising reduces menopausal symptoms. Furthermore, previous studies are few and

contradictory, so that, broader studies should be performed to address this question

(Pachman, Jones, and Loprin 2010; Daley, Stokes Lampard, and Macarthur 2011).

3
 Another fundamental measure for promotion of health in women is nutrition

(Baheiraei et al. 2012). A nutritional program in which micronutrients are received is a

potentially modifiable factor in alleviating early menopausal symptoms (Huang et al. 2010).

The findings about the effect of phytoestrogens on menopausal symptoms have been

inconsistent (Aghamiri et al. 2015; Sammartino et al. 2006; Ferrari 2009; Riesco et al. 2011).

. Moreover, appropriate nutrition is effective in reducing obesity, cardiovascular problems,

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hypertension, some types of cancer, and osteoporosis (Lang and Froelicher 2006). However,
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studies have shown that menopausal women often lack enough knowledge about the positive

effects on their health through increasing healthy behaviors (Chen et al. 2007; Hasanpour

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Azgadi and Abbasi 2006). An important factor to increase knowledge and improve

menopausal women’s performance is educating them (Golian Thehrani, Ghobadzade, and

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Arastou 2007; Manios et al. 2006). Most studies indicated the positive effect of education

with various methods to increased knowledge and QOL in menopausal women (Ueda et al.
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2009; Moridi et al. 2013; Yazdkhasti et al. 2012).

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However, given that the effect of education was not explained in detail in previous
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studies, and the previous studies about the effect of exercise are few and contradictory and
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given that no study has examined the effect of exercising and nutrition in combination, the
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present study was conducted to determine the effect of aerobic exercises and nutritional

education on early menopausal symptoms and QOL in menopausal and premenopausal

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women as primary outcomes and number of hot flashes as secondary outcomes.

Methods

Study design and participants

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 This study was a randomized controlled trial conducted on married premenopausal and

postmenopausal women aged 45-60 years in Kaleybar city, East Azerbaijan- Iran from

February 2013 until May 2014. Sampling was done in two health centers in Kaleybar, Iran. In

this study, only the data analyst was masked as to the type of intervention given to every

participant (single blinding).

Exclusion criteria included having kidney, thyroid, cardiovascular, and psychological

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diseases or diabetes; using estrogen up to three months prior; following a specific diet; and
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having severe stressors, such as the death of a close family member within the past month.

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According to the information available in in Yazdkhasti et al.’s study and regarding

mean QOL score before (m 1 =153.8) and after (m 2 =113.3) the intervention, SD 1 = 38.6,
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sd 2 =24.3, two-sided α=0.05 and β=0.1, the necessary sample size for each group was

calculated as 24, which we increased to 27 to cover a probable sample loss of 10%.

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Sampling
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Sampling started after obtaining permission from the Ethics committee of research and
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technology deputy of Tabriz University of Medical Sciences under the number 91153 and
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registering the trial in the IRCT website under the code IRCT2012111210324N6. The
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researcher went to the medical centers included in the study and prepared a list of women

aged 45-60 years from the list of families and active records in those centers. Then, the
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researcher called these women and invited them to participate in the study. In the first

session after the examination and confirmation of participants’ health status by a physician,

the objectives of the study were explained to participants, and written informed consent was

obtained. In this study, 630 women were assessed for eligibility; 370 women did not meet

eligibility criteria, and 152 of those remaining (58.5%) declined to participate in the study.

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 Randomization
A software program was used to assign the participants randomly to one of each of the four

groups by a non-involved member of the research team. Numbered sealed opaque envelopes

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containing their group information were used to conceal their allocation assignment.
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Participants were randomly allocated into one of three interventions or a control group by

block randomization stratified by menopausal status with block sizes of 4 and 8 with the

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allocation ratio 1:1:1:1. The interventions received by the intervention groups were: nutrition
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education (nutrition group), aerobic exercises (exercise group), or exercise along with

nutrition education (exercise plus nutrition group). The control group did not receive any
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intervention.
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Interventions
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The aerobic exercises were performed as walking for 12 weeks with mean intensity of 60%-
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70% heart rate reserve (HRR) and three times per week for 30-45 minutes under direct
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supervision of the first author. The exercise group did exercises in a gym for 30 minutes at an

intensity of 60% HRR in the first two weeks. Each session included warm-up for 5 minutes,
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continuous walking for 20 minutes and cool down for 5 minutes. The participants’ heart rate

was measured before and during each session by the first author of this study and a trained

research assistant using Polar stethoscope. After the first two weeks, the intensity of

exercising gradually reached 70% HRR, and the duration of exercising increased to 45

minutes.

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 The nutritional education was implemented in three sessions within three consecutive

weeks, once per week for 45-60 minutes. The number of participants in each class ranged

from 10 to 17. The last 15 minutes of each session was allocated to questions and answers.

The educational content of classes was about food groups and phytoestrogens and their role

in reducing menopausal symptoms. At the end of the first session, a booklet on the nutrition

was given to the participants.

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Instruments

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The data were collected using questionnaires on demographic information, menopause-

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specific QOL (MENQOL), and Greene menopausal scale and a checklist for recording the

number of hot flashes, completed before the intervention and at 8 and 12 weeks after the
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intervention.
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The demographic information consisted of self-reported age, height, weight,

menopausal age, educational level, occupation, sufficiency of monthly income for living
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costs, and family size.

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The menopause-specific QOL questionnaire (MENQOL) was developed by Hilditch

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at the University of Toronto, Canada to determine QOL among menopausal women (1996).
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The questionnaire consists of 29 closed questions according to six-point Likert scale and

divided into a vasomotor subscale (3 items), psychosocial subscale (7 items), physical

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subscale (16 items), and sexual subscale (3 items). The attainable score range is 0-174.

Higher scores indicated higher severity of the menopausal symptoms and lower QOL in

menopausal women. Yazdkhasti et al. (2012) assessed validity and reliability of the

instrument using test-retest method and reported the correlation coefficient r=0.84.

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 The Green inventory consists of 21 items on menopausal complications and

independently measured mental, physical, and vasomotor symptoms caused by menopause,

as each symptom was graded by the participants based on Likert scale (0-3). A study

conducted in Gonabad, Iran (2012) assessed the reliability of this instrument using test-retest

method and reported the correlation coefficient r=0.74 (Askari et al. 2012).

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Statistical analysis
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Normality of quantitative variables for each of the groups was confirmed using the

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Kolmogorov–Smirnov test. One Way ANOVA was used for comparison of the baseline

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scores and ANCOVA for comparison of the follow-up scores adjusted for the baseline values.

Sidak was used for multiple comparisons between the groups. Assumptions related to model
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fit, including independence of observations, linearity, outliers, homoscedasticity,

homogeneity of variances and normality were assessed. p values of less than .05 were
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considered statistically significant, and all pre-post analyses were performed by intention to
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treat. Data analysis was conducted using SPSS, version 14.0 (SPSS Inc., Chicago, IL, USA).
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Results
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Of the 27 participants allocated to each group, the following were excluded: two participants

in the exercise plus nutrition group (one participant for her sister’s death and severe mental
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problem and not completing the inventory in the 12th week and one participant for not

attending the exercise sessions regularly due to a backache and not completing the inventory

in the 8th and 12th weeks), three participants in the exercise group (one participant for

moving to another home and not completing the inventory in the 12th week and two

participants for not attending the exercise sessions regularly due to backache), and one

8
 participant in the control (due to use of hormone therapy) were excluded from the study

(Figure 1).

The studied groups were similar in terms of demographics characteristics: 56% were

menopausal, and 44% were premenopausal. Mean age and mean menopausal age of the

participants were 50.3 (SD = 3.1) years and 46.7 (SD = 4.3) years, respectively. The mean

body mass index of the participants was 31.1 (SD = 3.6), and 95% of them were overweight

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or obese. None of the women smoked. Almost one third of the women were illiterate, but
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20% had university degrees and high school diploma. Most of the participants were

housekeepers (80%), and almost one third of the women’s husbands had a high school

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diploma or higher degrees. Almost two thirds of the studied participants reported that their
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monthly income was sufficient (27%). Half of the participants (53%) were completely

satisfied with their life (Table 1).

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Based on ANOVA, the four groups were not significantly different before the

intervention in terms of total score for the Green inventory, QOL score, and number of hot
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flashes. Having adjusted the baseline scores and the menopausal status (menopausal and
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premenopausal), the ANCOVA showed a significant difference among the four groups 8 and
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12 weeks after the intervention.

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In comparing the three intervention groups with the control group, the total score for

the Green inventory was significantly lower 8 weeks after the intervention in the exercise
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group (adjusted difference: -5.1, 95% confidence interval: -9.4 to -0.8) and exercise plus

nutrition group (-8.0, -12.3 to -3.7) and 12 weeks after the intervention in all intervention

groups; nutrition (-4.8, -8.4 to -1.3), exercise (-8.7, -12.3 to -5.2) and exercise plus nutrition (-

13.2, -16.9 to -9.6) than that in the control group. However, no significant difference was

9
 observed between the nutrition group (-2.6, -6.9 to 1.5) and the control group 8 weeks after

the intervention (Table 2).

Mean QOL score (MENQOL) was significantly lower 8 weeks after the intervention

in the exercise group (-8.3, -15.6 to -0.95) and exercise plus nutrition group (-13.8, -21.2 to -

6.4) and 12 weeks after the intervention in nutrition (-6.6, -12.9 to -0.3), exercise (-13.5, -19.9

to -7.1) and exercise plus nutrition (-22.1, -28.5 to -15.7) groups than that in the control group

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However, no significant difference was observed between nutrition group (-4.2, -11.5 to 3.0)
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and the control group 8 weeks after the intervention (Table 3).

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The mean number of hot flashes was significantly lower 8 weeks after the

intervention in the exercise plus nutrition group (-1.3, -2.4 to -0.3) and 12 weeks after the
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intervention in nutrition (-2.3, -3.8 to -0.8), exercise (-1.9, -3.3 to -0.4) and exercise plus

nutrition (-3.3, -4.8 to -1.8) groups than that in the control group (Table 4) (Figure 2).
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Mean total score for the Green inventory was significantly lower 8 weeks after the

intervention in the exercise plus nutrition group (-5.3, -9.6 to -1.0) and 12 weeks after the
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intervention in the exercise group (-3.8, -7.4 to -0.3) and exercise plus nutrition group (-8.3, -
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12.0 to -4.7) than that in the nutrition group. In comparison of the exercise plus nutrition
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group with the exercise group, mean total score for the Green inventory was significantly
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lower in exercise plus nutrition group (-4.5, -8.1 to -0.8) than that in the exercise group only

12 weeks after the intervention.

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Mean QOL score (MENQOL) was significantly lower 8 weeks after the intervention

in the exercise plus nutrition group (-9.6, -17.0 to -2.2) and 12 weeks after the intervention in

the exercise group (-6.9, -13.3 to -0.6) and exercise plus nutrition group (-15.5, -21.9 to -9.1)

than that in the nutrition group.

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 Discussion
Based on the investigations, this study was the first to examine the effect of education and

exercising in combination on QOL and menopausal symptoms. Results of this study revealed

that the 12-week program of nutrition education and aerobic exercises with moderate

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intensity resulted in improvement of early menopausal symptoms and QOL and reduction of
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hot flashes in menopausal and premenopausal women in the three intervention groups.

The QOL score of the intervention groups in this study was significantly different

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from that of the control group, and this result conformed to that in Shabani Bahar and
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Pooraghaei’s study (2009), reporting that doing exercises three times per week for 12 weeks

improved the menopausal women’s QOL. Ueda's study (2004) conducted in Japan showed
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that a 12-week regular exercising improved the QOL score and developed a positive attitude

toward exercising in women aged 40-60 years. This result conformed to that of the present
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study and Delay et al.’s study (2007) in Turkey and Elavsky and McAuley study (2007) in
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Pennsylvania. These two studies reported that women doing aerobic exercises regularly had
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higher health-related quality of life score than women who did not do exercises. The
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conformity among these studies might be attributed to the fact that education and

encouraging menopausal women to exercise improved their attitude and, consequently, their
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performance.

The score of menopausal symptoms in the intervention groups was significantly lower

than that in the control group. Tartibian, Sharabiani, and Abbasi (2009) conducted a study in

Urmia, Iran and indicated that a 10-week exercise program with moderate intensity could

reduce vasomotor symptoms resulting from menopause. This result agrees with that of the

11
 present study because exercising reduced follicle stimulating hormone and luteinizing

hormone levels and, improved vasomotor symptoms. However, results of the present study

did not conform to those from a study performed in Netherland (van Poppel and Brown

2008), which reported that physical activity did not reduce vasomotor and mental symptoms

during menopause. This disagreement might be attributed to the different durations of the

study, as the above study examined participants during a rather long time (2001-2004), that in

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turn might have revealed the real effect of the intervention over time. Furthermore, the results
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of the present study did not conform to those of McAndrew et al.’s study (2009) conducted in

the United States, which showed that increased physical activity did not affect vasomotor

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problems during menopause. The probable reason for this difference might be the different

designs of these two studies, as McAndrew et al.’s study examined women in terms of the
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physical activity, while, in this study, participants received nutrition education and exercise

program, and these activities might improve participants' attitude, encourage them more than
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ever, and consequently, improve symptoms.

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In this study, the nutrition group was significantly different from the control group 12
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weeks after the intervention in terms of reduced menopausal symptoms, and this result
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conforms to that of most studies on nutrition education (Moridi et al. 2013; Forouhari et al.
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2010) and clinical trials (Yang et al. 2012; Ziaei, Kazemnejad, and Zarei 2007; Agemiri et al.

2006) on the effect of phytoestrogens on vasomotor symptoms. However, based on the results
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of Burke et al. (2003), it does not appear that isoflavones are n effective for relief of

vasomotor symptoms because in this study, no evidence was found of relief of vasomotor

symptoms from soy protein supplementation containing three different doses of isoflavones

(≤4 mg/day, 42 mg/day and 58 mg/day). The effectiveness of nutrition education might be

due to the improvement of women’s nutritional behaviors, higher use of food containing

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 phytoestrogens, and use of instructions taught for reducing early menopausal symptoms. In

fact, education through promoting people’s attitude resulted in reduction of menopausal

symptoms. As women’s level of knowledge increases, their menopausal symptoms decrease,

and women with positive attitude toward menopausal symptoms experience less frequent

symptoms (Yanikkerem et al. 2012).

In this study, the number of hot flashes per week was significantly lower in the

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exercise group and the exercise plus nutrition group than that in the control group, and this
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result did not agree with Nelson et al.’s study (2008) conducted in Philadelphia which did not

show any correlation between hot flashes and physical activity. This contradiction might be

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related to the duration of Nelson et al.’s study, as women were examined during 8 years in
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terms of physical activity, and this long-term physical activity might show a more realistic

effect of the educational intervention. Moreover, Nelson et al. examined participants’

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hormonal level as a possible confounding factor influencing the number of hot flashes, and

this analysis might be another reason for the difference in results between the present study
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and those from Nelson et al.’s (2008) study.

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This study was performed on normal menopausal and premenopausal women through
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an exercise program under direct supervision of the researcher and a nutrition education
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program along with changes in nutritional pattern under indirect supervision of the

researcher. Therefore, results of this study may not be generalized over menopausal women
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with underlying diseases and cases where the exercise program was performed without direct

supervision or changes in nutritional pattern were carried out under direct supervision.

Considering the small sample size of this study, it was not possible to determine the

effect of the educational intervention alone on menopausal and premenopausal women and,

consequently, the existence or lack of a difference between the two groups in terms of the

13
 effect of such an intervention. In this respect, further studies are recommended to examine the

effect of educational intervention alone on menopausal women.

Acknowledgments
We thank all staff at the Kaleybar who cooperated in sampling and all the participants in this

research.

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Funding

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This study was funded and supported by Tehran University of Medical Sciences (TUMS);
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Grant no. 92-01-155-21414.
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 TABLE 1 Socio-demographic characteristics of the participants by the groups

Nutrition Exercise Nutrition plus Control

Characteristics exercise P
(n = 27) (n = 27) (n = 27)
(n = 27)

N (%) N (%) N (%) N (%)

Age (years)

t
ip
50.0 50.2
Mean (SD)* 50.4 (3.2) 50.3 (3.1) .962 †
(2.9) (3.2)
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Menopausal age (years)

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46.0 45.8
Mean (SD)* 46.8 (4.6) 48.3 (4.4) .383 †
an (4.4) (3.8)

Menopausal status

Menopausal 15 (55.6) 15 (55.6) 15 (55.6) 15 (55.6)

1 ††
M
Premenopausal
69T 69T 12 (14.4) 12 (14.4) 12 (14.4) 12 (14.4)

Body mass index (kg/m2) P P

d

32.0 30.7
Mean (SD)* 31.1 (3.7) 30.7 (3.7) .549 †
e

(3.4) (3.7)
pt

Education level 69T

Illiterate 10.0 (37.0) 12 (44.4) 10 (37.0) 13 (48.1)

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Primary 5 (18.5) 6 (22.2) 6 (22.2) 6 (22.2)

.587 §
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Middle school 5 (18.5) 3 (11.1) 5 (18.5) 2 (7.4)

High school/diploma 5 (18.5) 4 (14.8) 5 (18.5) 4 (14.8)

University 2 (7.4) 2 (7.4) 1 (3.7) 2 (7.4)

Husband's education level

69T 69T154 69T154

Illiterate 3 (11.1) 3 (11.1) 2 (7.4) 6 (22.2)

.142 §
Primary 4 (14.8) 8 (29.6) 6 (22.2) 9 (33.3)

18
 Middle school 3 (11.1) 4 (14.8) 7 (25.9) 3 (11.1)

High school 6 (22.2) 2 (7.4) 0 (0.0) 2 (7.4)

Diploma 9 (33.3) 10 (37.0) 9 (33.3) 7 (25.9)

University 2 (7.4) 0 (0.0) 3 (11.1) 0 (0.0)

Life satisfaction
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Completely satisfy 13 (48.1) 14 (51.9) 16 (59.3) 15 (55.6)

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Relatively satisfy 11 (40.7) 10 (37.0) 7 (25.9) 9 (33.3) .086 §
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Completely dissatisfy 3 (11.1) 3 (11.1) 4 (14.8) 3 (11.1)

Economic status

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Income upper than spent 1 (3.7) 2 (7.4) 1 (3.7) 1 (3.7)

Income equal spent 17 (63.0) 19 (70.4) 21 (77.8) 20 (74.1) .493 §

an
Income lower than spent 9 (33.3) 6 (22.2) 5 (18.5) 6 (22.2)

Data indicate number (%); expect that the other is specified.

M

† †† ‡
* Mean (Standard deviation) P P One wey ANOVA Chi-square P Fisher exact test
P
d

§
Linear by linear chi-square
P P P
e
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 TABLE 2 Comparison of total mean score of Green scale in the study groups at different
69T 69T 69T 69T 69T 69T 69T 69T 69T 69T 69T 69T

time points

Baseline 8 weeks after 12 weeks after

Groups Mean (SD)† intervention intervention

Mean (SD)† Mean (SD)†

Nutrition 28.5 (10.0) 23.1 (9.5) 22.2 (9.0)

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Exercise 27.2 (12.2) 19.9 (9.7) 17.7 (8.3)
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Nutrition plus 28.2 (9.5) 17.7 (7.8) 14.2 (5.4)

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Exercise

Control 28.6 (9.2) 25.9 (8.3) 27.2 (8.1)

an
Group MD ( 95% CI
p MD ( 95% CI ) p MD ( 95% CI ) p
comparison )
M

Nutrition with -0.1 (-7.5 to -2.6 (-6.9 to -4.8 (-8.4 to -

1.000 0.453 .002
d

Control 7.3) 1.5) 1.3)

e

Exercise with -1.3 (-8.8 to -5.1 (-9.4 to - -8.7 (-12.3 to -

pt

.998 0.009 < .001

Control 6.1) 0.8) 5.2)
ce

Nutrition plus
-0.4 (-7.8 to -8.0 (-12.3 to - -13.2 (-16.9 to -
Exercise with 1.000 0.001 < .001
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7.0) 3.7) 9.6)

Control

Exercise with -1.2 (-8.7 to -2.4 (-6.7 to -3.8 (-7.4 to -

.999 0.536 .026
Nutrition 6.2) 1.7) 0.3)

Nutrition plus -0.3 (-7.7 to 1.000 -5.3 (-9.6 to - 0.007 -8.3 (-12.0 to - < .001

20
 Exercise with 7.1) 1.0) 4.7)

Nutrition

Nutrition plus
0.92 (-6.5 to -2.8 (-7.1 to -4.5 (-8.1 to -
Exercise with 1.000 0.391 .008
8.4) 1.4) 0.8)
Exercise

t
P (Four groups comparison) .963 .006 < .001

ip
N = Nutrition E= Exercise C= Control
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† ‡
Mean (Standard deviation) Mean Difference (%95 Confidence Interval)

us
No significant difference between the groups at baseline in Green score according to

ANOVA (p = .963)
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 TABLE 3 Comparison of total mean score of MENQOL in the study groups at different time
points

Baseline 8 weeks after 12 weeks after

Groups Mean (SD)† intervention intervention

Mean (SD)† Mean (SD)†

Nutrition 58.4 (17.4) 49.2 (14.5) 49.5 (13.7)

t
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Exercise 55.6 (24.0) 43.1 (24.6) 40.4 (22.0)
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Nutrition

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plus 59.5 (26.0) 40.1 (18.3) 35.4 (16.1)

Exercise
an
Control 60.8 (19.0) 55.2 (17.8) 57.8 (17.9)

Group MD ( 95% CI ) MD ( 95% CI )

M
p p MD ( 95% CI )‡ p
‡ ‡
comparison
d

Nutrition -2.4 (-13.7 to -4.2 (-11.5 to -6.6 (-12.9 to -

.675 .552 .034
e

with Control 8.9) 3.0) 0.3)

pt

Exercise -5.1 (-16.5 to -8.3 (-15.6 to - -13.5 (-19.9 to - <

.371 .018
ce

with Control 6.2) 0.95) 7.1) .001

Nutrition
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plus -1.2 (-12.5 to -13.8 (-21.2 to - -22.1 (-28.5 to - <

.832 <.001
Exercise 10.1) 6.4) 15.7) .001

with Control

Exercise -2.7 (-14.1 to .634 -4.0 (-11.4 to .589 -6.9 (-13.3 to - .024

22
 with 8.6) 3.2) 0.6)

Nutrition

Nutrition

plus
1.1 (-10.1 to -9.6 (-17.0 to - -15.5 (-21.9 to - <
Exercise .837 .004
12.5) 2.2) 9.1) .001
with

t
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Nutrition
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Nutrition

us
plus
3.9 (-7.4 to -5.5 (-12.9 to -8.5 (-15.0 to -
Exercise .495 .247 .004
15.2) 1.8) 2.1)
with
an
Exercise
M

<
P (Four groups comparison) .846 <.001
.001
e d

N = Nutrition E= Exercise C= Control

pt

‡ †
Mean Difference (%95 Confidence Interval) Mean (Standard deviation)
ce
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 TABLE 4 Comparison of the number of hot flashes per week in the study groups at different
time points

Baseline 8 weeks after 12 weeks after

Groups Mean (SD)† intervention intervention

Mean (SD)† Mean (SD)†

Nutrition 28.3 (18.3) 27.3 (17.4) 26.0 (16.8)

t
ip
Exercise 28.9 (16.5) 28.3 (15.7) 27.5 (15.2)
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Nutrition plus 29.5 (16.1) 28.6 (15.6) 27.4 (14.8)

us
Exercise

Control 30.3 (22.6) 30.3 (22.4) 30.3 (22.4)

an
‡ ‡
Group MD ( 95% CI MD ( 95% CI
‡
p p MD ( 95% CI ) p
comparison ) )
M

Nutrition with -2.0 (-15.4 to -0.9 (-2.0 to -2.3 (-3.8 to -

.068 < .001
d

Control 11.3) 0.04) 0.8)

e

Exercise with -1.3 (-14.7 to -0.6 (-1.7 to -1.9 (-3.3 to -

pt

1.000 .409 .005

Control 12.0) 0.3) 0.4)
ce

Nutrition plus
-0.8 (-14.2 to -1.3 (-2.4 to - -3.3 (-4.8 to -
Exercise with 1.00 .003 < .001
Ac

12.5) 0.3) 1.8)

Control

Exercise with 0.6 (-12.7 to 0.2 (-0.7 to

1.0 .977 0.4 (-1.0 to 1.9) .966
Nutrition 14.0) 1.3)

Nutrition plus 1.2 (-12.1 to 1.0 -0.4 (-1.4 to .891 -1.0 (-2.5 to .345

24
 Exercise with 14.6) 0.6) 0.4)

Nutrition

Nutrition plus
0.5 (-12.8 to 0.7 (-1.7 to -1.4 (-2.9 to
Exercise with 1.0 .346 .064
13.9) 0.3) 0.04)
Exercise

t
P (Four groups comparison) .981 .005 < .001

ip
N = Nutrition E= Exercise C= Control
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‡ †
Mean Difference (%95 Confidence Interval) Mean (Standard deviation)

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 Downloaded by [University of California, San Diego] at 04:38 09 March 2016

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FIGURE 1 Flowchart of the study

pt
e d

26
M
an
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 FIGURE 2 Trend in the total mean score of Greene and MENQOL scale and hot flashes
number at the two follow-up points.

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