Long-term effect of physical activity on health-related quality of life among menopausal women: a 4-year follow-up study to a randomised controlled trial

Long- e m e ec o physical ac i i y on heal h- ela ed quali y o li e among menopausal women: a 4-yea ollow-up s udy o a andomised con olled ial Ki si Mansikkamäki, 1,2 Jani Rai anen, 1,3 Clas-Håkan Nygå d, 3 Eija Tomás, 4 Ree a Ru anen, 3 Rii a Luo o 1 To ci e: Mansikkamäki K, Rai anen J, Nygå d C-H, e al. Long- e m e ec o physical ac i i y on heal h- ela ed quali y o li e among menopausal women: a 4-yea ollow-up s udy o a andomised con olled ial. BMJ Open 2015;5:e008232. doi:10.1136/bmjopen-2015- 008232 ▸P epublica ion his o y o his pape is a ailable online. To iew hese iles please isi he jou nal online (h p://dx.doi.o g/10.1136/ bmjopen-2015-008232). Recei ed 20 Ma ch 2015 Re ised 23 July 2015 Accep ed 28 July 2015 1 UKK Ins i u e o Heal h P omo ion Resea ch, Tampe e, Finland 2 Tampe e Uni e si y o Applied Sciences, Tampe e, Finland 3 School o Heal h Sciences, Uni e si y o Tampe e, Tampe e, Finland 4 Tampe e Uni e si y Cen al Hospi al, Tampe e, Finland Co espondence o Ki si Mansikkamäki; [email p o ec ed] ABSTRACT Objec i es: The aim o he s udy was o explo e he long- e m e ec s o physical ac i i y in e en ion on quali y o li e (QoL) 4 yea s a e an o iginal andomised con olled ial (RCT). Design: Coho s udy a e an RCT. Se ing: 95 o he 159 women om he o iginal RCT pa icipa ed in weigh , heigh and wais ci cum e ence measu emen s, pe o med he UKK 2 km Walk Tes and comple ed he SF-36 Heal h Su ey ques ionnai e. Mul ile el mixed eg ession models we e pe o med in o de o compa e he o iginal and cu en g oup in an RCT se ing. Pa icipan s: The e we e 159 pa icipan s in he o iginal RCT; 2.5 yea s la e , 102 o he women esponded o a ques ionnai e and 4-yea a e he ial, he e we e 95 esponden s. The inclusion c i e ia in he o iginal RCT we e: being symp oma ic, expe iencing daily ho lushes, age be ween 40 and 63 yea s, no using ho mone he apy now o in he pas 3 mon hs, seden a y li es yle and ha ing las mens ua ed 3–36 mon hs ea lie . Main ou come measu e: Heal h- ela ed QoL as measu ed wi h he SF-36 ins umen . Resul s: Women in he in e en ion g oup had a signi ican ly highe p obabili y o imp o ed physical unc ioning (OR 1.41; 95% CI 1.00 o 1.99) as compa ed wi h women in he con ol g oup. In addi ion, women in he in e en ion g oup had highe odds o good ole unc ioning (OR 1.21; 95% CI 0.88 o 1.67), physical heal h (OR 1.33; 95% CI 0.96 o 1.84) and gene al heal h (OR 1.14; 95% CI 0.81 o 1.62), ela i e o women in he con ol g oup, al hough he di e ences did no each s a is ical signi icance. Conclusions: Women in he in e en ion g oup showed posi i e long- e m e ec s on physical and men al dimensions o QoL a e 4 yea s. T ial egis a ion numbe : ISRCTN54690027. INTRODUCTION Many physiological and psychological signs and symp oms occu in he li es o middle-aged women. 1 A posi i e associa ion be ween physical ac i i y (PA) and quali y o li e (QoL) has been explo ed in many s udies. 2–7 PA has been associa ed wi h lowe a es o cogni i e and physical decline among pos menopausal women. 8 In add- i ion, PA appea s o ha e posi i e e ec s on wo k abili y, bo h sho and long e ms. 9 Ho mone he apy (HRT) is widely used as ea men o menopause symp oms, e en hough exe cise has been deemed an al e na i e op ion o alle ia ing hei symp- oms and imp o ing QoL in midli e. 110 In an 8-yea ollow-up s udy, PA has been ound o be a significan ac o among menopausal women who had s able weigh o we e highly educa ed. 4 Inc easing one’s le el o PA du ing menopausal ansi ion and he pos menopausal pe iod o a leas main ain- ing he ecommended le el has also been sugges ed o educe a ious psychological symp oms. 11 We p e iously epo ed esul s om ou menopausal heal h and PA in e en ion an- domised con olled ial (RCT) 612 examining ae obic aining, and imp o ed menopausal and heal h- ela ed QoL among menopausal women. Women in he in e en ion g oup showed significan ly la ge dec ease in he equency o nigh - ime ho flushes. These S eng hs and limi a ions o his s udy ▪The co e s eng hs o he s udy a e i s p ospec- i e s udy design and epea ed assessmen s o physical ac i i y beha iou a se e al ime poin s a e in e en ion. ▪Ou s udy unde lines he impo ance o physical ac i i y du ing menopausal ansi ion. ▪The esponse a e (59.7%) was low and women wi h an ad e se li es yle we e mo e likely o be ound among non- esponde s. Mansikkamäki K, e al.BMJ Open 2015;5:e008232. doi:10.1136/bmjopen-2015-008232 1 Open Access Resea ch g oup.bmj.com on May 18, 2016 - Published by h p://bmjopen.bmj.com/Downloaded om g oup.bmj.com on May 18, 2016 - Published by h p://bmjopen.bmj.com/Downloaded om g oup.bmj.com on May 18, 2016 - Published by h p://bmjopen.bmj.com/Downloaded om findings we e based on in o ma ion collec ed h ough mobile phone dia ies. Addi ionally, he dia ies poin ed o be e sleep quali y among women in he in e en ion g oup as compa ed o hose in he con ol g oup. 7 We also epo ed ha he 6-mon h exe cise in e en ion had e ec s on wo k abili y 2½ yea s a e he RCT. 9 The aim o he ollow-up s udy epo ed he e was o explo e he long- e m e ec s o he PA in e en ion on QoL 4 yea s a e he RCT. MATERIALS AND METHODS The s udy popula ion consis ed o a sample o women who pa icipa ed in a ollow-up 4 yea s a e he begin- ning o he ial, which was in 2009. 6 The in e en ion s udy in 2009 was a RCT (ISRCTN54690027, h p:// www.con olled- ials.com/) in which he women we e andomised in o an in e en ion and a con ol g oup. C i e ia o inclusion in he in e en ion s udy we e: being symp oma ic, expe iencing daily ho flushes, age be ween 40 and 63 yea s, no using HRT now o in he pas 3 mon hs, ha ing a seden a y li es yle (wi h ae obic aining unde wice a week) and ha ing las mens u- a ed 3–36 mon hs ea lie . Women who we e physically ac i e (exe cising wo o mo e imes a week, a leas 30 min a a ime); whose body mass index (BMI) was abo e 35 kg/m 2 ; o who had co ona y hea disease, o hopaedic o o he diseases p e en ing hem om exe cising, we e excluded om he s udy. Fu he , women who we e using medica ion influencing hea a e, o using β-blocke s, we e excluded, since hey would ha e biased he esul s pe aining o hea a e. Menopausal s a us was e ified ia assay o plasma ollicle-s imula ing ho mone (FSH exceeding 30 IU/L). Be o e he ial began, day ime and nigh - ime ho flushes we e eco ded in a 2-week dia y, wi h he women ins uc ed o eco d a sensa ion o wa m h, wi h o wi hou concomi an swea ing, as a ho flush, and he daily equency o ho flushes be o e he in e en ion was es ima ed. Du ing he in e en ion, he numbe o ho flushes, bo h day ime and nigh - ime, was calcula ed. In o al, 159 women pa icipa ed in he s udy, and he du a ion o he in e en ion was 6 mon hs. 6 The women in he in e en ion g oup engaged in ae obic aining ou imes a week, wi h 50 min o exe - cise each ime. They we e ins uc ed o exe cise a a le el o abou 64–80% o maximal hea a e, whe eas he women in he con ol g oup we e ins uc ed o keep hei PA habi s unchanged. In he in e en ion g oup, a leas wo PA sessions had o consis o walking o No dic walking, while he o he sessions could include walking, No dic walking, skiing, jogging, cycling, swimming, ae - obics and/o gymnas ics. The in e en ion p ima ily included walking because ea lie ials showed i o ha e a ou able e ec s on heal h among menopausal and pos menopausal women. 13 In o ma ion on ho flushes and ae obic aining was collec ed ia mobile phone ques ionnai es wice a day. Responses we e au oma ically ans e ed o digi al o ma ia 3G echnology. 14 The SF-36 Heal h Su ey ques ionnai e was used o measu e heal h- ela ed QoL. This ques ionnai e has been ali- da ed in Finland 15 and is known o be a eliable measu e o QoL. I is composed o 36 i ems, add essing eigh dimensions o QoL: physical unc ioning, physical ole limi a ions, bodily pain, gene al heal h, i ali y, social unc ioning, emo ional ole limi a ions and men al heal h. 6 The sco es o each o he eigh dimen- sions we e ans o med linea ly o a scale anging om 0 (maximal impai men ) o 100 (bes QoL). 6 The fi s ollow-up ques ionnai e was pos ed o he pa icipan s 2½ yea s a e he in e en ion began, and 102 o he 159 women esponded. Resul s om his ollow-up ques ionnai e ha e been epo ed in ea lie wo k. 9 Fou yea s a e he beginning o he ial, he pa ici- pan s (n=159) we e asked o ake pa in he second ollow-up s udy. A e his eques , 95 o he women esponded o he ques ionnai e and pa icipa ed in he measu emen s. All he pa icipan s ga e w i en consen . Weigh , heigh and wais ci cum e ence we e measu ed wi h ligh weigh clo hing by s a o he UKK Ins i u e, and he UKK 2 km Walk Tes was pe o med. 16 The pa - icipan s comple ed he SF-36 Heal h Su ey ques ion- nai e on heal h- ela ed QoL, a home. 15 In addi ion, hey ca ied a Hookie accele ome e o a week, in o de o measu e hei daily PA. Also, he women we e asked o ake no es, in a 1 week dia y, abou he ype and in ensi y o hei PA, and o no e he exe cise ime. Specific ques ions ela ed o accele ome e use and he UKK 2-km Walk Tes will be epo ed on in a sepa a e a icle. In addi ion, he pa icipan s we e asked o use a 1 week dia y o no e he numbe o day ime and nigh - ime ho flushes expe ienced, he ime hey ell asleep and woke up, and hei judgemen o hei sleep quali y. A flow cha o he pa icipan s’da a is shown in figu e 1. STATISTICAL ANALYSIS The cha ac e is ics o he s udy popula ion a e desc ibed bes in e ms o means and SEMs, o equencies and pe cen ages ( able 1). Mul ile el mixed e ec s logis ic eg ession models we e cons uc ed o accoun o he wi hin-subjec co - ela ion be ween ou ime poin s. The odds model was used o analysis o he associa ion be ween he ou - comes bo h on he physical dimensions (physical unc- ioning; ole unc ioning, physical; eedom om pain; and physical heal h) and on he psychological dimen- sions ( ole unc ioning; emo ional; i ali y; emo ional well-being; social unc ioning; gene al heal h; and men al heal h) o e ime and be ween he in e en ion e sus he con ol g oup. Mul ile el linea eg ession models could no be used, because he dis ibu ions o SF-36 a iables we e skewed o disc e e. Since he condi- ions necessa y o he use o mul ile el o dinal logis ic 2Mansikkamäki K, e al.BMJ Open 2015;5:e008232. doi:10.1136/bmjopen-2015-008232 Open Access g oup.bmj.com on May 18, 2016 - Published by h p://bmjopen.bmj.com/Downloaded om eg ession models we e no me , hese models could no be used ei he . The mul ile el model o dicho omous ou come y ij a ime i o pe son j can be exp essed as logi {P ðyij ¼1jxij; 6 jÞ}¼b1þb2x2j þb3x3ij þb4x2jx3ij þ 6 j; whe e x 2j ep esen s g oup, x 3ij ep esen s ime, x ij =(x 2j , x 3ij )′is a ec o con aining bo h co a ia es, and ζ j is a pe son-specific andom in e cep . This model allows o a di e ence be ween g oups a baseline β 2 , and linea changes in he log odds o ou come o e ime wi h slope β 3 in he con ol g oup and slope β 3 +β 4 in he in e en- ion g oup. The e o e, β 4 , he di e ence in he a e o imp o emen (on he log odds scale) be ween g oups, can be iewed as changing o e ime be ween g oups. 17 Also second-o de and hi d-o de unc ions o ime we e included in he model, o es ing o whe he a model wi h a non-linea e ec imp o ed he fi . A likelihood- a io es was used o models’compa ison, o iden i y he model fi ing bes . The pa ame e es i- ma es we e p esen ed as ORs wi h 95% CIs. The p opo ions o he physical and men al dimen- sions o QoL by ime a e shown in figu es 1 and 2. The ou comes o QoL dimensions we e classified in wo ca - ego ies acco ding o medians. P opo ions o women ha ing highe o equal sco e han median a e shown in figu es. Highe sco e defines mo e a ou able heal h s a e. The Wilson sco e me hod wi hou con inui y co ec ion: ð2np þz2+zffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffi ðz2þ4npq) p 2ðnþz2Þ; whe e n deno es he sample size, p is a single p opo - ion, q=1−p and z deno es he s anda d no mal de ia e Figu e 1 Pa icipan low cha . Mansikkamäki K, e al.BMJ Open 2015;5:e008232. doi:10.1136/bmjopen-2015-008232 3 Open Access g oup.bmj.com on May 18, 2016 - Published by h p://bmjopen.bmj.com/Downloaded om associa ed wi h a wo- ailed p obabili y α, was used o calcula e he 95% CIs o he p opo ions in figu es 1 and 2. 18 The significance o all es s was de e mined o be a a p alue <0.05, and da a analyses we e pe o med wi h S a a S a is ical So wa e, Release 12 ( om S a aCo p LP, College S a ion, Texas, USA). In hese models, we used all a ailable esponses om women e en i hey had no esponded o all poin s o da a collec ion. As sensi i i y analyses, we pe o med mul ile el mixed e ec s logis ic eg ession models also o women who esponded o all ou ime poin s (N=75). We also analysed he esul s by using only he second ollow-up (wi hou 2.5 yea s ollow-up). RESULTS Mos o he pa icipan s (68%) we e employed o pa - ime wo ke s (9%) when he in e en ion began. O e he cou se o he 4 yea s, 7–20% o he women we e in pa - ime employmen . The women pa icipa ing in he 4-yea ollow-up we e, on a e age, 58 yea s o age, and hei mean BMI was 26–27 kg/m 2 . In he ollow-up, no significan change in BMI was obse ed. The p opo ion o women using HRT was highe a he 4-yea ollow-up poin han be o e he in e en ion. In he ollow-up, no significan di e ences we e obse ed in use o blood p essu e and choles e ol medica ion. Use o headache medicine and o he painkille s, seda i es and sleeping pills, and an idep essan s, dec eased wi hin he in e en ion g oup and also among hose in he con ol g oup. The in e en ion and he ollow-up showed inc eased use o i amins and mine al p epa a- ions in he in e en ion g oup ( om 55.1% o 68.9%) while in he con ol g oup hei use declined ( om 51.9% o 34.0%); hese esul s a e p esen ed in able 1. The women in he in e en ion g oup had a g ea e likelihood o imp o emen on he a ious QoL dimen- sions om baseline o he end o 4-yea ollow-up. O e all, he esul s show ha women in he in e en ion g oup sus ained hei imp o ed QoL mo e o en han women in he con ol g oup did. Figu es 2 and 3show he p opo ions obse ed o he physical and men al dimensions o QoL. Wi h he ollow-up measu emen s, we ound ha women in he in e en ion g oup displayed an imp o e- men in physical unc ioning (OR 1.41; 95% CI 1.00 o 1.99) when compa ed wi h he con ol g oup. Howe e , no significan di e ences we e obse ed be ween g oups o he o he a iables, as is indica ed by able 2. Resul s o men al dimensions o QoL did no each s a is ical significance (shown in able 3). The women who did no pa icipa e in he 2½-yea and 4-yea ollow-up s udies (N=47, 28.1%) we e younge a baseline (53.0 yea s, in con as o 54.5 yea s), hey had a highe BMI (28.0, in con as o 26.3) and hey we e Table 1 Cha ac e is ics (mean and SEM o equency and pe cen age) o all pa icipan s Baseline End o in e en ion 2½ Yea s 4 Yea s INT CON INT CON INT CON INT CON N 7881758050524550 Age, mean (SEM) 54.4 (0.42) 54.1 (0.41) BMI, mean (SEM) 26.4 (0.45) 27.2 (0.50) 25.2 (0.53) 26.2 (0.62) 26.0 (0.56) 26.6 (0.79) Use o medicine in he pas 7 days Ho mone eplacemen he apy, N (%) 2 (2.6) 1 (2.8) 5 (6.7) 2 (2.5) 10 (20.4) 12 (24.5) 14 (31.1) 8 (16.0) Blood p essu e and choles e ol medicine, N (%) 16 (20.5) 12 (14.8) 12 (18.8) 12 (17.9) 13 (26.5) 16 (32.7) 10 (22.2) 11 (22.0) Headache medicine and o he painkille s, seda i es and sleeping pills, and an idep essan s, N (%) 43 (55.1) 33 (40.7) 32 (50.0) 38 (56.7) 25 (51.0) 29 (59.2) 14 (31.1) 14 (28.0) Vi amin and mine al supplemen s, N (%) 43 (55.1) 42 (51.9) 39 (60.9) 36 (53.7) 28 (57.1) 32 (65.3) 31 (68.9) 17 (34.0) BMI, body mass index; CON, con ol; INT, in e en ion. 4Mansikkamäki K, e al.BMJ Open 2015;5:e008232. doi:10.1136/bmjopen-2015-008232 Open Access g oup.bmj.com on May 18, 2016 - Published by h p://bmjopen.bmj.com/Downloaded om egula smoke s mo e o en (27.3%, in con as o 12.0%) han he women who pa icipa ed in he ollow-up s udy. As sensi i i y analyses, we pe o med mul ile el mixed e ec s logis ic eg ession models also o women who esponded o all ou ime poin s (N=75). When hese women wi h non-missing esponses we e aken in he analyses, in e en ion women had significan ly highe p obabili y o imp o ed men al heal h unc ioning (OR 1.96; 95% CI 1.13 o 3.40) as compa ed wi h con ol women (no shown in he figu es o ables). Resul s om he models including only 4-yea ollow-up esponses wi hou 2.5 yea esponses we e simila o he esul s in he cu en ables and figu es. DISCUSSION The physical exe cise in e en ion may ha e long- e m posi i e e ec s on heal h- ela ed QoL among he g oup o menopausal women expe iencing daily symp oms o menopause. Women in he in e en ion g oup had a highe p obabili y o imp o emen in physical unc ion- ing dimension o QoL om baseline o he end o 4-yea ollow-up. Among a subsample o women who esponded o bo h ollow-up s udies, significan esul s be ween he g oups we e ound be ween men al heal h dimensions. O e all, he esul s show ha women in he in e en ion g oup sus ained hei imp o ed QoL on bo h physical-heal h and men al-heal h dimensions mo e o en han did women in he con ol g oup. Findings om p e ious s udies ha e shown ha ge ing physical exe cise is co ela ed wi h lowe es i- ma es o he pe cei ed se e i y o symp oms and ha exe cise mode a es he psychological symp oms asso- cia ed wi h menopause. 19 20 Ou s udy is in line wi h hese findings bo h in physical and men al dimensions. A epo on an 8-yea popula ion-based ollow-up s udy om Finland 4 s a es ha mo i a ion o inc ease one’sPA du ing menopausal ansi ion migh be an explana o y ac o connec ed wi h imp o ed QoL. Acco ding o ha ollow-up s udy, women whose PA inc eased o emained s able, had a highe p obabili y o imp o ed QoL han women whose PA dec eased. 4 Ela sky 19 ound, in a longi- udinal s udy o middle-aged women, ha PA was asso- cia ed wi h sel -wo h and by his mechanism imp o ed QoL. Fu he mo e, S ojano ska e al 1 ecen ly published a e iew o he ole o PA in educing symp oms o menopause. They conside ed bo h soma ic and psycho- logical dimensions. On he basis o hei e iew, physical exe cise has been p oposed as an al e na i e o HRT, o imp o ing he QoL o menopausal women. Ou s udy has i s limi a ions, in he esponse a e (59.7%) and he ac ha women wi h an ad e se li e- s yle we e mo e likely o be ound among non- esponde s. All ini ial pa icipan s we e included in he analyses, e en i hey did no pa icipa e o he end o Figu e 2 P opo ions o he physical dimensions o quali y o li e (QoL) by ime. Ou comes o QoL dimensions we e classi ied in o wo ca ego ies acco ding o medians. P opo ions o women ha ing highe o equal sco e han median a e shown. Highe sco e de ines mo e a ou able heal h s a e. Mansikkamäki K, e al.BMJ Open 2015;5:e008232. doi:10.1136/bmjopen-2015-008232 5 Open Access g oup.bmj.com on May 18, 2016 - Published by h p://bmjopen.bmj.com/Downloaded om he in e en ion o he 2.5-yea ollow-up s udy. The esul s o he s udy showed a endency owa ds inc eased QoL, al hough he e we e no s a is ically significan di e ences o any co es on he physical and men al dimensions o QoL be ween he g oups. Ou findings a e simila o hose om a la ge mul ie hnic olun ee Table 2 Mul ile el mixed e ec s logis ic eg ession, ORs and 95% CIs o physical dimensions o QoL Physical unc ioning Physical ole unc ioning F eeness om pain Physical heal h N 159 159 159 159 G oup baseline 0.52 (0.17 o 1.61) 0.84 (0.33 o 2.12) 0.58 (0.22 o 1.54) 0.72 (0.28 o 1.81) Time 1.03 (0.10 o 11.1) 0.93 (0.75 o 1.17) 1.07 (0.85 o 1.34) 0.97 (0.77 o 1.22) G oup× ime 44.7 (1.45 o 1374)* 1.21 (0.88 o 1.67) 1.25 (0.90 o 1.73) 1.33 (0.96 o 1.84) Time 2 0.86 (0.19 o 3.82) G oup× ime 2 0.11 (0.01 o 0.91)* Time 3 1.04 (0.82 o 1.32) G oup× ime 3 1.41 (1.00 o 1.99)* *p<0.05. Figu e 3 P opo ions o men al dimensions o quali y o li e (QoL) by ime. Ou comes o QoL dimensions we e classi ied in o wo ca ego ies acco ding o medians. P opo ions o women ha ing highe o equal sco e han median a e shown. Highe sco e de ines mo e a ou able heal h s a e. 6Mansikkamäki K, e al.BMJ Open 2015;5:e008232. doi:10.1136/bmjopen-2015-008232 Open Access g oup.bmj.com on May 18, 2016 - Published by h p://bmjopen.bmj.com/Downloaded om coho o pos menopausal women, in which sel - epo ed PA was, o he mos pa , s able o e 8 yea s o ollow-up. The e was app oxima ely 0.3 me abolic equi alen (MET) o ac ual g ow h in ec ea ional PA pe yea ×8 yea s=2.4 MET h/week, which ep esen ed 30 min o b isk walking in his case. 21 Loss- o- ollow-up analysis showed di e ences be ween pa icipan s and hose los o ollow-up. Non- esponding women di e ed om esponding women in hei weigh , age and smoking s a us. Responden s we e ligh e , olde and we e less o en egula smoke s han non- esponding women. These di e ences migh ha e had an e ec on he findings in he ollow-up s udy. I all o he o iginal pa icipan s had been s udied, he di e ences be ween he g oups migh ha e been la ge . When limi ing he analyses o women esponding o bo h ollow-up mea- su emen s, he esul s di e ed. Explana ion o his may be due o he ac ha conscien ious women esponding o ques ionnai es may ha e benefi ed e en mo e om a ailable suppo o be physically ac i e. A ollow-up s udy in i sel can be conside ed an in e en ion, p oducing a non-di e en ial suppo o he o iginal g oups in he RCT. The co e s eng hs o he s udy epo ed he e a e i s p ospec i e s udy design and epea ed assessmen s o PA beha iou , which made i possible o examine he di e - ences be ween g oups in he ollow-up. 17 Many s udies ha e desc ibed PA pa e ns h ough he lens o c oss- sec ional da a, while ewe s udies ha e examined changes be ween se e al ime poin s a e an in e en- ion. PA has been epo ed o dec ease wi h age, 22 bu con a y findings ha e also been epo ed. Ea lie , ou esea ch g oup published he finding 6 ha women in menopausal ansi ion shi ed hei beha iou in he o he di ec ion. The e o e, inc eased PA could be explained by highe mo i a ion o li es yle changes du ing he menopausal ansi ion. In a longi udinal s udy by Smi h-DiJulio e al, 23 he esea che s ound ha a woman’s sense o con ol, o he li e and sa is ac ion wi h i , and he abili y o make use o he a ailable social suppo , p edic ed g ea e well-being du ing meno- pause. This is consis en wi h ou findings, as we obse ed imp o emen in i ali y, emo ional well-being and men al heal h du ing he ollow-up, e en hough he esul s did no each a le el o s a is ical significance. Ou esul s may be gene alised o menopausal women ha ing daily asomo o symp oms, such as ho flushes o sleep p oblems, acco ding o he inclusion c i e ia in he o iginal RCT. 6 O e all, ou s udy unde lines he impo ance o PA du ing menopausal ansi ion. In add- i ion, i suppo s he assump ion ha menopause can be seen as a window o oppo uni y, since i may mo i a e women o modi y hei li es yle. Menopausal women should be encou aged o pa icipa e in egula exe cise and suppo ed in his endea ou h ough de elopmen o easily implemen ed home-based exe cise p og ammes o inco po a ion o PA p og ammes in o public-heal h ini ia i es. 10 Table 3 Mul ile el mixed e ec s logis ic eg ession, ORs and 95% CIs o men al dimensions o QoL Emo ional ole unc ioning Vi ali y Emo ional well-being Social unc ioning Gene al heal h Men al heal h N 159 159 159 159 G oup baseline 1.74 (0.72 o 4.18) 1.93 (0.82 o 4.57) 2.50 (0.86 o 7.28) 1.46 (0.60 o 3.55) 1.04 (0.33 o 3.25) 1.98 (0.77 o 5.13) Time 1.25 (1.00 o 1.57)* 1.28 (1.03 o 1.58)* 1.31 (1.03 o 1.67)* 1.10 (0.89 o 1.36) 0.98 (0.78 o 1.24) 1.29 (1.03 o 1.63)* G oup× ime 0.93 (0.67 o 1.29) 0.97 (0.71 o 1.33) 1.02 (0.72 o 1.44) 1.05 (0.77 o 1.43) 1.14 (0.81 o 1.62) 0.97 (0.70 o 1.35) *p<0.05. QoL, quali y o li e. Mansikkamäki K, e al.BMJ Open 2015;5:e008232. doi:10.1136/bmjopen-2015-008232 7 Open Access g oup.bmj.com on May 18, 2016 - Published by h p://bmjopen.bmj.com/Downloaded om CONCLUSION Women in he in e en ion g oup showed posi i e long- e m e ec s on physical and men al dimensions o QoL a e 4 yea s. Menopause is a window o oppo uni y o inc easing PA and he eby u u e QoL. This finding is impo an , since an inc ease in PA may be associa ed wi h a lowe u u e disease bu den. Acknowledgemen s Biomedical labo a o y scien is s Ulla Hakala, Ulla Honkanen and Si ke Rasinpe ä; esea ch assis an Ta u Helenius; and Ka iina Ojala, MSc, o he UKK Ins i u e labo a o y, pe o med all he measu emen s o he esea ch and handled con ac wi h he pa icipan s. Anna She l pe o med language edi ing. Con ibu o s KM and RL p epa ed he i s e sion o he manusc ip . JR was esponsible o he s a is ical analyses. C-HN, ET and RR pa icipa ed in d a ing he manusc ip and ha e app o ed he inal e sion. Funding Financial suppo o he ollow-up s udy was ecei ed om he Juho Vainio Founda ion (Finland), he Pi kanmaa Compe i i e Resea ch Fund (Tampe e, Finland) and he Academy o Finland. Compe ing in e es s None decla ed. Pa ien consen Ob ained. E hics app o al The s udy was g an ed e hics app o al by he Pi kanmaa Hospi al Dis ic E hics Commi ee, Tampe e, Finland. P o enance and pee e iew No commissioned; ex e nally pee e iewed. Da a sha ing s a emen The e a e some da a om he ques ionnai es ha a e unpublished bu all da a conce ning he measu emen s a e published. Open Access This is an Open Access a icle dis ibu ed in acco dance wi h he C ea i e Commons A ibu ion Non Comme cial (CC BY-NC 4.0) license, which pe mi s o he s o dis ibu e, emix, adap , build upon his wo k non- comme cially, and license hei de i a i e wo ks on di e en e ms, p o ided he o iginal wo k is p ope ly ci ed and he use is non-comme cial. See: h p:// c ea i ecommons.o g/licenses/by-nc/4.0/ REFERENCES 1. 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Menopause 2008;15:1095–102. 8Mansikkamäki K, e al.BMJ Open 2015;5:e008232. doi:10.1136/bmjopen-2015-008232 Open Access g oup.bmj.com on May 18, 2016 - Published by h p://bmjopen.bmj.com/Downloaded om o a andomised con olled ial menopausal women: a 4-yea ollow-up s udy heal h- ela ed quali y o li e among Long- e m e ec o physical ac i i y on Ree a Ru anen and Rii a Luo o Ki si Mansikkamäki, Jani Rai anen, Clas-Håkan Nygå d, Eija Tomás, doi: 10.1136/bmjopen-2015-008232 2015 5: BMJ Open h p://bmjopen.bmj.com/con en /5/9/e008232 Upda ed in o ma ion and se ices can be ound a : These include: Re e ences #BIBLh p://bmjopen.bmj.com/con en /5/9/e008232 This a icle ci es 21 a icles, 2 o which you can access o ee a : Open Access h p://c ea i ecommons.o g/licenses/by-nc/4.0/non-comme cial. 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