Lifestyle interventions in later reproductive age women to offset cardiometabolic and bone disease: a scoping review

Abstract

Background

Non-communicable chronic disease is a major contributor to morbidity and mortality with potentially modifiable lifestyle factors. In women, the menopausal transition modifies women’s risk of chronic disease, and pregnancy-related complications have been highlighted as female-specific risk factors. Later reproductive years, before onset of menopause, may represent a window of opportunity for promotion of lifestyle modifications. The aim of this scoping review is to investigate which interventions promoting lifestyle modifications in women of later reproductive years may influence cardiometabolic and bone disease.

Methods

A search of three electronic databases (PubMed, Embase, CINAHL) in the English language was performed in January 2024. Eligible studies included women aged 40–55 participating in interventions focusing on lifestyle modification. Studies reporting outcomes related to cardiometabolic disease, bone disease or body composition were eligible for inclusion.

Results

Improvements in body composition occurred following interventions focusing on aerobic physical activity. Interventions focusing on health promotion and education, incorporating both dietary and physical activity modifications, prevented weight gain and improved cardiometabolic outcomes. Interventions incorporating elements of behavioural theories enhanced patient-motivated lifestyle modifications, with effects on body composition and cardiometabolic outcomes.

Conclusions

Lifestyle modifications in later reproductive years have the potential to influence cardiometabolic and bone disease. Our findings reinforce the benefits of regular aerobic physical activity, as well as health education, for improving body composition and lipid profile. This information could contribute to the development of clinical guidelines for the prevention of chronic disease.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12986-025-00908-1.

Background

The global burden of non-communicable, chronic disease (NCDs) is steadily increasing, contributing to 41 million deaths each year, and up to 74% of all global deaths [1]. Cardiovascular disease in particular, accounts for the largest proportion of deaths attributable to NCDs, up to 17.9 million people annually [1]. Additionally, musculoskeletal health, including osteoporosis and sarcopenia, is now recognized as a leading contributor to disability worldwide, across multiple age brackets [2], and may also be associated with development of chronic disease [3]. NCDs tend to be of chronic duration and slow progress, sharing common underlying modifiable risk factors including unhealthy diet, low levels of physical activity, and tobacco use [1], which may be the target of lifestyle modifications [4]. Furthermore, metabolic risk factors may contribute to changes in metabolic status, including hypertension, overweight or obesity, hyperglycaemia or hyperlipidaemia which increase the risk of development of NCDs [1].

While the incidence of cardiometabolic disorders continues to rise among both men and women, likely attributable to obesity-related metabolic risk factors, female-specific risk factors may contribute to the rising incidence of cardiometabolic disorders among younger women [5]. Notable differences include pregnancy-related complications such as hypertensive disorders in pregnancy and gestational diabetes [6, 7]. Women who develop pre-eclampsia in pregnancy have up to a 2–5 fold increased risk of developing cardiovascular disease [6], while women who develop gestational diabetes have an 8–10 fold increased risk of developing type 2 diabetes mellitus [8], and a two-fold increased risk of cardiovascular events [9]. Furthermore, hormonal influences are key in the progression of cardiometabolic disease, where on average women are affected by cardiometabolic disease approximately 7–10 years later than men, largely due to the protective effects of oestrogen during the reproductive years [6]. Menopause, a state characterised by oestrogen deficiency, is known to change the cardiometabolic risk profile for women, namely through alterations in lipid profile and increases in body mass [10]. Additionally, physical inactivity and lower hormone secretion in middle-aged women can also lead to decreased lean mass, muscle strength, and bone mass [11].

While female-specific risk factors for NCDs are acknowledged, there remains a paucity of data as to how best to implement risk reduction strategies. Despite increasing evidence, pregnancy-related complications are often not adequately incorporated into risk factor screening for NCDs, and timing for optimal intervention remains unclear [7]. The later reproductive years represents the stage in a woman’s life where child-bearing is complete, however the menopausal transition has not yet been reached [12], typically around the ages of 40–55. In this stage, women may begin to experience menstrual irregularities, but the onset of menopause has not yet occurred [12]. Therefore, we propose that the later reproductive years may represent a unique timepoint in a woman’s life to focus on lifestyle modifications before the onset of menopause.

The aim of the current scoping review is to identify and summarise interventions relating to lifestyle modifications which have been trialled in women of later reproductive years, that may have the potential to influence cardiometabolic and bone disease.

Methods

Study design

A scoping review was performed to identify types of lifestyle modification interventions that have been trialled, which may have potential to improve overall cardiometabolic and bone health among women in the later reproductive years. This scoping review was conducted based on the methodological frameworks of Arksey and O’Malley [13], and the Joanna Briggs Institute [14], while following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) [15]. A scoping review protocol was developed internally but not registered publicly.

Eligibility criteria

Eligibility was determined using PICO framework (Table 1).

Table 1.

PICO framework

Population	Women aged 40–55 who had not reached menopause
Intervention	Interventions focusing on lifestyle modification, e.g. physical activity, diet, supplements or behaviour change techniques
Comparator	No comparator
Outcome	Body composition, metabolic parameters (blood pressure, blood lipid profile, glucose and insulin homeostasis), inflammatory markers, bone and muscle health, or bone mineral density

Search strategy

The search strategy was developed by the research team, in collaboration with the medical librarian at the University College Dublin. The search consisted of a combination of Medical Subject Headings (MeSH) and focused keywords. The search was performed in January 2024 across three databases (PubMed, EMBASE and CINAHL). The full PubMed search strategy can be found in supplementary Table 1 (Additional File 1), and was similarly applied to the other electronic databases. Searches were limited to human studies, the English language, and randomized controlled trials (RCTs) or quasi-experimental clinical trials, as these represent the highest quality forms of evidence for interventions. There was no time limitation placed.

Study selection & data management

All records were exported into an EndNote™ (version 20, Clavariate, Philadelphia, USA) library, then uploaded to Covidence software (Veritas Health Innovation, Melbourne, Australia) and duplicates removed. Articles were screened by title and abstract, followed by full texts by two independent researchers (KD and GD), according to pre-determined eligibility criteria, with input from a third researcher (FMcA) to reach agreement in the event of a discrepancy. Manual searching of reference lists was also performed.

Data extraction and synthesis

Once eligible articles were finalized by the research team, relevant data was systematically extracted by the primary researcher into a standardized data extraction form in Microsoft Excel. The following variables were extracted: year, country, study design, subject characteristics and sample size, attrition, intervention description and duration, follow-up duration (if any), and primary findings. Descriptive statistics were generated using Microsoft Excel, and studies were classified according to primary outcome and intervention focus. Findings are described using a narrative synthesis approach.

Results

Selection of articles

The search strategy identified 2841 citations across three databases (Fig. 1). After removal of duplicates and title abstract screening, 418 full-text articles were retrieved and reviewed. Of these citations, 37 were eligible for inclusion, with 4 further articles identified from hand-searching reference lists, ultimately yielding 41 publications for inclusion. A detailed summary of all interventions is presented in supplementary Table 2 (Additional File 2).

Fig. 1.

PRISMA-ScR flow chart. PRISMA-ScR flow diagram of study selection

Study characteristics

Table 2 details the study characteristics of the 41 studies, representing results from 25 RCTs (61.0%) and 16 quasi-experimental clinical studies (39.0%). There were 33 primary interventions, 7 articles detailing follow-up studies of primary interventions, and one secondary analysis of a primary intervention. The majority of studies (n = 15, 36.6%) originated from Asia, followed by North America (n = 11, 26.8%), Africa & The Middle East (n = 7, 17.1%), Australia (n = 3, 7.3%), Europe (n = 3, 7.3%), and Latin & South America (n = 2, 4.9%).

The majority of studies focused on healthy participants (n = 19, 46.3%), or participants with overweight/obesity and no medical co-morbidities (n = 13, 31.7%). A small number of studies (n = 4, 9.8%) examined women with a previous diagnosis of a metabolic co-morbidity, such as type 2 diabetes mellitus or dyslipidaemia, and 5 studies (12.2%) only specified the women were experiencing perimenopausal symptoms.

The interventions described were of variable duration and follow-up; 36.6% of interventions (n = 15) lasted for 8 weeks or less, 29.23% (n = 12) of interventions lasted for 9–12 weeks, 26.8% (n = 11) of interventions lasted for 13–26 weeks, with only 3 studies (7.3%) lasting 27–52 weeks in duration. The majority of studies described the intervention only (n = 28, 68.3%). One primary intervention included a follow-up period of 6 months [16]. Another primary intervention included a 12 month maintenance period, and was discussed in 3 studies [17–19]. The “40-something RCT” included follow-up to 24 months, and was reported across 3 studies [20–22]. The “Women’s Healthy Lifestyle Project” followed up participants to 54 months, and results were presented across 4 publications [23–26] (See Table 2).

Table 2.

Study characteristics

Characteristics		Number of studies (%)
Study characteristics	Primary intervention	33 (80.5%)
	Follow-up of primary intervention	7 (17.1%)
	Secondary analysis	1 (2.4%)
	Randomized controlled trial	25 (61.0%)
	Quasi-experimental clinical trial	16 (39.0%)
Study participants	Healthy	19 (46.3%)
	People with overweight or obesity	13 (31.7%)
	Peri-menopausal only	5 (12.2%)
	Metabolic co-morbidity	4 (9.8%)
Sample size	≤ 10	-
	11–50	12 (29.3%)
	51–99	17 (41.5%)
	≥ 100	12 (29.23%)
Duration of intervention (weeks)	≤ 8 weeks	15 (36.6%)
	9–12 weeks	12 (29.3%)
	13–26 weeks	11 (26.8%)
	27–52 weeks	3 (7.3%)

Interventions with effects on body composition

Of 24 interventions with effects on body composition, 41.7% (n = 10/24) focused on physical activity, 16.7% (n = 4/24) focused on use of supplements, 2 primary interventions focused on behaviour change techniques with follow-up of participants in a further 4 studies, and 2 primary interventions focused on health promotion and education with follow-up of participants in a further 2 studies. Sample sizes ranged from 16 to 300, and duration of intervention ranged from 8 weeks to 54 months (Table 3).

Table 3.

Summary of interventions with effects on body composition

Author	Primary focus of intervention	Key findings
Aneis et al. [28]b	Physical activity	Aerobic +/- strength training for 12 weeks reduced BMI and waist circumference
Chung et al. [29]b	Physical activity	Multiple short exercise sessions reduced waist circumference
Cussler et al. [17]d	Behaviour change techniques and follow-up	Following the “Healthy Weight for Life” program, there was no significant difference in weight re-gain or energy expenditure in women who utilized the internet for ongoing support
El Shebini et al. [86]c	Supplements	Turmeric and ginger supplementation along with a hypocaloric diet for 8 weeks improved body composition
El Shebini et al. [87]d	Supplements	Foeniculum vulgare (fennel powder) and Salvia hispanica (chia seeds) supplementation along with a hypocaloric diet for 8 weeks improved body composition
Hao et al. [27]c	Health promotion & education	Routine health education centred on DASH dietary principles and increasing physical activity reduced body mass
Hollis et al. [20]b	Behaviour change techniques and follow-up	The effect of “The 40-something RCT” was maintained up to 24 months following the intervention. Encouraging women to take at least 10,000 steps and consume 5 servings of vegetables per day accounted for the weight loss observed
Karatrantou et al. [30]c	Physical activity	Performance of low-impact aerobic dance and calisthenics for 3 months decreased body fat, improved body composition, and increased indices of overall fitness
Krishnan et al. [31]b	Physical activity	Aerobic exercise performed 3 times per week and resistance exercise performed 3 times per week for 6 months induced body weight and fat loss
Moaty et al. [88]c	Supplements	Turmeric and ginger supplementation along with a hypocaloric diet for 8 weeks decreased anthropometric measurements
Moslehi et al. [38]c	Supplements	250 mg magnesium oxide taken daily for 8 weeks reduced body fat percentage and fat mass
Oh et al. [32]a	Physical activity	Aerobic exercise of vigorous or moderate intensity for 8 weeks decreased weight and body fat
Park et al. [35]b	Physical activity	Aerobic exercise only decreased subcutaneous and visceral fat, whereas aerobic +/- resistance training for 24 weeks improved blood lipid profile
Pilch et al. [33]a	Physical activity	Aerobic exercise alternating high-intensity and low-intensity movements for 12 weeks improved body composition
Ribeiro et al. [34]d	Physical activity	Aerobic training for 12 weeks reduced weight and waist circumference, whereas a pedometer-based intervention had greatest impact on increasing overall step count
Simkin-Silverman [24]d	Health promotion & education	“Women’s Healthy Lifestyle Project”, an intervention emphasising lifestyle modifications to lower cholesterol and increase physical activity, demonstrated significant improvements in lipid profile and modest weight loss after a 20 week intervention
Simkin-Silverman [26]d	Health promotion & education and follow-up	18 months after the “Women’s Healthy Lifestyle Project”, those who participated in the intervention demonstrated greater levels of physical activity, lower caloric intake, and lower BMI
Simkin-Silverman [25]d	Health promotion & education and follow-up	54 months after the “Women’s Healthy Lifestyle Project”, women in the intervention group had maintained weight loss and remained more physically active
Teixeira et al. [18]d	Behaviour change techniques	“Healthy Weight for Life” program, based off cognitive and behavioural strategies to motivate progressive changes in lifestyle, over 16 weeks resulted in significant improvements in body weight and body composition
Teixeira et al. [19]d	Behaviour change techniques and follow-up	Following the “Healthy Weight for Life” program, 1 year of ongoing support did not influence change in weight, compared with no additional contact from the study group
Tsai et al. [36]c	Physical activity	Muscle/tendon change classic (MTCC) qigong performed daily for 8 weeks reduced waist-to-hip ratio and BMI
Williams et al. [79]b	Behaviour change techniques	“The 40-something RCT” utilized a lifestyle motivation centred upon motivational interviewing to promote behaviour change in relation to lifestyle changes to improve weight control over 3 months. Women in the motivational interviewing group lost more weight during the intervention period
Williams et al. [21]b	Behaviour change techniques and follow-up	Women in the motivational interviewing group in “The 40-something RCT” lost significantly more weight during the intervention period, regained some of the weight by 18 months, but maintained a stable weight up to 24 months post-intervention
Zhang et al. [42]d	Physical activity	Aerobic exercise performed as “walking with strides” improved blood lipid profile

Note: Behaviour change techniques included social, cognitive or behavioural theory components as part of the lifestyle modification intervention. Health education and promotion combined multiple lifestyle elements, such as dietary modifications and physical activity, into a composite lifestyle intervention. ^a Sample size ≤ 20, ^b Sample size 21–50, ^c Sample size 51–99, ^d Sample size ≥ 100. Abbreviations– BMI: body mass index; RCT: randomized controlled trial; MTCC: Muscle/tendon change classic

The “Women’s Healthy Lifestyle Project” successfully prevented weight gain and reduced waist circumference over a period of 5 years [23–26], during the menopausal transition, when women typically experience increased body mass. The “40-something RCT” also prevented weight gain over 24 months of the menopausal transition by employing motivational interviewing techniques with a focus on obesity prevention [20–22]. The “Healthy Weight for Life” intervention made use of cognitive and behavioural strategies to improve adherence with the lifestyle modifications, and also demonstrated significant reductions in weight, body mass index (BMI), fat mass and waist circumference [18, 19]. Hao et al. demonstrated that an intervention combining changes in diet and physical activity reduced body mass [27].

As well, increased physical activity was noted to improve body composition and promote weight loss. Any type of aerobic and/or strength training induced significant improvements in body composition [28–34]. Most studies reported a global improvement following intervention, with no significant differences between aerobic training alone versus aerobic training combined with strength and/or resistance training [28, 29, 31, 32]. Interestingly, multiple short sessions of exercise were more effective in reducing waist circumference when compared with a single prolonged session of exercise [29], and combining aerobic training with resistance training was more effective in reducing subcutaneous and visceral adipose tissue when compared to aerobic training alone [35]. Practicing MTCC qigong daily over the course of 8 weeks significantly reduced waist-to-hip ratio and BMI [36].

The only supplement noted to improve body composition was magnesium [37, 38]. A dose of 250 mg daily for 8 weeks resulted in lower body fat percentage and fat mass [37], along with increased lean mass [38] when compared to baseline values.

Interventions with effects on cardiometabolic outcomes

Of 22 interventions with effects on cardiometabolic outcomes, 54.5% (n = 12/22) focused on physical activity, 22.7% (n = 5/22) focused on use of supplements, while 3 primary interventions focused on health promotion and education with follow-up of participants in a further 2 studies. Sample sizes ranged from 20 to 489, with duration of intervention ranging from 8 weeks to 54 months (Table 4).

Table 4.

Summary of interventions with effects on cardiometabolic outcomes

Author & reference	Primary focus of intervention	Key findings
Aneis et al. [28]b	Physical activity	Aerobic +/- strength training for 12 weeks improved blood lipid profile and insulin sensitivity
Beak et al. [89]a	Physical activity	Combined aerobic and resistance training for 8 weeks improved inflammation markers
Chung et al. [29]b	Physical activity	Single prolonged exercise session improved blood lipid profile, whereas multiple short exercise sessions reduced blood glucose
Costa et al. [39]b	Physical activity	Water-based aerobic training for 12 weeks improved blood lipid profile
El Shebini et al. [86]c	Supplements	Turmeric and ginger supplementation along with a hypocaloric diet for 8 weeks improved fasting blood glucose and serum lipid profile
El Shebini et al. [87]d	Supplements	Foeniculum vulgare (fennel powder) and Salvia hispanica (chia seeds) supplementation along with a hypocaloric diet for 8 weeks improved blood pressure. Fennel powder improved fasting glucose and lipid profile more than chia seeds
Farahati et al. [40]b	Physical activity	High-intensity interval training and moderate-intensity continuous training for 12 weeks both improved markers of vascular function and blood lipid profile
Hao et al. [27]c	Health promotion & education	Routine health education centred on DASH dietary principles and increasing physical activity improved blood lipid profile
Hassan et al. [16]c	Health promotion & education	“Women Wellness Workshop” in the primary care setting significantly reduced blood pressure and increased daily energy expenditure
Kim et al. [41]b	Physical activity	Dynamic exercise (combining low-impact aerobics and weight-bearing exercise) for 8 weeks reduced total cholesterol levels
Krishnan et al. [31]b	Physical activity	Aerobic exercise performed 3 times per week and resistance exercise performed 3 times per week for 6 months improved insulin sensitivity
Kuller et al. [23]d	Health promotion & education and follow-up	54 months after the “Women’s Healthy Lifestyle Project”, there was a significantly smaller increase in LDL cholesterol
Moaty et al. [90]c	Supplements	Hyphaenae thebaica (doum flour) supplement in combination with a hypocaloric diet for 8 weeks decreased lipid accumulation products
Moaty et al. [88]c	Supplements	Turmeric and ginger supplementation along with a hypocaloric diet for 8 weeks improved lipid profile and insulin sensitivity
Obaya et al. [43]c	Physical activity	Aerobic exercise with slow deep breathing and mindfulness techniques for 6 weeks reduced cortisol levels and improved fasting glucose values in type 2 diabetic women
Oh et al. [32]a	Physical activity	Aerobic exercise of vigorous or moderate intensity for 8 weeks improved blood lipid profile
Park et al. [35]b	Physical activity	Aerobic exercise only decreased subcutaneous and visceral fat, whereas aerobic +/- resistance training for 24 weeks improved blood lipid profile
Pilch et al. [33]a	Physical activity	Aerobic exercise alternating high-intensity and low-intensity movements for 12 weeks improved blood lipid profile
Simkin-Silverman [24]d	Health promotion & education	“Women’s Healthy Lifestyle Project”, an intervention emphasising lifestyle modifications to lower cholesterol and increase physical activity, demonstrated significant improvements in lipid profile and modest weight loss after a 20 week intervention
Simkin-Silverman [26]d	Health promotion & education and follow-up	18 months after the “Women’s Healthy Lifestyle Project”, those who participated in the intervention demonstrated lower LDL cholesterol levels
Washburn et al. [44]b	Supplements	Soya protein containing phytoestrogen consumed over 6 weeks improved lipid profile and diastolic blood pressure
Zhang et al. [42]d	Physical activity	Aerobic exercise performed as “walking with strides” reduced weight, BMI, and waist circumference

Note: Behaviour change techniques included social, cognitive or behavioural theory components as part of the lifestyle modification intervention. Health education and promotion combined multiple lifestyle elements, such as dietary modifications and physical activity, into a composite lifestyle intervention. ^a Sample size ≤ 20, ^b Sample size 21–50, ^c Sample size 51–99, ^d Sample size ≥ 100. Abbreviations–RCT: randomized controlled trial; LDL– low density lipoprotein

Similar to body composition, any form of aerobic exercise in previously sedentary women demonstrated significant improvements in lipid profile [29, 32, 33, 35, 39–42], regardless of intensity [32] or form of aerobic exercise [39, 41, 42]. A single prolonged exercise session was more effective in improving lipid profile, compared with multiple short sessions of exercise [29]. Water aerobics [39] and “walking with strides” [42] also improved serum lipid profile.

Insulin sensitivity and markers of glucose homeostasis were improved following multiple primary interventions [28, 31, 43]. Aerobic exercise in combination with resistance training significantly improved insulin sensitivity [28, 31], while multiple short sessions of aerobic exercise lowered serum glucose levels in healthy, sedentary, pre-menopausal women [29]. Combining aerobic exercise with slow, deep breathing and mindfulness techniques improved circulating cortisol levels and fasting glucose values in pre-menopausal women with type 2 diabetes mellitus [43].

The “Women’s Healthy Lifestyle Project” was able to mitigate the rise in low density lipoprotein (LDL) cholesterol which is known to occur during the menopausal transition. Women in the intervention group had significantly smaller increases in LDL cholesterol levels throughout the intervention and maintenance period [23–26]. Additionally, the intervention by Hao et al., which combined education regarding diet using the DASH principles and the benefits of exercise, also demonstrated significant improvements in lipid profile, and successful reduction of blood pressure [27].

Soya supplements containing phytoestrogens demonstrated a reduction in total cholesterol and LDL cholesterol, in addition to a reduction in diastolic blood pressure, in the absence of any changes in weight [44].

Interventions with effects on bone health

Of 5 interventions with effects on bone health, 1 intervention focused on physical activity, 3 interventions focused on use of supplements, and 1 was a secondary analysis of an intervention focused on health promotion and education. Sample sizes ranged from 58 to 535, with interventions lasting 8 weeks in duration (Table 5).

Table 5.

Summary of interventions with effects on bone health outcomes

Author & Reference	Primary Focus of Intervention	Key Findings
Kheyruri et al. [45]c	Supplements	Co-supplementation of 50,000 units of vitamin D weekly and 250 mg magnesium oxide daily for 8 weeks improved muscle function and handgrip strength, but had no effect on knee extension strength or body composition
Moaty et al. [90]c	Supplements	Hyphaenae thebaica (doum flour) supplement in combination with a hypocaloric diet for 8 weeks decreased bone-specific alkaline phosphatase
Moslehi et al. [38]c	Supplements	250 mg magnesium oxide taken daily for 8 weeks increased lean mass and decreased fat mass, without alterations in muscle strength or functional mobility
Salamone et al. [46]d	Health promotion & education	Women who lost weight as part of the “Women’s Healthy Lifestyle Project” demonstrated 3 times greater rate of bone mineral density loss
Tsai et al. [36]c	Physical activity	Muscle/tendon change classic (MTCC) qigong performed daily for 8 weeks improved muscle endurance

Note: Behaviour change techniques included social, cognitive or behavioural theory components as part of the lifestyle modification intervention. Health education and promotion combined multiple lifestyle elements, such as dietary modifications and physical activity, into a composite lifestyle intervention. ^a Sample size ≤ 20, ^b Sample size 21–50, ^c Sample size 51–99, ^d Sample size ≥ 100. Abbreviations– MTCC: Muscle/tendon change classic

The practice of traditional MTCC qigong was found to increase muscle endurance [36]. The co-supplementation of vitamin D and magnesium was associated with increased handgrip strength and improved muscle function [45], whereas magnesium supplementation alone was associated with increased lean mass without alterations in muscle strength or functional mobility [38]. Lastly, weight loss during the “Women’s Healthy Lifestyle Program” was associated with a 3-times higher rate of loss of bone mineral density [46].

Interventions with equivocal outcomes

A number of interventions demonstrated uncertain significance, where 1 primary intervention focused on physical activity, and 4 interventions trialled use of supplements (Table 6).

Table 6.

Summary of interventions with equivocal outcomes

Author & Reference	Primary Focus of Intervention	Key Findings
Abiri et al. [50]c	Supplements	1000 units of oral vitamin D supplement daily for 12 weeks did not significantly change weight, BMI or functional muscle strength
Chinnappan et al. [47]c	Supplements	“NuFemme”, a supplement containing Labisia pumila and Eurycoma longifolia at a dose of 400mg L. pumila and 100mg E. longifolia for 24 weeks demonstrated a non-significant trend towards improving lipid profile, with no significant difference in markers of bone health
Jamshidi et al. [51]c	Supplements	Vitamin D supplementation of 50,000 units weekly, in combination with a synbiotic (combination of prebiotic and probiotic) for 8 weeks demonstrated a decreasing trend in body fat percentage, fat mass and visceral fat area
Luzzi et al. [48]b	Supplements	“Pycnogenol”, a supplement derived from Pinus pinaster, consumed at a dose of 100 mg daily for 8 weeks normalized borderline metabolic risk factors
Mortimer et al. [91]a	Physical activity	Blood pressure was reduced in all participants in response to laboratory monitoring for 5 days, regardless of performance of isometric handgrip training

Note: Behaviour change techniques included social, cognitive or behavioural theory components as part of the lifestyle modification intervention. Health education and promotion combined multiple lifestyle elements, such as dietary modifications and physical activity, into a composite lifestyle intervention. ^a Sample size ≤ 20, ^b Sample size 21–50, ^c Sample size 51–99, ^d Sample size ≥ 100. Abbreviations– BMI: body mass index

Compounds which exerted hormone-like effects were explored as potential supplements for modifying menopausal symptoms and metabolic risk profile. An herbal supplement containing Labisia pumila and Eurycoma longifolia (“NuFemme”) was examined as an alternative to hormonal replacement therapy [47], and demonstrated a trend towards improved lipid profile, with no improvement in markers of bone health. In this study, 119 participants initiated the study, with an attrition rate of 44 participants, which may explain the equivocal results [47]. Additionally, the use of an extract derived from Pinus pinaster (“Pycnogenol”) normalized borderline risk factors for metabolic syndrome in perimenopausal women that were present prior to initiation of the supplement [48]. Due to the age of the participants, the small sample size, and the fact use of the supplement was completely voluntary, results were considered equivocal [49].

The effect of vitamin D alone was explored [50], but did not significantly alter body composition for functional muscle strength. Vitamin D was also explored with co-supplementation with a synbiotic (combination of prebiotic and probiotic to improve host gut microflora), resulting in a trend towards reduced body fat percentage and visceral fat area [51]. These interventions were of relatively short duration (8 weeks), which may limit the ability to observe significant results.

Discussion

Main findings

The purpose of this scoping review was to identify and examine the existing literature regarding lifestyle modifications trialled among women of later reproductive age which may have the potential to improve cardiometabolic and bone health. In this scoping review, 41 studies were eligible for inclusion. Improvements in body composition and anthropometry were most notable following interventions which focused on aerobic physical activity of any nature or intensity. Additionally, interventions which focused on health promotion and education incorporating both dietary and physical activity modifications appeared successful in preventing weight gain. Interventions which incorporate elements of behavioural, social and cognitive theories were also noted to enhance patient-motivated lifestyle modifications, with effects on body composition and cardiometabolic outcomes. Supplements were explored in relation to their effects on body composition, cardiometabolic and bone outcomes, however they did not appear to have consistent benefits on body composition or lipid profile, but may have some effects on bone health.

Mechanisms

The later reproductive years mark the beginning of the menopausal transition, which spans until the early post-menopausal period [52]. During this time, complex endocrinology potentially influences cardiometabolic and bone metabolism. Fluctuations in oestrogen, follicle stimulating hormone (FSH) and luteinizing hormone (LH) during this time period have been linked to negative effects on bone and cardiometabolic health [52].

Across the menopausal transition, it has been noted there is a worsening in lipid profile, namely through increases in total cholesterol and LDL cholesterol [53, 54]. Not only is weight gain particularly prevalent during the mid-life years, a change in body composition and fat distribution is noted, with a shift away from lean mass and greater central obesity noted following menopause [55]. Physical activity improves dyslipidaemia and markers of chronic inflammation across the menopausal transition, however the exact mechanisms underpinning these observations remains unknown [56]. Additionally, the definition of a ‘healthy diet’ is constantly evolving and changing based on emerging evidence. Alterations in dietary patterns are postulated to regulate pathways involved in glucolipid and energy balance, suppression of inflammation and alteration of the gut microbiome [57]. Lifestyle modifications which target metabolic changes that occur across the menopausal transition may have potential to modulate later-life cardiometabolic risk.

The three years surrounding the final menstrual period are characterised by a rapid phase of bone loss, with on average 2.5% decline in bone mineral density of the lumbar spine each year [58]. It is postulated that these changes are driven by alterations in oestradiol and FSH levels, altering the balance of bone turnover markers and changing the composition of the bone [59]. Other important factors which increase fracture risk include co-morbid conditions such as diabetes, obesity and chronic inflammation [59]. Physical activity which promotes mechanical strain on bone regulates the complex interplay between bone formation and remodelling, promoting enhanced bone mass [60]. Additionally, dietary supplementation with calcium and vitamin D are an integral component of osteoporosis prevention [61]. Specific recommendations regarding lifestyle modifications with effects on bone health remain undefined among women of later reproductive years.

Comparison with existing literature

Lifestyle modification interventions which target multiple potential risk factors appear to be the most effective. For example, The Diabetic Prevention Program sets specific goals for participants to achieve moderate weight loss and increases in physical activity, which has resulted in a 58% reduction in diabetes incidence [62]. Similarly, interventions combining alterations in diet and physical activity appeared to be most effective in targeting postpartum weight retention and promoting weight loss [63, 64]. Additionally, a composite healthy lifestyle score which incorporates domains relating to diet, physical activity, alcohol consumption, smoking and healthy BMI has demonstrated beneficial effects on systemic inflammation [65], pro-atherogenic lipoprotein profile [66], and childhood adiposity [67], highlighting the importance of healthy lifestyle promotion across multiple potential risk factors and stages of life.

Of late, the importance of pregnancy complications and their relationship to later life women’s health has gained increasing recognition [7, 68]. It has been suggested that women who experience GDM in pregnancy are followed prospectively in order to enable preventive measures and promote early diagnosis of type 2 diabetes mellitus, before onset of complications [68]. However, studies suggest that women who developed GDM rarely follow recommended dietary advice and physical activity guidelines in the postpartum period [69], despite evidence that modest weight loss in the postpartum period has beneficial effects on glucose homeostasis [70]. It has been suggested that increased education focusing on awareness of the magnitude and risk of later life diabetes development after GDM could provide an opportunity to introduce dietary, lifestyle, or pharmacological interventions which may prevent or delay onset of type 2 diabetes mellitus [71]. Overall, multiple interventions which include modifications to diet, promotion of weight loss, and increased physical activity appear to be effective in decreasing risks of maternal morbidity following pregnancy complications [68]. Similarly, in this scoping review, interventions which focused on physical activity and health education and promotion incorporating combined aspects of diet and physical activity modifications demonstrated beneficial effects on body composition and cardiometabolic risk factors among women in their later reproductive years.

Additionally, the importance of the post-menopausal years on women’s cardiometabolic and bone health has been previously evaluated in systematic reviews and clinical trials. Interventions focusing on diet and physical activity among postmenopausal women have demonstrated clear improvements in cardiovascular outcomes with physical activity [72, 73]. Exercise has been shown to be beneficial to maintaining balance, coordination, flexibility and muscle strength, but with conflicting evidence relating to bone health and bone mineral density [72]. No specific recommendations regarding diet have been noted [72, 73]. One intervention incorporating aspects of physical activity, health education, and behavioural change demonstrated effects on diet, exercise and motivation in post-menopausal women, which was effective in improving bone health and bone mineral density [74]. Similarly, we noted that interventions focusing on physical activity in the later reproductive years were effective in ameliorating cardiometabolic outcomes and body composition among peri-menopausal women, highlighting the possibility of earlier intervention for promotion of lifestyle modifications. Additionally, we also similarly noted no interventions focusing solely on diet recommendations, and a paucity of literature relating to bone health and bone mineral density in women of later reproductive years.

The current World Health Organization (WHO) physical activity recommendations among adults aged 18–64 is at least 150–300 min of moderate-to-vigorous aerobic activity throughout the week, in combination with muscle-strengthening activity on two or more days per week [75]. The WHO suggests 1 in 4 adults do not meet global recommended levels of physical activity [76]. In this review, improvements in cardiometabolic risk factors and body composition were noted following interventions that incorporated an element of aerobic activity and/or resistance training. Unfortunately due to wide variation in the types of exercise examined, a meta-synthesis was not achievable, and no clear consensus on the best method of aerobic or strength training, duration or intensity could be reached.

The Department of Health have published national dietary recommendations for Irish women across the lifespan, focusing on those aged 19–50 years and aged over 50 years. The recommendations for women aged 19–50 include recommendations for meeting calcium and vitamin D requirements through diet for bone health, and promotion of healthy weight during the child-bearing years. Once women are over age 50, the recommendations change to promote dietary patterns for a healthy heart, and increased intake of calcium and vitamin D through supplementation if dietary intake is insufficient, in efforts to protect against bone loss [77]. In this scoping review, there were no studies that exclusively investigated dietary patterns or calcium supplementation. A small number of studies evaluated the use of vitamin D, with equivocal outcomes, likely owing to small sample sizes and short duration of study.

While most research has focused on either the child-bearing years or post-menopausal years, the importance of the puerperium has gained recognition. The influence of body composition and implications of obesity are central in mitigating the rising incidence of NCDs [1], with postpartum weight retention gaining recognition as a potential modifiable risk factor [64]. Unfortunately, the majority of women receive little education regarding the importance of weight loss or physical activity after childbearing, highlighting the postpartum period as a potential missed opportunity for lifestyle modification [78]. Systematic reviews evaluating postpartum weight retention highlight the early postpartum years when women are still engaging heavily with health services for their children as an ideal time to initiate lifestyle modifications incorporating aspects of diet, physical activity and individualised support, in order to promote healthy weight and target postpartum weight retention [64]. While not related directly to the postpartum period, this scoping review highlighted a number of publications related to the “Women’s Healthy Lifestyle Project”, an intervention designed to promote weight control through alterations in consumption of dietary fat and cholesterol, and increase in purposeful lifestyle activity over 54 months [23–26]. The intervention was provided by allied healthcare professionals who met with participants weekly or bi-weekly for 20 weeks and provided ongoing support throughout the 54 month maintenance period [23–26]. While this was a labour-intensive intervention, this collection of publications demonstrated it was possible to promote lifestyle modifications in perimenopausal women that would prevent long-term weight gain and increases in serum cholesterol levels during the menopausal transition, another highly influential time in a woman’s life [23–26]. Acknowledging the beneficial effect of the “Women’s Healthy Lifestyle Project”, but also its intensive protocol, the “40-something RCT”, adopted a similar intervention approach with a less intensive demand on healthcare professionals, which could be implemented at a population level [79]. Motivational interviewing techniques during regular consultations with healthcare professionals, was implemented to promote weight control over 24 months during the menopausal transition. The publications resulting from this RCT included easy to promote public health messages, encouraging premenopausal women to take 10,000 steps per day and eat 5 servings of vegetables daily to prevent weight gain [20]. During the maintenance phase, women who engaged in self-directed lifestyle changes gained back the weight they had lost during the 3 month intervention, whereas ongoing support from healthcare professionals allowed weight loss to be maintained [21]. It has been suggested that interventions targeting lifestyle modifications provided by health professionals which utilize evidence-based behaviour change techniques to motivate and support participants are better equipped to support women with their overall nutrition and health [80]. While both of these interventions required extensive support from healthcare professionals, they both demonstrated that promoting a healthy lifestyle during the later reproductive years has the potential to improve risk factors associated with NCDs. The intensive protocol and demand on personnel may limit the ability to implement these strategies into routine clinical settings and pose a difficulty for long-term sustainability at a population level. Mobile health (mHealth) technology is increasing in prevalence, and may offer the support required for effective lifestyle modification, without increasing demand on clinicians [81]. In pregnancy, there has been an increased prevalence of mHealth technology to support healthy weight management [82]. Studies have demonstrated the ability of this technology to support behaviour change and lifestyle modifications [83], in a format which is acceptable to the user [84]. However, further investigation of the potential use of mHealth technology in other age groups, and across longer durations may be of benefit in promoting increased uptake of this technology to promote lifestyle modifications across multiple populations.

Clinical implications

This scoping review provides an overview of interventions focusing on potential lifestyle modifications which may be initiated during the later reproductive years. We propose the later reproductive years as an important time point in a woman’s life course where promoting a healthy lifestyle has the potential to reduce the burden of NCDs. Female-specific risk factors for cardiometabolic disease have the potential to be identified at an early age [6, 85], therefore lifestyle modifications for these women, and indeed women in general, have the potential to offset the risk of developing cardiometabolic disease in the future.

Strengths & limitations

The present scoping review possesses a number of strengths, namely ensuring evidence regarding interventions promoting lifestyle modifications in later reproductive age women are collated and presented together for consideration. This review included only human interventional studies, including RCTs and clinical trials, to gather the highest possible quality of evidence relating to lifestyle interventions. This scoping review was conducted in accordance with Arksey and O’Malley and the Joanna Briggs Institute, a process detailed extensively in the methods section in order to ensure the transparency and clarity of the scoping review.

Notwithstanding these strengths, a few limitations should be acknowledged. In general, scoping reviews synthesize a broad range of sources to identify gaps in the existing literature, often generating further research questions rather than answering only one. The frameworks used for this scoping review recommend searching multiple electronic databases, as well as manual searching of reference lists, which was performed [13, 15]. However, it must be acknowledged that it is not practical to search all possible avenues, and it is possible that other interventions have been explored, but not published. This scoping review was limited to studies published in English, potentially allowing a language bias. A significant proportion of studies also relied on self-reported patient outcomes, which may introduce response bias. Additionally, a large number of studies had small sample sizes, varying research design and were of short duration, therefore a significant degree of heterogeneity was present which limited the ability to perform meta-synthesis in order to evaluate intervention effectiveness and provide specific recommendations.

Future research

This scoping review highlighted a small number of citations from Western cultures, and Europe in particular, which would lend well to future intervention studies, in order to cover a broad range of cultural approaches to lifestyle modifications. Additionally, we noted no studies which investigated the role of dietary interventions alone, a topic that may prove beneficial in helping mitigate the future burden of chronic disease. We also noted a paucity of data in relation to outcomes related to bone disease and bone health, which should be prioritized in future research. While it has been noted that lifestyle modifications, namely increased physical activity and altered dietary pattern, have effects on cardiometabolic and bone health, the detailed mechanisms underlying these observations remains unclear and represent an important area for future study.

Since this scoping review highlighted a significant degree of variation among the included studies despite employing a systematic search protocol, this heterogeneity may limit the ability to compare results directly and provide generalised recommendations. The number of studies which investigated long-term maintenance following lifestyle modification was relatively small, highlighting an important area for future research in order to evaluate long-term sustainability of lifestyle modifications among later reproductive age women. Large scale clinical trials which investigate long-term adherence, as well as cost effectiveness of interventions, would be of benefit in addressing long-term feasibility of lifestyle modification. Future work may build on the present scoping review to systematically review evidence and conduct meta-analysis in larger clinical trials with more objective outcome measures in order to address heterogeneity and provide more specific recommendations.

Conclusion

The later reproductive years represents an important time-point in a woman’s life, and this scoping review is one of few to map interventions of lifestyle modifications related to cardiometabolic and bone disease in later reproductive age women. We present a narrative summary of interventions focusing on lifestyle modification in women of later reproductive age which may have the potential to modulate later-life NCDs. While this outcome appears possible, many uncertainties persist regarding the most effective approach to promote lifestyle change among this unique population of women.

Body composition and lipid profile were among the risk factors most commonly improved by the lifestyle interventions, however there was considerable variation among the interventions. It appeared that incorporation of regular aerobic physical activity, as well as health education targeting multiple risk factors were the most effective in improving body composition and lipid profile in women during the later reproductive years. Additionally, we have highlighted the later reproductive years as an important time point in a woman’s life where lifestyle modifications have the potential to modulate later non-communicable, chronic disease. While there are no consensus guidelines regarding the most effective interventions for lifestyle modifications among women of later reproductive age, the findings of this scoping review help strengthen the evidence for the benefit of lifestyle modifications. This information may help inform the development of clinical guidelines in the prevention of chronic disease in women in the future.

Electronic supplementary material

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Abbreviations

BMI

Body mass index

DASH

Dietary approaches to stop hypertension

LDL cholesterol

Low density lipoprotein cholesterol

MeSH

Medical subject headings

MTCC qigong

Muscle/tendon change classic qigong

NCDs

Non-communicable, chronic diseases

PICO

Population, Intervention, Comparator, Outcome framework

PRISMA-ScR

Preferred Reporting Items for Systematic Reviews and Meta-analyses Extension for Scoping Reviews

RCT

Randomized controlled trial

WHO

World Health Organization

FSH

Follicle stimulating hormone

LH

Luteinizing hormone

mHealth

Mobile health

Author contributions

KD designed and carried out the search, screened citations, reviewed the data and wrote the manuscript. GD screened citations, reviewed the data and reviewed the manuscript. RKC critically appraised the manuscript for intellectual content. CP critically appraised the manuscript for intellectual content. PT critically appraised the manuscript for intellectual content. FMcA conceived the idea for the review and revised and approved the manuscript. All authors read and approved the final manuscript.

Funding

Funding agencies had no role in this review.

Data availability

The full search strings for the PubMed database are available in supplementary Table 1 (Additional File 1). No new data was created in this study. Detailed summary of all interventions are available in supplementary file 2 (Additional file 2). The data extraction form is available from the corresponding author upon reasonable request.

Declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Competing interests

The authors declare that they have no competing interests.