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Adobe Flash Player is required to view this feature. If you are using an operating system that does not support Flash, we are working to bring you alternative formats. Original Article Walking Compared with Vigorous Exercise for the Prevention of Cardiovascular Events in Women JoAnn E. Manson, M.D., Dr.P.H., Philip Greenland, M.D., Andrea Z.

LaCroix, Ph.D., Marcia L. Stefanick, Ph.D., Charles P. Mouton, M.D., Albert Oberman, M.D., M.P.H., Michael G. Perri, Ph.D., David S. Sheps, M.D., Mary B. Pettinger, M.S., and David S.

Siscovick, M.D., M.P.H. N Engl J Med 2002; 347:716-725 DOI: 10.1056/NEJMoa021067. Methods We prospectively examined the total physical-activity score, walking, vigorous exercise, and hours spent sitting as predictors of the incidence of coronary events and total cardiovascular events among 73,743 postmenopausal women 50 to 79 years of age in the Women's Health Initiative Observational Study. At base line, participants were free of diagnosed cardiovascular disease and cancer, and all participants completed detailed questionnaires about physical activity. We documented 345 newly diagnosed cases of coronary heart disease and 1551 total cardiovascular events. Free Ielts Academic Reading Practice Test With Answers Pdf.

Results An increasing physical-activity score had a strong, graded, inverse association with the risk of both coronary events and total cardiovascular events. There were similar findings among white women and black women.

Women in increasing quintiles of energy expenditure measured in metabolic equivalents (the MET score) had age-adjusted relative risks of coronary events of 1.00, 0.73, 0.69, 0.68, and 0.47, respectively (P for trend. Physical activity has been associated with a reduced risk of cardiovascular disease in epidemiologic studies, but data for women and members of minority ethnic groups have been sparse. Moreover, the specific role of walking, the most common form of exercise among women, has been addressed only minimally. Federal guidelines from the Centers for Disease Control and Prevention and the American College of Sports Medicine, as well as the Surgeon General's Report on Physical Activity and Health, endorse at least 30 minutes of moderate-intensity physical activity on most, and preferably all, days of the week, in contrast to earlier guidelines that recommended vigorous endurance exercise for at least 20 minutes three or more times per week. Although the federal guidelines encourage a level of activity that is safe, accessible, and feasible for most Americans (at least 75 percent of whom have less than the recommended level of activity ), the potential benefits of moderate-intensity activity in preventing cardiovascular events remain uncertain. Moreover, the role of time spent in sedentary behavior, such as sitting, in predicting risk remains relatively unexplored. We therefore compared the roles of walking and vigorous exercise in the prevention of coronary and cardiovascular events in a large, ethnically diverse cohort of postmenopausal women.

Using detailed assessments of physical activity, we examined the magnitude of associations between each of the measures of physical activity (the total physical-activity score, the intensity of exercise [walking vs. Vigorous exercise], and the hours spent sitting) and the incidence of cardiovascular events. Study Population The study population consisted of 73,743 women who were enrolled in the Women's Health Initiative Observational Study, which involved a national, multicenter cohort of postmenopausal women who were 50 to 79 years of age at entry. The Women's Health Initiative is a prospective, ethnically and racially diverse, multicenter clinical trial and observational study designed to address the major causes of illness and death in postmenopausal women (see the Appendix for a list of study investigators). A total of 93,676 women were enrolled in the observational study at 40 clinical centers between 1994 and 1998. Criteria for exclusion from the study included the presence of any medical condition associated with predicted survival of less than three years (e.g., class IV congestive heart failure, obstructive lung disease requiring supplemental oxygen, or severe chronic liver or kidney disease), alcoholism, mental illness, or dementia. In addition, women were excluded from the present analyses if, at base line, they had a history of coronary heart disease, stroke, or cancer; were nonambulatory (unable to walk at least one block); or had missing data on the physical-activity questionnaire.

After women had been excluded for these reasons, 73,743 women remained in the analysis. Of these women, 61,574 were non-Hispanic white, 5661 were non-Hispanic black, 2880 were Hispanic, 2288 were Asian or Pacific Islander, and 1340 were American Indian or of other racial or ethnic background. Race was self-assigned. Details of the scientific rationale, design, eligibility requirements, and base-line characteristics of the cohort have been published elsewhere. Exposure Assessment All women enrolled in the Observational Study were required to come for a clinic visit for base-line screening. At this visit, women completed self-administered questionnaires related to personal and family medical history, physical activity, smoking, diet, and other behavioral and lifestyle-related factors.

Clinical measurements including height, weight, waist and hip circumferences, and blood pressure were obtained by trained staff members. All women provided written informed consent, and the study protocol was approved by the institutional review board of each center. Recreational physical activity was assessed by a detailed questionnaire on the frequency and duration of walking and of several other types of activity (strenuous, moderate, and mild). Walking was assessed by a series of questions about the frequency of walks outside the home for more than 10 minutes without stopping, the average duration of each walk, and the usual walking pace. Vigorous exercise was defined as that in which “you work up a sweat and your heart beats fast,” and examples included aerobics, aerobic dancing, jogging, tennis, and swimming laps. Moderate exercise was defined as that which was “not exhausting,” and examples included biking outdoors, using an exercise machine (such as a stationary bicycle or a treadmill), calisthenics, easy swimming, and popular or folk dancing.

Examples of mild exercise were slow dancing, bowling, and golf. Using a standardized classification of the energy expenditure associated with physical activities, we calculated a weekly energy-expenditure score in metabolic equivalents (MET score) for walking and for total physical activity. Finally, participants were asked to estimate the number of hours per day they spent engaged in sedentary behavior, including time spent sitting as well as lying down or sleeping. Reproducibility and Validation of the Physical-Activity Assessment A sample of participants in the Observational Study (1092 women) was recruited into a reliability study to assess the reproducibility of selected questionnaires, including the physical-activity assessment. The average time between base line and repeated assessments was three months.

The test–retest reliability for recreational physical activity, including walking and strenuous activity, was assessed (weighted kappas among all women ranged from 0.67 to 0.71). The intraclass correlation coefficient for the primary summary variable (total energy expenditure in MET from all recreational physical activity) was 0.77.

A similar physical-activity questionnaire has been found to be correlated with physical-activity diaries (r=0.62) and with one-week recall of activity (r=0.79) in a cohort of female health professionals. Ascertainment of End Points The primary end points for this study were newly diagnosed coronary heart disease (nonfatal myocardial infarction or death from coronary causes) and total cardiovascular events (myocardial infarction, death from coronary causes, coronary revascularization, angina, congestive heart failure, stroke, or carotid revascularization) that occurred after the return of the base-line questionnaire but before August 27, 2000. Newly diagnosed cardiovascular events were identified on the basis of annual mailed follow-up questionnaires (response rates have been above 95 percent), and permission to review medical records was requested. Study physicians with no knowledge of the self-reported risk-factor status reviewed the records. The diagnosis of nonfatal myocardial infarction was confirmed if data in the hospital record met standardized criteria of diagnostic electrocardiographic changes, elevated cardiac-enzyme levels, or both.

Treatment with coronary or carotid revascularization was confirmed by documentation of the procedure in the medical record. The presence of angina was confirmed by hospitalization and confirmatory evidence on angiography, diagnostic stress test, or diagnosis by a physician and medical treatment. The occurrence of stroke was confirmed by documentation in the medical record of the rapid onset of a neurologic deficit consistent with stroke and lasting at least 24 hours or until death. The presence of congestive heart failure was confirmed by hospitalization and diagnostic confirmatory tests. Fatal coronary disease was considered confirmed if there was documentation in the hospital or autopsy records or if coronary disease was listed as the cause of death on the death certificate and evidence of previous coronary disease was available. For deaths from other cardiovascular causes, a review of confirmatory evidence by physician-adjudicators was required.

Statistical Analysis Our primary analyses used the detailed physical-activity assessment at base line. Person-time for each woman was calculated from the date of return of the base-line questionnaire to the date of a confirmed cardiovascular event, death from any cause, or August 27, 2000, whichever came first. Age-adjusted relative risks were computed as the incidence rate in a specific category of activity divided by the incidence rate in the lowest quintile, with adjustment for one-year age categories. We conducted tests of linear trend by treating the categories as a continuous variable and assigning the median score for each category.

All tests of statistical significance were two-sided. We used Cox proportional-hazards regression to adjust simultaneously for potential confounding variables, including age, smoking status, body-mass index (the weight in kilograms divided by the square of the height in meters), the ratio of the waist circumference to the hip circumference, alcohol consumption, age at menopause, use of hormone-replacement therapy, parental history of premature myocardial infarction (before 55 years of age in the father or before 65 years of age in the mother), race or ethnic group, education, family income, and several dietary variables. Additional models controlled for history or absence of history of hypertension, diabetes, and high cholesterol levels, as well as for functional status and a summary score for mental and emotional health. The total MET score, the MET score for walking, time spent in vigorous exercise, walking pace, and hours spent sitting and lying down or sleeping were analyzed separately.

Differences in the results for activity according to race (white women vs. Black women), age, and body-mass index were assessed. Secondary analyses excluded data for the first year of follow-up in order to minimize potential bias caused by the presence of subclinical disease. Results During up to 5.9 years of follow-up (mean, 3.2 years; total, 232,971 person-years), we documented 345 newly diagnosed cases of coronary disease (287 nonfatal myocardial infarctions and 58 deaths from coronary causes), 309 strokes, and 1551 first cardiovascular events among the 73,743 women 50 to 79 years of age who completed a detailed physical-activity questionnaire, were ambulatory, and were free of cardiovascular disease and cancer at base line. The base-line characteristics of the cohort and the distribution of physical-activity profiles and other risk factors have been described elsewhere. The total physical-activity score (in MET-hours per week) at base line had a strong inverse relation with the risk of coronary heart disease during the follow-up period ( Table 1 Relative Risks of Cardiovascular Disease According to Quintile of Total Physical-Activity Score and Categories of Walking and Vigorous Exercise. Dell Vista Upgrade Windows 7 Free Download Programs.

In age-adjusted analyses, the relative risk declined with increasing quintiles of the total MET score (1.00, 0.73, 0.69, 0.68, and 0.47, respectively; P for trend. Discussion These prospective data from an ethnically diverse cohort of postmenopausal women indicate that both walking and vigorous exercise are associated with substantial reductions in the incidence of cardiovascular events. In contrast, prolonged time spent sitting predicts increased risk.

We observed similar magnitudes of risk reduction with walking and vigorous exercise, and the results were similar among white women and black women as well as among women in different age groups and categories of body-mass index. These findings extend those of previous analyses from predominantly white populations to a racially and ethnically diverse cohort of women in the United States. The results also lend further support to current federal exercise guidelines that endorse moderate-intensity exercise for at least 30 minutes on most, and preferably all, days of the week. Women who either walked briskly or exercised vigorously at least 2.5 hours per week had a risk reduction of approximately 30 percent. Evidence of the applicability of these guidelines to nonwhite women is of particular importance because of the high prevalence of sedentary lifestyles, obesity, and related conditions in minority populations. Strengths of the present study include the prospective design, the large size, the racial and ethnic diversity of the cohort, the detailed assessment of physical activity as well as sedentary behavior, and the uniform and strict criteria for the coronary and cardiovascular end points. Women with diagnosed cardiovascular disease or cancer at base line and those who were nonambulatory (unable to walk at least one block) were excluded from the analyses.

These exclusions and the prospective design minimized any influence of preexisting disease on the level of physical activity. Moreover, we performed secondary analyses excluding data from the first year of follow-up in order to minimize bias related to the presence of subclinical disease. The strong dose–response gradient observed between the physical-activity level and the reduced risk of cardiovascular disease and the consistency of the findings across strata of age, race, and body-mass index lend further credence to a causal interpretation. Other strengths of the study include the high follow-up rate and the detailed information about potential confounding variables. Because our multivariate analyses controlled for several factors that could be considered to be intermediate biologic variables, such as body-mass index and waist-to-hip ratio, and additional models controlled for history of hypertension, hypercholesterolemia, and diabetes, our analyses provide a conservative estimate of the relation between activity and cardiovascular disease.

Physical activity may be associated with even greater reductions in cardiovascular risk — closer to the 50 percent reductions found in our age-adjusted analyses — given that the relative risks derived from the multivariate models estimate the effects of exercise without taking into account its favorable influence on adiposity and related morbidity. Some limitations of our study also deserve attention. Physical activity was assessed by questionnaire, and some misclassification of exposure was inevitable.

Nondifferential misclassification of exposure, however, would be expected to bias the risk estimate toward unity; thus, it cannot explain the strong inverse associations observed between the level of physical activity and the incidence of cardiovascular events. Despite the fact that we controlled for a large number of potentially confounding variables in our multivariate analyses, residual confounding by lifestyle-related factors cannot be excluded. Finally, our study population of volunteers in the Women's Health Initiative, although of more diverse racial and ethnic background and socioeconomic status than most previously studied cohorts, is not an entirely representative cross-section of women in the United States.

More than 40 epidemiologic studies have addressed the relation between exercise and cardiovascular disease, but only one third of published studies have included women, and few of these have specifically addressed the role of walking. In previous studies, results for women have been generally similar to those for men, indicating that risk among both sexes is reduced by 30 to 50 percent with regular physical activity. Recent reports from several large-scale cohort studies involving women have suggested that moderate and vigorous exercise have similar cardiovascular benefits, but these cohorts were predominantly white. Moreover, to our knowledge, no previous large-scale study has addressed the relation between walking and cardiovascular events in black women or the role of sitting after accounting for recreational energy expenditure in women. The evidence that moderate-intensity activity is associated with a similar magnitude of reduction in cardiovascular risk among white women and black women, among younger and older postmenopausal women, and across the spectrum of adiposity is important for the targeting of these diverse groups with health-promotion activities. The cardiovascular benefits of walking and even moderate levels of physical fitness also appear to apply to men. An important role for both moderate and vigorous exercise in reducing cardiovascular risk is also biologically plausible.

Increasing intensity or duration of exercise has a graded relation to improvements in lipid levels and insulin sensitivity. Moderate-intensity activity may produce reductions in diastolic blood pressure similar to those achieved with vigorous exercise and may produce even greater reductions in systolic blood pressure. Moderate exercise coupled with modification of the diet led to a reduced risk of type 2 diabetes among subjects with impaired glucose tolerance. Moreover, equivalent energy expenditure with moderate or vigorous exercise leads to similar reductions in adipose mass.

Finally, physical activity of any intensity has been linked to improvement in emotional well-being. In conclusion, these prospective data from a large and diverse cohort of postmenopausal women indicate that both walking and vigorous exercise are associated with substantial reductions in the risk of cardiovascular events. A graded inverse relation was observed among both white women and black women, lean women and obese women, and younger women and older women.

Moreover, prolonged time spent sitting predicted increased risk. These findings lend support to current federal guidelines that endorse moderate-intensity activity, including walking. Although vigorous exercise should not be discouraged for those who choose a higher intensity of activity, our results indicate that moderate-intensity exercise confers substantial health benefits for postmenopausal women.

Source Information From the Division of Preventive Medicine, Harvard Medical School and Brigham and Women's Hospital, Boston (J.E.M.); the Department of Preventive Medicine, Northwestern University Medical School, Chicago (P.G.); the Fred Hutchinson Cancer Research Center (A.Z.L., M.B.P.) and the Departments of Medicine and Epidemiology (D.S.S.), University of Washington, Seattle; Stanford Center for Research in Disease Prevention, Stanford, Calif. (M.L.S.); the University of Texas Health Science Center, San Antonio (C.P.M.); the Division of Preventive Medicine, University of Alabama at Birmingham, Birmingham (A.O.); and the Department of Clinical and Health Psychology (M.G.P.) and Division of Cardiology (D.S.S.), University of Florida, Gainesville. Address reprint requests to Dr. Manson at the Division of Preventive Medicine, Brigham and Women's Hospital, 900 Commonwealth Ave., Boston, MA 02215,.

Appendix The following persons are members of the Women's Health Initiative Study Group. Program office: J.E. Morris (National Heart, Lung, and Blood Institute, Bethesda, Md.).

Clinical coordinating center: R. Patterson, A. McTiernan (Fred Hutchinson Cancer Research Center, Seattle); S. Rautaharju (Bowman Gray School of Medicine, Winston-Salem, N.C.); E.

Stein (Medical Research Labs, Highland Heights, Ky.); S. Cummings (University of California at San Francisco, San Francisco); J. Himes (University of Minnesota, Minneapolis); S. Heckbert (University of Washington, Seattle). Clinical centers: S. Wassertheil-Smoller (Albert Einstein College of Medicine, Bronx, N.Y.); J. Hays (Baylor College of Medicine, Houston); J.

Manson (Brigham and Women's Hospital and Harvard Medical School, Boston); A.R. Assaf (Brown University, Providence, R.I.); L.

Phillips (Emory University, Atlanta); S. Beresford (Fred Hutchinson Cancer Research Center, Seattle); J. Hsia (George Washington University Medical Center, Washington, D.C.); C. Ritenbaugh (Kaiser Permanente Center for Health Research, Portland, Oreg.); B. Caan (Kaiser Permanente Division of Research, Oakland, Calif.); J. Morley Kotchen (Medical College of Wisconsin, Milwaukee); B.V. Howard (Medstar Research Institute, Washington, D.C.); L.

Van Horn (Northwestern University, Chicago and Evanston, Ill.); H. Black (Rush–Presbyterian–St. Luke's Medical Center, Chicago); M.L. Stefanick (Stanford Center for Research in Disease Prevention, Stanford University, Stanford, Calif.); D. Lane (State University of New York at Stony Brook, Stony Brook); R. Jackson (Ohio State University, Columbus); C.B.

Lewis (University of Alabama at Birmingham, Birmingham); T. Bassford (University of Arizona, Tucson and Phoenix); M. Trevisan (State University of New York at Buffalo, Buffalo); J. Robbins (University of California at Davis, Sacramento); A. Hubbell (University of California at Irvine, Orange); H.

Judd (University of California at Los Angeles, Los Angeles); R.D. Langer (University of California at San Diego, LaJolla and Chula Vista); M.

Gass (University of Cincinnati, Cincinnati); M. Limacher (University of Florida, Gainesville and Jacksonville); D.

Curb (University of Hawaii, Honolulu); R. Wallace (University of Iowa, Iowa City and Davenport); J.

Ockene (University of Massachusetts, Worcester); N. Lasser (University of Medicine and Dentistry of New Jersey, Newark); M.J.

O'Sullivan (University of Miami, Miami); K. Margolis (University of Minnesota, Minneapolis); R.

Brunner (University of Nevada, Reno); G. Heiss (University of North Carolina, Chapel Hill); L. Kuller (University of Pittsburgh, Pittsburgh); K.C. Johnson (University of Tennessee, Memphis); R. Schenken (University of Texas Health Science Center, San Antonio); C. Allen (University of Wisconsin, Madison); G. Burke (Wake Forest University School of Medicine, Winston-Salem, N.C.); S.

Hendrix (Wayne State University School of Medicine and Hutzel Hospital, Detroit).

In finance, a foreign exchange option (commonly shortened to just FX option or currency option) is a derivative financial instrument that gives the right but not the obligation to exchange money denominated in one currency into another currency at a pre-agreed exchange rate on a specified date.[1] See Foreign exchange derivative. The foreign exchange options market is the deepest, largest and most liquid market for options of any kind. Most trading is over the counter (OTC) and is lightly regulated, but a fraction is traded on exchanges like the International Securities Exchange, Philadelphia Stock Exchange, or the Chicago Mercantile Exchange for options on futures contracts. The global market for exchange-traded currency options was notionally valued by the Bank for International Settlements at $158.3 trillion in 2005 For example, a GBPUSD contract could give the owner the right to sell?1,000,000 and buy $2,000,000 on December 31. In this case the pre-agreed exchange rate, or strike price, is 2.0000 USD per GBP (or GBP/USD 2.00 as it is typically quoted) and the notional amounts (notionals) are?1,000,000 and $2,000,000.

This type of contract is both a call on dollars and a put on sterling, and is typically called a GBPUSD put, as it is a put on the exchange rate; although it could equally be called a USDGBP call. If the rate is lower than 2.0000 on December 31 (say 1.9000), meaning that the dollar is stronger and the pound is weaker, then the option is exercised, allowing the owner to sell GBP at 2.0000 and immediately buy it back in the spot market at 1.9000, making a profit of (2.0000 GBPUSD? 1.9000 GBPUSD)? 1,000,000 GBP = 100,000 USD in the process. If instead they take the profit in GBP (by selling the USD on the spot market) this amounts to 100,000 / 1.9000 = 52,632 GBP. Although FX options are more widely used today than ever before, few multinationals act as if they truly understand when and why these instruments can add to shareholder value.

To the contrary, much of the time corporates seem to use FX options to paper over accounting problems, or to disguise the true cost of speculative positioning, or sometimes to solve internal control problems. The standard clich? About currency options affirms without elaboration their power to provide a company with upside potential while limiting the downside risk. Options are typically portrayed as a form of financial insurance, no less useful than property and casualty insurance.

This glossy rationale masks the reality: if it is insurance then a currency option is akin to buying theft insurance to protect against flood risk. The truth is that the range of truly non-speculative uses for currency options, arising from the normal operations of a company, is quite small. In reality currency options do provide excellent vehicles for corporates' speculative positioning in the guise of hedging. Corporates would go better if they didn't believe the disguise was real.

Let's start with six of the most common myths about the benefits of FX options to the international corporation -- myths that damage shareholder values. Historically, the currency derivative pricing literature and the macroeconomics literature on FX determination have progressed separately. In this Chapter I argue the joint study of these two strands of literature and give an overview of FX option pricing concepts and terminology crucial for this interdisciplinary study. I also explain the three sources of information about market expectations and perception of risk that can be extracted from FX option prices and review empirical methods for extracting option-implied densities of future exchange rates. As an illustration, I conclude the Chapter by investigating time series dynamics of option-implied measures of FX risk vis-a-vis market events and US government policy actions during the period January 2007 to December 2008. Chapter 2: This Chapter proposes using foreign exchange (FX) options with different strike prices and maturities to capture both FX expectations and risks. We show that exchange rate movements, which are notoriously difficult to model empirically, are well-explained by the term structures of forward premia and options-based measures of FX expectations and risk.

Although this finding is to be expected, expectations and risk have been largely ignored in empirical exchange rate modeling. Using daily options data for six major currency pairs, we first show that the cross section options-implied standard deviation, skewness and kurtosis consistently explain not only the conditional mean but also the entire conditional distribution of subsequent currency excess returns for horizons ranging from one week to twelve months. At June 30 and September 30, the value of the portfolio was?1,050,000. Note, however, that the notional amount of Ridgeway's hedging instrument was only?1,000,000. Therefore, subsequent to the increase in the value of the pound (which is assumed to have occurred on June 30), a portion of Ridgeway's foreign currency exchange risk was not hedged. For the three-month period ending September 30, exchange rates caused the value of the portfolio to decline by $52,500.

Of that amount, only $50,000 was offset by changes in the value of the currency put option. The difference between those amounts ($2,500) represents the exchange rate loss on the unhedged portion of the portfolio (i.e., the 'additional'?50,000 of fair value that arose through increased share prices after entering into the currency hedge). At June 30, the additional?50,000 of stock value had a U.S.

Dollar fair value of $45,000. At September 30, using the spot rate of 0.85:1, the fair value of this additional portion of the portfolio declined to $42,500. Ridge way will exclude from its assessment of hedge effectiveness the portion of the fair value of the put option attributable to time value. That is, Ridgeway will recognize changes in that portion of the put option's fair value in earnings but will not consider those changes to represent ineffectiveness. Aitan Goelman, the CFTC’s Director of Enforcement, stated: “The setting of a benchmark rate is not simply another opportunity for banks to earn a profit.

Countless individuals and companies around the world rely on these rates to settle financial contracts, and this reliance is premised on faith in the fundamental integrity of these benchmarks. The market only works if people have confidence that the process of setting these benchmarks is fair, not corrupted by manipulation by some of the biggest banks in the world.” The Commission finalized rules to implement the Dodd-Frank Wall Street Reform and Consumer Protection Act regarding Regulation of Off-Exchange Retail Foreign Exchange Transactions and Intermediaries. The Commission also finalized Conforming Changes to existing Retail Foreign Exchange Regulations in response to the Dodd-Frank Act. Additional information regarding these final rules is provided below, including rules, factsheets, and details of meetings held between CFTC Staff and outside parties.