Cardiovascular disease remains the leading cause of death in women, and hypertension is a major contributing factor, particularly after menopause. The sympathetic nervous system — historically viewed as the “fight or flight” part of our autonomic nervous system — is involved in regulating blood pressure (BP) and can contribute to the development of hypertension. Previous studies have shown that BP increases more in postmenopausal women during exercise compared to younger women. This exaggerated exercise-induced BP response increases cardiovascular risk in postmenopausal women, yet the underlying mechanism(s) remain unknown. Moreover, it is unclear if these exaggerated BP responses are due to aging or if they are related to declines in ovarian hormones like estradiol that are associated with menopause.

In our current study in the March 2022 issue of Medicine & Science in Sports & Exercise_®, we examined the BP response during isometric handgrip exercise. We sought to determine if the large increases in BP during exercise in postmenopausal women are due to changes in the sympathetic nervous system. We directly measured sympathetic nervous system activity using a technique called microneurography. This method allows us to assess how frequently the nervous system is firing at rest and in response to isometric handgrip exercise. This measurement, along with beat-to-beat BP, was compared between young premenopausal women and postmenopausal women. We also tested a separate group of postmenopausal women before and following one month of transdermal estradiol therapy. Our data show that the sympathetic nervous system is overactive and increases to a greater extent during handgrip exercise in postmenopausal women, contributing, in part, to the larger increases in BP. However, these large increases in sympathetic nervous system activity and BP during handgrip exercise were attenuated in postmenopausal women after one month of estradiol therapy. We conclude that both aging and changes in estradiol that occur with menopause contribute to the exaggerated increases in sympathetic nervous system activity and BP during isometric exercise in postmenopausal women.

Since the release of the Women’s Health Initiative data roughly 20 years ago, numerous research studies have demonstrated that hormone therapy can be safely used by the majority of postmenopausal women. Although hormone therapy may not serve as a primary prevention to reduce the development of cardiovascular disease, it has become clear that it does not necessarily carry the risk once thought if used within established guidelines. Our data show that transdermal estradiol therapy can attenuate sympathetic nervous system activity and BP during exercise. However, in terms of primary prevention for cardiovascular disease, it is well established that exercise is a cornerstone therapy for lowering BP and improving cardiovascular health. Our data bring awareness to the importance of monitoring BP in women during physical activity while reinforcing the need to specifically consider BP in exercise-prescription guidelines for women. Notably, recent data suggest that the risk for development of cardiovascular disease begins at a lower BP threshold for women compared to men.

The inclusion of women in research is paramount for improving human health. Our findings demonstrate that studies focused on women remain important to gain a better understanding of cardiovascular disease risk in women. 

Megan M. Wenner, Ph.D., is an associate professor in the Department of Kinesiology and Applied Physiology at the University of Delaware. She received a Ph.D. in physiology from the University of Delaware and completed her postdoctoral training at the John B. Pierce Laboratory and Yale School of Medicine. Dr. Wenner’s research focuses on cardiovascular health in women throughout the lifespan, with a focus on sex hormones and menopause.

Paul J. Fadel, Ph.D., is a professor in the Department of Kinesiology and associate dean for Research at the University of Texas at Arlington. Dr. Fadel’s research focuses on neural cardiovascular control mechanisms in human health and disease, with a specific emphasis on the sympathetic branch of the autonomic nervous system.

Viewpoints presented in SMB commentaries reflect opinions of the authors and do not necessarily represent ACSM positions or policies. Active Voice authors who have received financial or other considerations from a commercial entity associated with their topic must disclose such relationships at the time they accept an invitation to write for SMB.

My name is Vanessa Valle, and I’m an exercise physiologist at the Cardiac Rehabilitation and Wellness Center at the University of California, San Francisco (UCSF). Our program opened in October 2019 and, just as we were gaining some kind of semblance of momentum, we shut down due to the COVID-19 pandemic. Every policy and procedure that we’d barely finished writing changed, and my role as an exercise physiologist took a different identity.

So I could write about what I do as an exercise physiologist in a cardiac rehab clinic — write exercise prescriptions, monitor patients’ telemetry and blood pressure — but we all know that. I’m going to talk about our roles as listeners and how my role as health care provider during the pandemic challenged me in a different way.

Before the pandemic, our center saw seven patients at a time. It was a fun, social group setting, which was something I loved about cardiac rehab. When COVID-19 started rearing its ugly head, we decided to shut down since many patients became too afraid to come in and, honestly, we as a staff were scared too. We decided to work from home, and I couldn’t fathom what that would look like, especially since IT sure had a hard time configuring my laptop for home use. I was given the task of calling current patients for a weekly check-in and to keep them apprised of our projected reopening.

I became their social outlet. I would call to just check in and would speak to a patient for almost an hour — getting to learn about them as a person and not only as a patient. During those first few weeks, I often felt like I was the only person they regularly got to talk to. And maybe exercise was only 25% of our conversation, but there was a lot of value in that other 75%.

My role changed from writing out exercise prescriptions to figuring out how to get patients to simply move instead of being glued to the TV. I learned so much about a patient’s family, but trying to convince the patient that they need to take care of themselves when they were worried about their aging parents and figuring out how to work from home plus homeschool their kids. I would worry about a patient that lived in an unsafe part of town but only wanted to walk late at night because there were less crowds. It was relatively easy to demonstrate bicep curls to a patient in the center but a whole different challenge to convince that same patient that doing laundry does not count as exercise. And that watching the news is not helping their heart health either.

I had this one wonderful patient who was quite the introvert and always had high blood pressure, which he attributed to “white coat syndrome.” In the first couple weeks of the pandemic, he revealed to me that he was feeling quite lonely. His main social outlet was volunteering at Golden Gate Park helping maintain the gardens. We didn’t focus too much on exercise initially, but I enjoyed talking about his children and Golden Gate Park, and we spent a lot of time helping him figure out Zoom for his medical appointments. Eventually, I was able to get him to use Golden Gate as his playground for exercise. I learned he took up photography in his retirement years and loved to take pictures of wildlife at Stow Lake. So we used his number of laps around Stow as measurements of progress and using the benches and his camera equipment to complete weighted squats. I shared his photography with my coworkers, and we became his friends, giving him a social outlet.

Another patient was eating too many carbs and high-sodium processed foods because he didn’t know how to cook. He relied on his job for free lunches, and his physical activity consisted of walking from building to building. I had to figure out how to motivate a patient who is newly working from home, lacks intrinsic motivation to exercise and has a high-stress, sedentary job. I foolishly asked him if he had a cast iron pan to use as a substitute for weights. He got a good laugh out of that since he did not cook whatsoever! I learned he used to play ice hockey, so I developed an exercise program that included skate jumps and wood chops with the hockey equipment he dug out — plus exercises he can do while his dog chooses to sniff on their walks instead of consistently maintaining the 30-45 minutes of moderate walking intensity that we wish our pups understood.

As we started to slowly reopen, our initial group setting of seven went to a maximum of two patients. Instead of our usual routine of using cardio equipment, we spent more time working one on one and developing an exercise routine patents could complete at home with no exercise equipment. From those months of weekly phone calls, I learned to develop highly individualized exercise programs, spending a lot of time on YouTube finding the perfect exercise video for each patient.

I have a new appreciation — actually a new passion — for teaching leg-strengthening and balance exercises. In my job prior to UCSF, the daily roster consisted of three staff members working with 12 patients. It was almost impossible for one staff member to stay with one deconditioned patient doing weights and balance exercise when you had to help get blood pressures and rates of perceived exertion. Now, I spend more time talking to patients about what exercises they can do at their kitchen countertops, such as heel raises and side kicks. They enjoyed doing some exercise while waiting for water to boil! Initially, I felt guilty taking time away from their NuStep machine and cardio exercises since that was what cardiac rehab centers focus on. However, knowing that our patients would never join a community gym due to COVID-19 surges, we found it more important to develop a routine they could do at home.

So as more mandates are getting lifted and we start to increase our capacity, I’ve learned to not get too focused on taking blood pressures and whipping out exercise prescriptions on the cardio equipment, but instead to think of our patients outside the cardiac rehab center — getting to know them beyond their medical history and to be able to describe them other than what their EF may be. To discover what scares them and what motivates them, and to make exercise more meaningful to them. Instead of calling an exercise by its formal name, like “frontal shoulder raise,” I’ve called it “lift your cat” or “lift your grandchildren.” Does the patient miss travel? I’d call the “overhead press” “luggage in the overhead bin” to make it more meaningful and practical. Do they miss dancing? Patients will appreciate it if you curate YouTube home Zumba videos for them.

Something patients often suggest in our satisfaction surveys is that we have some kind of follow-up months or a year after they complete the program. Unfortunately, I’ve never been at a cardiac rehab that had the staffing to do that. It’s too easy for patients to stop exercising after cardiac rehab since they no longer have the accountability we provide them or access to cardio machines. But if we can spend time creating a very personalized exercise program, particularly more time with a transition-to-graduation plan, we can create a long-lasting motivation that they can find in their everyday life. Maybe they’ll actually buy that cast iron pan.

Should your clients use energy drinks to improve their exercise performance? The short answer is no. But it’s important to understand why.

Energy drinks, or “EDs,” are fundamentally different from sports drinks (e.g., Gatorade) and traditional beverages like coffee, tea, soft drinks, juices and flavored water. Most contain three major components: high levels of caffeine, sugar and an herbal “energy blend” consisting of taurine, glucuronolactone, guarana, gingko, B vitamins and L-carnitine.

Critically, many people consume multiple ED in one session—and some individuals are more sensitive to caffeine because of their genetics. EDs’ high caffeine content, combined with the fact that many of those who consume them are often caffeine naive—i.e., teenagers and young adults who don’t drink coffee every day—can lead to negative outcomes.

Because of the research my colleagues and I have performed, I don’t recommend people consume energy drinks in general, regardless of whether they’re exercising. EDs are associated with a number of complications, and with respect to the cardiovascular system specifically, ED consumption is associated with increased demand on the heart via increased sympathetic tone, blood pressure, inotropy and arrhythmias. Individuals may also experience reduced coronary artery blood supply via endothelial dysfunction, platelet aggregation, coronary thrombosis and coronary spasm. These factors can lead to acute issues for cardiac patients and healthy people alike.

Such effects are particularly prominent in certain vulnerable populations. Young people, those who are inexperienced with caffeine or particularly sensitive to it, smaller individuals, individuals with underlying cardiovascular or other conditions, pregnant or breastfeeding women, and people who consume multiple energy drinks in one session are all at higher risk for complications.

Children and adolescents appear to be especially vulnerable because they often fall into more than one of the above categories: caffeine naiveite, smaller body size and heavy or frequent ED consumption.

As with many topics, we need to do more research on the effects and safety of EDs in various populations. Though we are aware of many of the acute cardiovascular consequences of consuming EDs, we still have a lot to learn about their chronic cardiovascular consequences.

So, what’s the takeaway?

In general, people with a balanced diet that includes the appropriate macronutrients (proteins, carbohydrates, fats) for their levels of training and recovery shouldn’t need to use EDs to enhance their performance.

For short-duration exercise (< 1 hour), your clients should stick to drinking cool water only. If they are performing endurance exercise for more than an hour, especially if they are sweating a lot, sports drinks may improve their performance. Steer clear of EDs.

Related links:
ACSM statement | Energy Drinks: A Contemporary Issues Paper
Blog | Sports Supplements & Performance
Visual Abstract | Individualized Hydration Plans for Endurance Athletes

John P. Higgins, MD, MBA, MPHIL, is a professor of cardiology at McGovern Medical School at The University of Texas Health Science Center at Houston and Senior Cardiologist at Harris Health’s Lyndon B. Johnson Hospital. He is director of Exercise Physiology at Memorial Hermann Ironman Sports Medicine Institute and a sports cardiologist who works with the Houston Rockets and Rice University Athletics. He received his MD from the University of Queensland, Australia; a Master’s in Philosophy from the University of Cambridge; and an MBA from George Washington University. He completed a cardiology fellowship from Brigham and Women’s Hospital-Harvard. His research includes cardiovascular screening of athletes, energy drinks, smartphone apps and activity trackers, and teaching children first-aid. A strong advocate of “exercise as medication,” he is a marathon runner and has co-authored a children’s book on first-aid.

D-Glucosamine is an amino sugar synthesized from glucose and glutamine. It is found in cartilage, tendons and ligaments in our body. It is a component of glycoproteins, proteoglycans and glycosaminoglycans, which are the building blocks of cartilage. In human beings, glucosamine is synthesized endogenously from glucose but also may be obtained from exogenous dietary supplements. Glucosamine or its precursors, like collagen-containing food supplements, are commonly recommended to promote osteoarticular health. A typical use is to attenuate osteoarthritis in humans because of glucosamine’s high concentration in joint tissue. After oral administration, 87% of glucosamine is absorbed, and it is mainly incorporated into skeletal muscle and articular cartilage. Different studies have shown that oral glucosamine supplementation stimulates the synthesis of synovial fluid, inhibits degradation and improves healing of articular cartilage. However, despite extensive research, the data related to glucosamine’s effect on pain relief in patients with osteoarthritis have been inconsistent.

In the last few years, elite athletes have been taking glucosamine supplements because of their potential chondro-protective effects. But recently, some studies have shown that glucosamine has a favorable effect on cellular energy metabolism. The VITAL study evaluated the associations between a 10-year average intake of 20 dietary supplements (including 13 vitamins and minerals, fish oil, Gingko biloba, glucosamine, fiber and garlic) and mortality in a cohort of 77,719 subjects. For most of the supplements examined, there was no association with mortality. However, the strongest association with decreased risk of total mortality was that observed for glucosamine and chondroitin supplementation.

In our manuscript, published in the March 2022 issue of Medicine & Science in Sports & Exercise_®, we aimed to study the potential beneficial effects of glucosamine on mitochondrial content, physical performance and oxidative stress in mice that were aerobically trained and supplemented with three different doses of glucosamine for a period of six weeks. We measured exercise performance (grip strength, motor coordination and running capacity) before and after the training period. Proteins involved in mitochondrial biogenesis or content, like PGC-1, NRF-1 and cytochrome c, were increased by glucosamine supplementation in skeletal muscle. We did not observe changes in markers of oxidative stress (GSSG/GSH) or a damage like increase in lipid peroxidation (MDA) or protein carbonylation.

Our findings showed that glucosamine increases the protein levels of mitochondrial biogenesis markers and content. This resulted in an increase in motor coordination and also endurance capacity (i.e., the capacity to run long distances). This suggests that glucosamine could improve exercise performance, and it might be considered as an ergogenic aid — especially for cardio-respiratory training. Because glucosamine has an excellent safety profile and its adverse effects are uncommon and mild, it could be considered for use as a supplement for endurance athletes.

Jose Viña is a full professor of physiology at the University of Valencia in Valencia, Spain, where he combines his teaching duties with research work, the latter in two main lines: ageing and exercise. Viña leads a successful research group (FreshAge) working on different aspects of oxidative stress, with whom he has won numerous prizes for research work. He has published more than 300 papers on glutathione, mitochondria, exercise, ageing and nutrition.

Mari Carmen Gomez-Cabrera is also a full professor of physiology at the University of Valencia. She is the author of more than 120 peer-reviewed international publications, which have collectively accumulated over 8,500 citations in the broad area of exercise redox biology and more recently in healthy aging, frailty and sarcopenia.

Disclosure: Jose Viña is a member of the Scientific Advisory Board of NuSkin Pharmanex Research.

Viewpoints presented in SMB[JS2]  commentaries reflect opinions of the authors and do not necessarily represent ACSM positions or policies. Active Voice authors who have received financial or other considerations from a commercial entity associated with their topic must disclose such relationships at the time they accept an invitation to write for SMB. 

Wellcoaches created the animated movie How Coaching Works to explain health and well-being coaching when the field was in its infancy. Now with almost 2 million views, the video remains a useful illustration of the best qualities of a helping relationship. Let’s take a look at the psychological underpinnings of the cartoon, which will provide insight into useful coaching-psychology principles and processes for the exercise professional.

Scene One: MEET

In this scene you find the coach in the office with a client. You may expect that it’s the coach’s job to tell the client what to do. Instead, the coach asks the client to create a picture of their vision, symbolized by the mountains off in the distance.

The client is eager to move toward that vision, and has even started doing some of the thinking necessary to get there, but feels overwhelmed by the things that stand between reality and the dream. The knotted path represents the many possible ways to reach the vision. It’s up to the client, with the coach’s support, to figure out which path is the best one.

The coach and client first agree on how they are going to work together. They shake hands, symbolizing the important boundary-setting conversation and agreement that starts a coaching relationship. For this relationship to promote growth, the coach radiates warmth, empathy, confidence, zest, humor and courage.

Scene Two: VISION

In the next scene, the coach encourages the client to get very clear about what it is that they want, and why. The coach gets the client motivated by encouraging them to explore why change is important now. The coach determines what it is exactly that the client wants to create—noting that all of life is invented and that together they will experiment with how to get from point A to point B.

Did you know that it’s all invented? According to the constructionist principle, we construct our reality—what we perceive, what we believe, what things mean and what we value. In other words, it’s all made up! And it’s from this frame of reference that the best coaches work with their clients. They playfully support the client in making up the rules to the client’s “game of life” and in experimenting with the ways to play it. The Art of Possibility, by authors Ben and Rosamund Zander, is a great source of inspiration for coaches. Check it out, and learn to say “How fascinating!” about all of life’s knots in the road.[JS1] 

Scene Three: THE PLAN

Notice that when the client works on their plan, the coach digs into the toolbox and hands over a tool—a big pencil. The client isn’t sure they can handle the pencil, but the coach’s certainty is greater than the client’s doubt. From the domain of hope psychology, we know clients have the willpower—now they just need to develop the “waypower.” And waypower isn’t best developed by being told what to do or having something done for you. It’s best developed by experimenting with the change yourself.

So the client gets specific about what they want to have happen—the specific changes that will take place in their life to get to the mountains in the vision. The more specific, the better. The box that the client draws represents the importance of focus and clarity when setting one’s goals. The client is exploring the question of what they’re going to take responsibility for creating—and doing—to reach the beckoning goal.

Scene Four: THE JOURNEY

As the coach presents the next tool, a trampoline, the client is beginning to feel more confident in their ability to take that first leap. The trampoline represents the power of setting goals that are appealing, specific and measurable—and of thinking through all that it will take to be successful, including the ever-important supporting relationships.

The coach invites the client to recall other times when they have achieved life or work goals, as well as their strengths and talents. It’s an opportunity to learn from past successes and to apply one’s strengths rather than focusing on what’s hard.

Now they construct more building blocks—the steppingstones to reaching success. The vision of the client’s best self becomes clearer and closer.

But as the client continues to experiment, they fall off of the ladder, missing a challenging step. This, of course, happens in real life—we lapse and fall back into our old habits. The coach brings a safety net, a nonjudgmental space in which they can explore what happened and what they learned from it. How fascinating! This leads to the client’s insight and decision to create smaller steps, drawn onto the ladder.

How important it is to move to action at the right time, with the right goal in mind? There is little benefit to clients of working on goals that are beyond their capability. When clients set goals that are well matched to their readiness to move forward, with enough stretch to be engaging but not too much to produce anxiety, they become aligned with their best self.

The client rises above the challenge, achieves the plan and jumps up, having grown into the image of their best self. They are excited as they experience what it feels like to be there—and that will propel more successes going forward.

Scene Five: SUCCESS

The coach and client end with a celebration—the client has found the best path, outgrown perceived roadblocks and become the vision of their best self. Together they heartily acknowledge the accomplishment.

The final scene is a cliff-hanger, so to speak. Its message of “To Be Continued” speaks to the fact that change is a journey, a process to revisit continually. We know that as the client continues down the road toward the vision, there will be another knot, or a ditch or a seemingly impenetrable object. Yet, through the coaching partnership that cultivates hope and the acknowledgement of strengths and abilities, the client will continue on the path and further develop their best self.