Physical Activity Level and Self-Esteem in Middle-Aged Women

Background: Physical activity (PA) is a behavioral modality that may help decrease negative symptoms of menopause and enhance some positive aspects of mental health, including self-esteem. Reduced self-esteem may put menopausal women at higher risk of negative outcomes of menopause and result in a more unpleasant and stressful menopausal experience. The objective of this study was to examine the role of physical activity level on self-esteem in middle-aged women. Methods: Women aged 45–60 from Poland took part in this study. The Rosenberg Self-Esteem Scale, the International Physical Activity Questionnaire, the Menopause Rating Scale and Beck Depression Inventory were used in this study. Results: Among the 111 women, the mean age was 51.7 ± 4.7. The most severe symptoms among studied women concerned sexual problems (1.71 ± 1.5), irritability (1.58 ± 1.37) and joint and muscular discomfort (1.56 ± 1.55). Women with higher total PA level had better self-esteem (p = 0.001). Conclusions: The results of this study showed that physical activity levels can be associated with self-esteem. Most middle-aged women reported high physical activity levels. These results have clinical implications for the inclusion of PA in the lives of middle-aged women to improve self-esteem and mental health.


Introduction
An aspect of a woman's health in the middle-age period has attracted the attention of many researchers. Women spend half of their life in the middle age and afterwards, and during this time they experience physical and mental changes, as well as undergoing social role changes [1].
Menopausal transition has been related to a number of health impairments and variability of symptoms women experience as a result of hormone changes [2]. These, in turn, can affect self-esteem and life satisfaction [3]. The media create an ideal image of women, and all exceptions related to the inconveniences associated with menopausal symptoms and mental or physical disorders are sometimes stigmatized [4]. The results of Hunter and Rental (2007) showed that women with a higher severity of vasomotor symptoms and experiencing stress, report lower self-esteem [5]. Bloch (2002) showed that the severity of psychological symptoms decreased the self-esteem of menopausal women [6]. Włodarczyk et al. (2017) showed that women with high intensity of psychological, vasomotor and somatic menopausal symptoms had lower self-esteem [7]. Lower self-esteem is identified as one of the most common negative symptoms during this time [8,9].
Self-esteem is an essential component of well-being, an important factor of emotional and social adjustment, and is defined as an individual belief that one is a "good enough" and valuable person [10,11]. People with lower levels of self-esteem appear to be more susceptible to negative effects such as anxiety, lack of satisfaction, lower body esteem and depression [12,13]. Reduced self-esteem may put menopausal women at higher risk for This tool was used to assess the level of physical activity. IPAQ is a self-report questionnaire evaluating physical activity level. It is intended for adults aged 15-69 years. It consists of questions about the previous 7 days and asks about the frequency and duration of low, moderate and high intensity PA lasting at least 10 min [28]. PA level was expressed as Metabolic Equivalent of Work (MET)-min (where the metabolic equivalent of 1MET is defined as the amount of oxygen consumed when sitting at rest and is 3.5 mL O 2 per kg body weight/min) per week. According to the IPAQ scoring protocol, women were classified into groups with low, moderate or high levels of physical activity, and weekly energy expenditure for each PA level was calculated by multiplying the MET by number of days during the week. In accordance with IPAQ methodology, vigorous PA was assigned to 8 MET, moderate PA to 4 MET and walking to 3 MET [29].

The Menopause Rating Scale
This validated and standardized scale was used to assess the severity of menopausal symptoms. The scale ensures documented credibility, sensitivity, reliability and duplication of results. MRS is a self-administered tool consisting of 11 descriptions of climacteric symptoms. All items are divided into 3 domains: psychological (depressive mood, physical and mental exhaustion, irritability and anxiety), somato-vegetative (hot flushes, heart discomfort, muscle and joint problems and sleeping problems), urogenital (sexual problems, dryness of vagina and bladder problems).
Total score is the sum in each of the domains and ranges from 0 (asymptomatic) to 44 (highest degree of complaints) [30,31].

The Beck Depression Inventory-Second Edition
This inventory was used to evaluate the presence and severity of depressive symptoms [32]. This questionnaire is a 21-item self-reporting screening tool, with each item rated on a 4-point scale from 0 (not present) to 3 (severe). The total score ranges from 0 to 63, with higher values indicating more severe depressive symptoms. The BDI-II score from 0 to 13 was interpreted as no depressive symptoms, 14 to 19 as mild depression, 20-28 as moderate depression and 29-63 as severe depression [32].

Statistical Analysis
Statistical analysis was performed using the Statistica 10 (Statistica v10, StatSoft, Krakow, Poland). For measurable variables, such values as arithmetic means, median, standard deviations were calculated. For qualitative variables, percentage was calculated. The Shapiro-Wilk test was used to determine normality of data distribution. The analysis of variance (ANOVA) with post hoc Tuckey test was used. The level of α = 0.05 was assumed as statistically significant.

Results
Among 111 women, the mean age was 51.7 ± 4.7. The mean BMI value of women was 26.12. The majority of women were living in a city of up to 100,000 citizens (47.75%), did not smoke (75.68%), were higher educated (45.05%), married or cohabitating (80.18%) and had irregular periods (46.85%). According to IPAQ, 41.44% of women had a high PA level, 31.53% of participants had an average PA level, while 27.03% presented a low PA level. The majority of women had no depressive symptoms (82.88%). The results showed that 15.32% of women reported very high self-esteem. Approximately one-third of participants had high (29.73%) or average (24.32%) self-esteem and one-fifth had very low self-esteem (Table 1). The results of the MRS showed that the most severe symptoms among studied women concerned sexual problems (1.71 ± 1.5), irritability (1.58 ± 1.37) and joint and muscular discomfort (1.56 ± 1.55). Sleep problems and physical and mental exhaustion were evaluated at the similar mean value (1.46 and 1.48, accordingly). The mean value of depressive mood was 1.11 (Table 2). According to MRS domains (urogenital, somato-vegetative and psychological), the highest degree of complaints were observed in the somato-vegetative domain (5.6 ± 3.69), while the lowest degree of complains were reported in the urogenital domain (3.82 ± 3.4). The psychological domain had a mean value of 5.6 ± 3.69 (Table 2). A significant relationship was observed between self-esteem and the physical activity level in specific PA levels and in total (Table 3). Women with higher total PA level had better self-esteem (p = 0.001). Significant between-group differences in self-esteem and PA level were observed between very low and high self-esteem, as well as very low and very high self-esteem. According to the moderate and high PA level in relation to self-esteem, the higher the self-esteem the higher mean value of MET-min/week was observed. Specific intergroups relations are presented in Table 3. In terms of walking, women with high self-esteem had a slightly higher walking MET-value than the participants with very high self-esteem; however, no significant relation between these two groups was observed. iety (NAMS) recommends changing lifestyle in e first line of defense against the adverse conseity has a direct impact on many adverse consen to improve self-esteem [16][17][18]. Women with ausal symptoms and worse quality of life, while onent of mental health [14,19]. e physical activity level and self-esteem in midxamining whether PA level influenced self-esel into low, moderate and high, according to se 41.44% of women reported a high PA level. us study from Poland [18]. a reduction in daily energy expenditure and a ring the menopausal transition [34,35]. A crosst the majority of women aged 47-55 reported a from Poland showed similar results [15]. A significant relationship was observed between self-esteem and the physical activity level in specific PA levels and in total (Table 3). Women with higher total PA level had better self-esteem (p = 0.001). Significant between-group differences in self-esteem and PA level were observed between very low and high self-esteem, as well as very low and very high self-esteem. According to the moderate and high PA level in relation to self-esteem, the higher the self-esteem the higher mean value of MET-min/week was observed. Specific intergroups relations are presented in Table 3. In terms of walking, women with high selfesteem had a slightly higher walking MET-value than the participants with very high selfesteem; however, no significant relation between these two groups was observed.

Discussion
The North American Menopause Society (NAMS) recommends changing lifestyle in terms of increasing physical activity as the first line of defense against the adverse consequences of menopause [33]. Physical activity has a direct impact on many adverse consequences of menopause and has been shown to improve self-esteem [16][17][18]. Women with low self-esteem report more severe menopausal symptoms and worse quality of life, while healthy self-esteem is an important component of mental health [14,19].
In the present study, we evaluated the physical activity level and self-esteem in middle-aged women. We were interested in examining whether PA level influenced self-esteem. We classified physical activity level into low, moderate and high, according to IPAQ. The results were surprising because 41.44% of women reported a high PA level. Our results are consistent with the previous study from Poland [18].
However, earlier studies have shown a reduction in daily energy expenditure and a shift toward a more sedentary lifestyle during the menopausal transition [34,35]. A crosssectional study from Finland showed that the majority of women aged 47-55 reported a moderate PA level (62.32%) [36]. A study from Poland showed similar results [15]. Another large cross-sectional study from Japan showed that 57.84% of perimenopausal women (aged 44-56) had a low PA level [37]. Our  ed between self-esteem and the physical activity able 3). Women with higher total PA level had tween-group differences in self-esteem and PA d high self-esteem, as well as very low and very ate and high PA level in relation to self-esteem, value of MET-min/week was observed. Specific le 3. In terms of walking, women with high self--value than the participants with very high selfetween these two groups was observed.
PAQ) and self-esteem (SES). iety (NAMS) recommends changing lifestyle in e first line of defense against the adverse conseity has a direct impact on many adverse consen to improve self-esteem [16][17][18]. Women with ausal symptoms and worse quality of life, while nent of mental health [14,19]. e physical activity level and self-esteem in midxamining whether PA level influenced self-esel into low, moderate and high, according to se 41.44% of women reported a high PA level. us study from Poland [18]. a reduction in daily energy expenditure and a ring the menopausal transition [34,35]. A crosst the majority of women aged 47-55 reported a from Poland showed similar results [15]. A significant relationship was observed between self-esteem and the physical activity evel in specific PA levels and in total (Table 3). Women with higher total PA level had etter self-esteem (p = 0.001). Significant between-group differences in self-esteem and PA evel were observed between very low and high self-esteem, as well as very low and very igh self-esteem. According to the moderate and high PA level in relation to self-esteem, he higher the self-esteem the higher mean value of MET-min/week was observed. Specific ntergroups relations are presented in Table 3. In terms of walking, women with high selfsteem had a slightly higher walking MET-value than the participants with very high selfsteem; however, no significant relation between these two groups was observed. elationship between physical activity level (IPAQ) and self-esteem (SES).

. Discussion
The North American Menopause Society (NAMS) recommends changing lifestyle in erms of increasing physical activity as the first line of defense against the adverse conseuences of menopause [33]. Physical activity has a direct impact on many adverse conseuences of menopause and has been shown to improve self-esteem [16][17][18]. Women with ow self-esteem report more severe menopausal symptoms and worse quality of life, while ealthy self-esteem is an important component of mental health [14,19].
In the present study, we evaluated the physical activity level and self-esteem in midle-aged women. We were interested in examining whether PA level influenced self-eseem. We classified physical activity level into low, moderate and high, according to PAQ. The results were surprising because 41.44% of women reported a high PA level. ur results are consistent with the previous study from Poland [18].
However, earlier studies have shown a reduction in daily energy expenditure and a hift toward a more sedentary lifestyle during the menopausal transition [34,35]. A crossectional study from Finland showed that the majority of women aged 47-55 reported a oderate PA level (62.32%) [36]. A study from Poland showed similar results [15]. Anther large cross-sectional study from Japan showed that 57.84% of perimenopausal omen (aged 44-56) had a low PA level [37]. Our study included women in the 45-65 age roup, thus the difference in PA level may result from age. It may indicate that postmenpausal women are more physically active. A significant relationship was observed between self-esteem and the physical activity level in specific PA levels and in total (Table 3). Women with higher total PA level had better self-esteem (p = 0.001). Significant between-group differences in self-esteem and PA level were observed between very low and high self-esteem, as well as very low and very high self-esteem. According to the moderate and high PA level in relation to self-esteem, the higher the self-esteem the higher mean value of MET-min/week was observed. Specific intergroups relations are presented in Table 3. In terms of walking, women with high selfesteem had a slightly higher walking MET-value than the participants with very high selfesteem; however, no significant relation between these two groups was observed.

Discussion
The North American Menopause Society (NAMS) recommends changing lifestyle in terms of increasing physical activity as the first line of defense against the adverse consequences of menopause [33]. Physical activity has a direct impact on many adverse consequences of menopause and has been shown to improve self-esteem [16][17][18]. Women with low self-esteem report more severe menopausal symptoms and worse quality of life, while healthy self-esteem is an important component of mental health [14,19].
In the present study, we evaluated the physical activity level and self-esteem in middle-aged women. We were interested in examining whether PA level influenced self-esteem. We classified physical activity level into low, moderate and high, according to IPAQ. The results were surprising because 41.44% of women reported a high PA level. Our results are consistent with the previous study from Poland [18].
However, earlier studies have shown a reduction in daily energy expenditure and a shift toward a more sedentary lifestyle during the menopausal transition [34,35]. A crosssectional study from Finland showed that the majority of women aged 47-55 reported a moderate PA level (62.32%) [36]. A study from Poland showed similar results [15]. An- A significant relationship was observed between self-esteem and the physical activity level in specific PA levels and in total (Table 3). Women with higher total PA level had better self-esteem (p = 0.001). Significant between-group differences in self-esteem and PA level were observed between very low and high self-esteem, as well as very low and very high self-esteem. According to the moderate and high PA level in relation to self-esteem, the higher the self-esteem the higher mean value of MET-min/week was observed. Specific intergroups relations are presented in Table 3. In terms of walking, women with high selfesteem had a slightly higher walking MET-value than the participants with very high selfesteem; however, no significant relation between these two groups was observed.

Discussion
The North American Menopause Society (NAMS) recommends changing lifestyle in terms of increasing physical activity as the first line of defense against the adverse consequences of menopause [33]. Physical activity has a direct impact on many adverse consequences of menopause and has been shown to improve self-esteem [16][17][18]. Women with low self-esteem report more severe menopausal symptoms and worse quality of life, while healthy self-esteem is an important component of mental health [14,19].
In the present study, we evaluated the physical activity level and self-esteem in middle-aged women. We were interested in examining whether PA level influenced self-esteem. We classified physical activity level into low, moderate and high, according to IPAQ. The results were surprising because 41.44% of women reported a high PA level. Our results are consistent with the previous study from Poland [18].
However, earlier studies have shown a reduction in daily energy expenditure and a shift toward a more sedentary lifestyle during the menopausal transition [34,35]. A crosssectional study from Finland showed that the majority of women aged 47-55 reported a moderate PA level (62.32%) [36]. A study from Poland showed similar results [15]. Another large cross-sectional study from Japan showed that 57.84% of perimenopausal women (aged 44-56) had a low PA level [37]. Our study included women in the 45-65 age group, thus the difference in PA level may result from age. It may indicate that postmenopausal women are more physically active. ed between self-esteem and the physical activity able 3). Women with higher total PA level had etween-group differences in self-esteem and PA d high self-esteem, as well as very low and very ate and high PA level in relation to self-esteem, value of MET-min/week was observed. Specific le 3. In terms of walking, women with high self--value than the participants with very high selfetween these two groups was observed.
IPAQ) and self-esteem (SES). ciety (NAMS) recommends changing lifestyle in e first line of defense against the adverse conseity has a direct impact on many adverse consen to improve self-esteem [16][17][18]. Women with ausal symptoms and worse quality of life, while onent of mental health [14,19]. e physical activity level and self-esteem in midexamining whether PA level influenced self-esel into low, moderate and high, according to se 41.44% of women reported a high PA level. us study from Poland [18]. n a reduction in daily energy expenditure and a ring the menopausal transition [34,35] A significant relationship was observed between self-esteem and the physical activity level in specific PA levels and in total (Table 3). Women with higher total PA level had better self-esteem (p = 0.001). Significant between-group differences in self-esteem and PA level were observed between very low and high self-esteem, as well as very low and very high self-esteem. According to the moderate and high PA level in relation to self-esteem, the higher the self-esteem the higher mean value of MET-min/week was observed. Specific intergroups relations are presented in Table 3. In terms of walking, women with high selfesteem had a slightly higher walking MET-value than the participants with very high selfesteem; however, no significant relation between these two groups was observed.

SES
Relationship between physical activity level (IPAQ) and self-esteem (SES).

Discussion
The North American Menopause Society (NAMS) recommends changing lifestyle in terms of increasing physical activity as the first line of defense against the adverse consequences of menopause [33]. Physical activity has a direct impact on many adverse consequences of menopause and has been shown to improve self-esteem [16][17][18]. Women with low self-esteem report more severe menopausal symptoms and worse quality of life, while healthy self-esteem is an important component of mental health [14,19].
In the present study, we evaluated the physical activity level and self-esteem in middle-aged women. We were interested in examining whether PA level influenced self-esteem. We classified physical activity level into low, moderate and high, according to IPAQ. The results were surprising because 41.44% of women reported a high PA level. Our results are consistent with the previous study from Poland [18].
However, earlier studies have shown a reduction in daily energy expenditure and a shift toward a more sedentary lifestyle during the menopausal transition [34,35]. A crosssectional study from Finland showed that the majority of women aged 47-55 reported a moderate PA level (62.32%) [36]. A study from Poland showed similar results [15]. Another large cross-sectional study from Japan showed that 57.84% of perimenopausal women (aged 44-56) had a low PA level [37]. Our study included women in the 45-65 age group, thus the difference in PA level may result from age. It may indicate that postmen- A significant relationship was observed between self-esteem and the physical activity level in specific PA levels and in total (Table 3). Women with higher total PA level had better self-esteem (p = 0.001). Significant between-group differences in self-esteem and PA level were observed between very low and high self-esteem, as well as very low and very high self-esteem. According to the moderate and high PA level in relation to self-esteem, the higher the self-esteem the higher mean value of MET-min/week was observed. Specific intergroups relations are presented in Table 3. In terms of walking, women with high selfesteem had a slightly higher walking MET-value than the participants with very high selfesteem; however, no significant relation between these two groups was observed.

Discussion
The North American Menopause Society (NAMS) recommends changing lifestyle in terms of increasing physical activity as the first line of defense against the adverse consequences of menopause [33]. Physical activity has a direct impact on many adverse consequences of menopause and has been shown to improve self-esteem [16][17][18]. Women with low self-esteem report more severe menopausal symptoms and worse quality of life, while healthy self-esteem is an important component of mental health [14,19].
In the present study, we evaluated the physical activity level and self-esteem in middle-aged women. We were interested in examining whether PA level influenced self-esteem. We classified physical activity level into low, moderate and high, according to IPAQ. The results were surprising because 41.44% of women reported a high PA level. Our results are consistent with the previous study from Poland [18].
However, earlier studies have shown a reduction in daily energy expenditure and a shift toward a more sedentary lifestyle during the menopausal transition [34,35] A significant relationship was observed between self-esteem and the physical activity level in specific PA levels and in total (Table 3). Women with higher total PA level had better self-esteem (p = 0.001). Significant between-group differences in self-esteem and PA level were observed between very low and high self-esteem, as well as very low and very high self-esteem. According to the moderate and high PA level in relation to self-esteem, the higher the self-esteem the higher mean value of MET-min/week was observed. Specific intergroups relations are presented in Table 3. In terms of walking, women with high selfesteem had a slightly higher walking MET-value than the participants with very high selfesteem; however, no significant relation between these two groups was observed.

Discussion
The North American Menopause Society (NAMS) recommends changing lifestyle in terms of increasing physical activity as the first line of defense against the adverse consequences of menopause [33]. Physical activity has a direct impact on many adverse consequences of menopause and has been shown to improve self-esteem [16][17][18]. Women with low self-esteem report more severe menopausal symptoms and worse quality of life, while healthy self-esteem is an important component of mental health [14,19].
In the present study, we evaluated the physical activity level and self-esteem in middle-aged women. We were interested in examining whether PA level influenced self-esteem. We classified physical activity level into low, moderate and high, according to IPAQ. The results were surprising because 41.44% of women reported a high PA level. Our results are consistent with the previous study from Poland [18].
However, earlier studies have shown a reduction in daily energy expenditure and a shift toward a more sedentary lifestyle during the menopausal transition [34,35]. A crosssectional study from Finland showed that the majority of women aged 47-55 reported a moderate PA level (62.32%) [36]. A study from Poland showed similar results [15]. Another large cross-sectional study from Japan showed that 57.84% of perimenopausal women (aged 44-56) had a low PA level [37]. Our study included women in the 45-65 age group, thus the difference in PA level may result from age. It may indicate that postmen- A significant relationship was observed between self-esteem and the physical activity evel in specific PA levels and in total (Table 3). Women with higher total PA level had etter self-esteem (p = 0.001). Significant between-group differences in self-esteem and PA evel were observed between very low and high self-esteem, as well as very low and very igh self-esteem. According to the moderate and high PA level in relation to self-esteem, he higher the self-esteem the higher mean value of MET-min/week was observed. Specific ntergroups relations are presented in Table 3. In terms of walking, women with high selfsteem had a slightly higher walking MET-value than the participants with very high selfsteem; however, no significant relation between these two groups was observed.
Relationship between physical activity level (IPAQ) and self-esteem (SES).

. Discussion
The North American Menopause Society (NAMS) recommends changing lifestyle in erms of increasing physical activity as the first line of defense against the adverse conseuences of menopause [33]. Physical activity has a direct impact on many adverse conseuences of menopause and has been shown to improve self-esteem [16][17][18]. Women with ow self-esteem report more severe menopausal symptoms and worse quality of life, while ealthy self-esteem is an important component of mental health [14,19].
In the present study, we evaluated the physical activity level and self-esteem in midle-aged women. We were interested in examining whether PA level influenced self-eseem. We classified physical activity level into low, moderate and high, according to PAQ. The results were surprising because 41.44% of women reported a high PA level. ur results are consistent with the previous study from Poland [18].
However, earlier studies have shown a reduction in daily energy expenditure and a hift toward a more sedentary lifestyle during the menopausal transition [34,35]. A crossectional study from Finland showed that the majority of women aged 47-55 reported a oderate PA level (62.32%) [36]. A study from Poland showed similar results [15]. Anther large cross-sectional study from Japan showed that 57.84% of perimenopausal A significant relationship was observed between self-esteem and the physical activity level in specific PA levels and in total (Table 3). Women with higher total PA level had better self-esteem (p = 0.001). Significant between-group differences in self-esteem and PA level were observed between very low and high self-esteem, as well as very low and very high self-esteem. According to the moderate and high PA level in relation to self-esteem, the higher the self-esteem the higher mean value of MET-min/week was observed. Specific intergroups relations are presented in Table 3. In terms of walking, women with high selfesteem had a slightly higher walking MET-value than the participants with very high selfesteem; however, no significant relation between these two groups was observed.

Discussion
The North American Menopause Society (NAMS) recommends changing lifestyle in terms of increasing physical activity as the first line of defense against the adverse consequences of menopause [33]. Physical activity has a direct impact on many adverse consequences of menopause and has been shown to improve self-esteem [16][17][18]. Women with low self-esteem report more severe menopausal symptoms and worse quality of life, while healthy self-esteem is an important component of mental health [14,19].
In the present study, we evaluated the physical activity level and self-esteem in middle-aged women. We were interested in examining whether PA level influenced self-esteem. We classified physical activity level into low, moderate and high, according to IPAQ. The results were surprising because 41.44% of women reported a high PA level. Our results are consistent with the previous study from Poland [18].
However, earlier studies have shown a reduction in daily energy expenditure and a shift toward a more sedentary lifestyle during the menopausal transition [34,35]. A crosssectional study from Finland showed that the majority of women aged 47-55 reported a moderate PA level (62.32%) [36]. A study from Poland showed similar results [15]. Another large cross-sectional study from Japan showed that 57.84% of perimenopausal observed between self-esteem and the physical activity otal (Table 3). Women with higher total PA level had icant between-group differences in self-esteem and PA low and high self-esteem, as well as very low and very moderate and high PA level in relation to self-esteem, r mean value of MET-min/week was observed. Specific in Table 3. In terms of walking, women with high selfg MET-value than the participants with very high selfation between these two groups was observed. level (IPAQ) and self-esteem (SES). use Society (NAMS) recommends changing lifestyle in y as the first line of defense against the adverse conseal activity has a direct impact on many adverse consen shown to improve self-esteem [16][17][18]. Women with menopausal symptoms and worse quality of life, while component of mental health [14,19]. ated the physical activity level and self-esteem in midted in examining whether PA level influenced self-esity level into low, moderate and high, according to because 41.44% of women reported a high PA level. previous study from Poland [18]. A significant relationship was observed between self-esteem and the physical activity level in specific PA levels and in total (Table 3). Women with higher total PA level had better self-esteem (p = 0.001). Significant between-group differences in self-esteem and PA level were observed between very low and high self-esteem, as well as very low and very high self-esteem. According to the moderate and high PA level in relation to self-esteem, the higher the self-esteem the higher mean value of MET-min/week was observed. Specific intergroups relations are presented in Table 3. In terms of walking, women with high selfesteem had a slightly higher walking MET-value than the participants with very high selfesteem; however, no significant relation between these two groups was observed.

Discussion
The North American Menopause Society (NAMS) recommends changing lifestyle in terms of increasing physical activity as the first line of defense against the adverse consequences of menopause [33]. Physical activity has a direct impact on many adverse consequences of menopause and has been shown to improve self-esteem [16][17][18]. Women with low self-esteem report more severe menopausal symptoms and worse quality of life, while healthy self-esteem is an important component of mental health [14,19].
In the present study, we evaluated the physical activity level and self-esteem in middle-aged women. We were interested in examining whether PA level influenced self-esteem. We classified physical activity level into low, moderate and high, according to IPAQ. The results were surprising because 41.44% of women reported a high PA level. Our results are consistent with the previous study from Poland [18].
However, earlier studies have shown a reduction in daily energy expenditure and a shift toward a more sedentary lifestyle during the menopausal transition [34,35]. A crosssectional study from Finland showed that the majority of women aged 47-55 reported a moderate PA level (62.32%) [36]. A study from Poland showed similar results [15]. An-p < 0.05 average versus very high; p < 0.05 low versus high;~p < 0.05 average versus high; IPAQ-International Physical Activity Questionnaire. SES-Self-esteem Scale, Rosenberg.

Discussion
The North American Menopause Society (NAMS) recommends changing lifestyle in terms of increasing physical activity as the first line of defense against the adverse consequences of menopause [33]. Physical activity has a direct impact on many adverse consequences of menopause and has been shown to improve self-esteem [16][17][18]. Women with low self-esteem report more severe menopausal symptoms and worse quality of life, while healthy self-esteem is an important component of mental health [14,19].
In the present study, we evaluated the physical activity level and self-esteem in middleaged women. We were interested in examining whether PA level influenced self-esteem. We classified physical activity level into low, moderate and high, according to IPAQ. The results were surprising because 41.44% of women reported a high PA level. Our results are consistent with the previous study from Poland [18]. However, earlier studies have shown a reduction in daily energy expenditure and a shift toward a more sedentary lifestyle during the menopausal transition [34,35]. A crosssectional study from Finland showed that the majority of women aged 47-55 reported a moderate PA level (62.32%) [36]. A study from Poland showed similar results [15]. Another large cross-sectional study from Japan showed that 57.84% of perimenopausal women (aged 44-56) had a low PA level [37]. Our study included women in the 45-65 age group, thus the difference in PA level may result from age. It may indicate that postmenopausal women are more physically active.
Different studies have shown a significant decline in body muscle power and handgrip strength in postmenopausal women when compared to premenopausal women [38,39]. However, Bondarev et al. (2018) showed no difference in a 6-min walking test distance in three menopause status groups [36]. This may indicate that menopausal status does not affect the cardiovascular and respiratory system. In another study carried out on middle-aged women, no decline in maximal oxygen consumption during the menopausal transition was observed [40].
To the best of our knowledge, no previous studies have concentrated on the level of PA according to self-esteem in middle-aged women. Our results revealed significant differences between PA level and self-esteem in women. For moderate and high PA levels, higher self-esteem in women was reported together with a higher mean value of MET-min/week. It is interesting that the mean value of MET-min/week in walking was highest when compared with the moderate or high PA level. Even women with very low self-esteem reported 353.93 MET-min/week walking compared to 144 MET-min/week in the high PA level group or 261 MET-min/week in the moderate PA level group. A similar relation was observed in all self-esteem levels. Walking MET-min/week showed the highest value. This may indicate that walking is a highly prevalent and preferred form of PA among middle-aged women. Elavsky et al. (2007) enrolled middle-aged women in a 4-month randomized trial with yoga exercises and walking. The analysis of the follow-up study showed a small improvement in self-esteem in the walking and yoga groups compared to a control group [25]. These findings suggest that non-aerobic type exercise such as yoga or walking at low intensities are effective for the enhancement of self-esteem.
Self-esteem in middle-aged women was directly analyzed in a few previous studies; specifically, the relationship between body esteem and self-esteem in middle-aged women was evaluated, and the results were mixed. Some studies have reported that body esteem was not related to global self-esteem and that BMI or body image did not play a significant role [27,41]. Contrary to this, different studies showed that more active middle-aged women reported significantly higher body esteem and global self-esteem [19,42]. A longitudinal study evaluating the exercise and self-esteem mode in middle-aged women also showed that women with lower BMI reported a higher level of physical self-worth, which was related to global self-esteem [43].
Our study has several limitations. Firstly, it was a cross-sectional study, thus, a proper randomization was not achieved and there is a possibility of a selection bias. Such a study also gives restrictions on drawing causal effects. Secondly, the results should be interpreted with caution because the study sample is too small to generalize the obtained results. Thirdly, self-reported questionnaires were used; however, these are the usual methods in the literature. These findings may have been influenced by the common methods bias. In the future, a longitudinal study conducted on a representative sample will provide a detailed analysis showing the impact of different variables on self-esteem in women.

Conclusions
The results of this study showed that physical activity levels are associated with selfesteem. Middle-aged women with higher physical activity levels had better self-esteem. Most middle-aged women reported high physical activity levels.
These results have clinical implications for the inclusion of PA in the lives of middleaged women to improve self-esteem and mental health. Middle-aged women with low self-esteem may benefit from increasing their PA level, for example, by making walking a routine. A further study in a larger, representative sample of middle-aged women is warranted.

Conflicts of Interest:
The authors declare no conflict of interest.