Why women have higher cardiovascular risk than you think
Levels advisor Sara Gottfried on why cardiometabolic disease is so common—and so overlooked—in women.
Cardiometabolic health is still often thought of as primarily affecting men, but in reality, some women may have a higher risk of developing cardiometabolic conditions. For example, women aged 35-54 are more likely than men to be hospitalized for heart attack.
Understanding the differences men and women face, both biologically and socially, and why women are at such a disadvantage is critical for improving women’s cardiometabolic health globally.
Cardiometabolic diseases are a group of common conditions such as stroke, Type 2 diabetes, high blood pressure, and heart disease. Despite the preventable nature of these conditions, they are still the primary reasons for illness and death today. For example, heart disease is the leading cause of death in women in the United States.
For an episode of the podcast A Whole New Level, Levels Co-Founder and Chief Medical Officer Dr. Casey Means spoke to Levels Advisor, physician, and author of four New York Times bestsellers Dr. Sara Gottfried to discuss women’s cardiometabolic health, and why women have a higher risk of metabolic dysfunction and cardiovascular disease than men.
“I think a lot of folks have this misunderstanding that men die more of cardiometabolic health, and it’s just not true. In some ways, men keep getting better, and those benefits are not equally applied,” says Dr. Gottfried. Another reason this gender gap persists, she adds, “is that when metabolic health declines, it’s mostly silent.”
In her recently published article Women: Diet, Cardiometabolic Health, and Functional Medicine, Dr. Gottfried highlights the differences in physiology and care that affect women and cardiometabolic disease. She notes that the statistics are bleak: half of the women in developed countries will die of mostly preventable heart disease or stroke, while one woman dies of cardiovascular disease every 80 seconds in the United States.
Women have unique physical cardiometabolic risks
Even beyond healthcare inequalities, women face more significant—and in some cases more fatal—cardiometabolic health risks.
Although factors like hypertension, smoking, and high cholesterol are the same for both men and women, some, such as smoking and diabetes, can be more damaging for women. Additionally, women face many unique risk factors that men don’t, such as those stemming from pregnancy, menopause, and oral contraceptive use. Researchers have identified some of the sex and gender differences that can influence the risk of cardiometabolic outcomes:
- Higher glucose levels and insulin resistance. The risk of coronary heart disease increases in women with higher fasting glucose at a lower threshold than it does for men though the reason remains unclear. Women begin to show a higher risk of coronary heart disease at ≥110mg/DL, while the risk increases for men at ≥126/mg/dL.
- Diabetes. Diabetes increases the risk of cardiovascular disease for women more than for men. This is partly because women with diabetes have a higher rate of abdominal fat, which increases the risk of high blood pressure, high cholesterol, and imbalanced blood sugar levels, all of which increase cardiovascular disease risk.
- Pregnancy. Women experience significant physiological changes during pregnancy, which can lead to complications such as gestational diabetes, preeclampsia, and hypertension. These complications can increase the risk of cardiometabolic disease for women in the future.
- Birth control. Combined oral contraceptives like the birth control pill increase the risk of heart attack and stroke due to their higher estrogen dosage.
- Polycystic ovary syndrome (PCOS). Some studies find that women with infertility caused by PCOS might be at greater risk of heart disease. Women with PCOS also tend to have higher rates of high cholesterol and blood pressure, two common risk factors for heart disease.
- Menopause. Due to the decrease in reproductive hormones during menopause—particularly estrogen—women have a higher chance of developing metabolic syndrome. This condition increases the risk of Type 2 diabetes and heart disease.
- Mood disorders. Worldwide, women have a 1.7-fold greater incidence of experiencing depression, which is a significant risk factor for developing heart disease. Interestingly, this is a two-way relationship, as having a heart attack also increases the odds of developing depression. The mechanisms behind this relationship remain unknown, though sex differences in immune response and inflammation likely play a role.
- Sleep. The prevalence of sleep disturbances and insomnia is significantly higher in women than in men, mainly due to hormonal changes women experience throughout their lives. Research demonstrates a strong link between insomnia and an elevated risk of cardiovascular diseases.
- Smoking. Although smoking is a risk factor for both men and women, women who smoke have a 25% higher risk of heart disease than men, according to a meta-analysis of data from more than 2.4 million people worldwide published in The Lancet. The reason why smoking is more harmful to women isn’t fully understood. Still, the study authors speculate that the absorption and effects of toxins from cigarette smoke might be greater in women. Women are also less successful than men when they try to quit smoking and are more likely to start smoking again.
- Caregiving burden. Women experience greater stress associated with gendered social roles—mainly housework and caregiving—linked to a higher risk of cardiovascular disease.
The good news is that metabolic health issues are often reversible, and there is a lot that individuals can do to mitigate these effects and lessen the risks listed. In her latest research, Dr. Gottfried details how lifestyle changes like nutrition, microbiome, and hormone therapy can improve women’s cardiometabolic health. Dr. Gottfried notes that the Mediterranean diet may be beneficial, while new research demonstrates the probiotic strain Akkermansia holds promise, as well.
Other research has found that weight loss, regular exercise, quitting smoking, and limiting alcohol consumption can also improve women’s cardiometabolic health.
How bias in healthcare affects women’s cardiometabolic health
In addition to biological differences, the gender health gap can also impact cardiometabolic health.
The gender health gap is an umbrella term that describes bias and inequality within healthcare research and treatment. This is a key reason why women are worse off regarding cardiometabolic health.
“There’s a confluence of factors,” explains Dr. Gottfried, “I would say first is the research bias. Women were not included in research routinely until the 90s. That’s shocking to me, but it’s true. So it was assumed that the experience of men and what was found in research studies also applied to women until pretty recently.”
Both sex and gender play a role every step of the way—from clinical understanding to symptom presentation, diagnosis, and treatment.
Women are vastly underrepresented in clinical research looking at coronary heart disease.
When it comes to symptoms, women are less likely to experience the recognized symptoms of heart disease, such as chest pain. Women are also likely to experience milder and less obvious signs of heart disease, such as fatigue, disturbed sleep, and pain in the back, arms, neck, or jaw without any chest pain.
From a diagnostic perspective, women are twice as likely to receive a wrong initial diagnosis when having a heart attack, primarily because they can experience different symptoms compared to men. Even if a woman’s symptoms are recognized, and the proper diagnosis is given, data shows that women don’t always receive the appropriate medications after a heart attack.
A review published in the Journal of the American College of Cardiology finds that women are more likely to receive treatment for heart disease when their doctor is a woman compared to when they’re seen by a male physician.
“It’s something that we’ve got to change with male physicians. And you might ask, ‘Well, what about if you’re a guy and you have a heart attack?’ The survival was the same whether they saw a male or female physician,” says Dr. Gottfried.
“So that speaks to not a sex difference—like smaller coronary arteries or this differential effect of glucose. It speaks to a gender difference, which is socially constructed.”
Where do we go from here?
Cardiometabolic diseases, such as heart disease, are women’s leading cause of death. And yet, little has been done to address the biological markers and social discrepancies that cause millions of preventable deaths worldwide.
Lack of awareness, healthcare inequalities, and a poor understanding of how sex-based differences can increase the risk of cardiometabolic disease are all factors that contribute to the high female mortality rate.
To improve women’s health, we must first challenge the idea that cardiometabolic conditions are mainly a male issue. Increasing awareness of this problem among the public can empower patients to recognize when there is a problem and demand better care. Finally, we need policy change to bridge the gender gap in medical research and clinical practice. Prioritizing this issue can have an instrumental impact on the health and longevity of all women.
For more insights on women’s cardiometabolic health, listen to A Whole New Level’s episode “What half of women in America will die of, and how to fix it” with Dr. Sara Gottfried and Levels’ Dr. Casey Means.
