Heart disease kills more women
than almost all other diseases combined.
But the incidence of this killer disease can be reduced. The following
describes how; but the challenge we have is to deliver the message.
The annual or routine medical
checkup is the appropriate time for the clinician to search for clues as to
whether women are at risk for heart and blood vessel disease, or in fact
already have problems. Routinely this includes, beyond the history and physical
examination, doing an EKG and sending a blood sample to the lab. More
sophisticated tests are only necessary when the question of more advanced
Blood tests may indicate that presence
of elevated ‘bad’ blood fats, like
cholesterol, LDL (low-density lipoproteins), triglycerides, and so on, or there may
be excessively low levels of the so-called “good” lipids like HDL (high-density lipoproteins).
The treatment of virtually
every disease begins with prevention. The alterable risk factors for heart
disease are as follows:
Potentially Alterable Risk
1. Abnormal blood fat levels,
2. High blood pressure (hypertension)
5. Cigarette smoking
6. Poor diet
7. Physical inactivity
8. Surgical menopause
9. Low levels of estrogen
10. Starting HT more than 10 years after
It has to be made obvious to the individual at risk that the general
principal of healthy living is the first and foremost best weapon to prevent
disease. Absolute rule number one is
to modify lifestyle with attention to good nutrition (especially avoiding the
trans fats), maintaining a healthy body weight, a half hour of moderate to
vigorous exercise every day, no smoking, moderation with alcohol, and avoidance
of habit-forming drugs. This can lower risk of heart disease by 80% and costs
nothing except strength of purpose – no visits to the doctor, no drugs, no
surgery, and saving the cigarette money!
When we get to active
treatments and pharmacotherapy, the devil may be in the details, so let me go
though the above list of potentially alterable risk factors.
Abnormal blood fat levels, particularly cholesterol
Beyond the healthy living
there are today a wide range of effective drugs to treat abnormal fat levels. Top
of the list are the statins. These
include names like atorvastatin
(Lipitor), fluvastatin (Lescol), lovastatin (Mevacor), pravastatin (Pravachol), rosuvastatin (Crestor), and simvastatin (Zocor). These are gradually
becoming generic and cheaper. Side effects can include muscle aches,
indigestion, and abdominal pain. Liver problems are rare, but your clinician
must monitor therapy.
HDL, the good cholesterol, can
be raised by exercise, a daily glass of red wine (this is genuine!), or vitamin
B3, also called niacin. Niacin can
also lower the triglycerides, but the dose for these effects has to be high,
needs to be monitored by a clinician, and can have nasty side effects like hot
The most effective drugs for
lowering triglycerides are the fibrates.
Available as gemfibrozil (Lopid) and fenofibrate (Tricor), it is uncertain
whether the fibrates actually reduce death rates even though they lower the
High blood pressure (hypertension)
A red flag for risk of heart
attack and stroke, high blood pressure (hypertension)
affects 25% of women. While many
women can treat hypertension successfully through healthy living, for others
pharmacotherapy may be unavoidable.
First round drug choice are
the diuretics. These are
water-eliminating drugs, for example, thiazides.
Unfortunately, single drugs are not dramatically effective and so a clinician
may select a combination of a diuretic with another active drug. Options
angiotensin-converting enzyme inhibitors, angiotensin-receptor blockers, and
calcium channel antagonists. It is quite remarkable how few people really
stick to their treatments, despite the significant health benefits they can
achieve, so every effort needs to be made to encourage adherence to therapy.
Adult-onset diabetes is the
new epidemic disease. It is integrally related to overweight and obesity, and
in turn with dramatically increased risk of CVD, including heart attack,
stroke, and peripheral vascular disease, the leading causes of death in people
with diabetes. Moreover, the poor control of blood sugar through decreased
ability t0 produce insulin, leads to damage to small blood vessels in eyes,
feet, and kidneys. In turn this increases the risk of impaired vision, gangrene
of the toes, and kidney failure.
Obviously, the answer is to
prevent onset of diabetes through healthy diet, weight reduction, exercise, and
lowering blood pressure and abnormal cholesterol. Amazingly, an active exercise
program by diabetics can lower their death rate four times more than taking
The pharmacotherapy of
diabetes is varied and complex, beyond the scope of this blog.
Obesity and overweight are not
exactly the same. Indeed, there can be overweight individuals who are fit and
healthy, and thin women who are not. Things like our genes, our socio-economic
status, the rate our body metabolisms function, activity, stress, and personal
habits, will all impact weight gain, and whether it reaches an unhealthy
status. In turn, this combination of factors determines which overweight
individuals will be at increased risk of heart disease, diabetes, and some
Beyond doubt, the evidence is
clear that healthy living – good eating habits, regular exercise, maintaining a
healthy bodyweight – leads to good health.
The diet industry in the
United States is really big business, estimated at up to $50 billion being
spent per year. Much of this money is spent on fruitless efforts to either
reduce weight or to maintain that weight loss.
Unfortunately, the achievement
of a healthy weight is a life long exercise, needs a strong sense of purpose,
and constant vigilance. The word diet should be removed from our vocabulary if
it means simply a temporary way of adjusting what we eat. For most overweight
people, the sad fact is that weight loss is invariably regained within 3-4
years, as one diet is forgotten and another one looked for. We need therefore
to concentrate on healthy eating, to get into the habit, and to maintain the
There are multiple drugs, both
prescription and nonprescription, on the market, and an escalating surgical
intervention industry. To deal with these fairly and adequately would require several
blogs, and the extent of this subject exceeds my personal area of expertize. I
would however like to stress a few actions that could be of value:
· Concentrate on diet-style and
healthy eating, and try and make this a life-long habit.
· Exercise every day.
· Read food labels and be willing to
modify diet style. Remember that “low fat” often means “high carbs” so be alert
to what you purchase.
· Substitute a cereal for a processed
food or protein through an egg or tofu instead of fatty red meat.
Cigarette smoking is a curse.
Of course, you already know about the increased risks of so many types of
cancer, of heart disease, and chronic obstructive lung disease, to name the
most frequent killers.
Did you know that smoking
causes premature aging? It brings forward the age of menopause by several
years, it ages skin, accelerates the arrival of wrinkles, has an unpleasant
odor, and indeed does nothing good for health.
Definitely, smoking is an
addiction, which is why the industry focuses on getting kids to smoke. For
those truly addicted, they need to really want to stop smoking. Then seeking
good medical help is most likely to be effective, including the use of the new
antismoking agents. Remember, many people have to quit more than once before
they are successful.
Poor diet and physical inactivity
I think I have hammered these
points home. I do not want to annoy you with excessive repetition, but I do
want you to emphasize to women the essential need for a healthy diet-style and
regular exercise. Just doing it makes any of us feel better and proves my
As healthcare providers we
have a huge responsibility for spreading the above
message to all women.
All the best
Wulf Utian MD PhD DSc
Author; CHANGE YOUR
MENOPAUSE – Why one size does not fit