Samulowitz, A., Gremyr, I., Eriksson, E., & Hensing, G. (2018). âBrave Menâ and âEmotional Womenâ: A Theory-Guided Literature Review on Gender Bias in Health Care and Gendered Norms towards Patients with Chronic Pain. Pain Research & Management. The Journal of the Canadian Pain Society, 14. http://dx.doi.org.myaccess.library.utoronto.ca/10.1155/2018/6358624
The Implication of Gender Bias and Norms on Cardiovascular Health
âYou throw like a girlâ and âYou need to man upâ are two common phrases used that emphasize how society expects men and women to act. Such phrases perpetuate stereotypes that associate masculinity with positive traits (strength, courage, etc.) and associate femininity with negative traits (openness, fragility, etc.) (Samulowitz et al., 2018). Although strides have been taken to disassociate the positive and negative connotations of masculine and feminine values, gender norms serve to regulate male dominance in society (Samulowitz et al., 2018) and influence the quality of healthcare women receive.
As strength is associated with masculinity, women are often presumed to be weak and have low pain tolerances. The gendered bias towards women has led health professionals to believe women are overreacting when in pain and therefore devalue the severity of womenâs complaints (Samulowitz et al., 2018). As a result, women experience a lower urgency in a hospital setting and are 20% less likely to be treated immediately for presumed heart attack than men (Mackay, 2020).
Through gender norms, the white male body has been socially classified as the ânormalâ body. Therefore, most standardized symptoms and treatments are based upon the male body. Consequently, these gender norms serve to disadvantage women as they are only viewed in comparison to men, leading to misdiagnosis. (Alcalde-Rubio et al., 2020). For example, the most common symptom associated with heart attacks is chest pain; however, women often present instead with jaw or neck pain. Due to different symptom presentations, women are half as likely to be referred to a cardiologist (Clerc Liaudat et al., 2018).
In conclusion, the differential treatment of men and women in the healthcare field is not a result of biological differences but a product of gender bias and norms for which the healthcare system was formed.
P.S. Press keep reading for a full list of references!
Alcalde-Rubio, L., HernĂĄndez-Aguado, I., Parker, L. A., Bueno-Vergara, E., & Chilet-Rosell, E. (2020). Gender disparities in clinical practice: are there any solutions? Scoping review of interventions to overcome or reduce gender bias in clinical practice. International Journal for Equity in Health, 19. https://doi.org/10.1186/s12939-020-01283-4
Clerc Liaudat, C., Vaucher, P., De Francesco, T., Jaunin-Stalder, N., Herzig, L., Verdon, F., Favrat, B., Locatelli, I., & Clair, C. (2018). Sex/gender bias in the management of chest pain in ambulatory care. Womenâs Health, 14. https://doi.org/10.1177/1745506518805641
Mackay M., (2020). Sex disparities in acute coronary syndrome care: time to move from understanding to action. Heart,106(2), 92-93. http://doi.org /10.1136/heartjnl-2019-315887Â
Samulowitz, A., Gremyr, I., Eriksson, E., & Hensing, G. (2018). âBrave Menâ and âEmotional Womenâ: A Theory-Guided Literature Review on Gender Bias in Health Care and Gendered Norms towards Patients with Chronic Pain. Pain Research & Management. The Journal of the Canadian Pain Society, 2018, 14. http://dx.doi.org.myaccess.library.utoronto.ca/10.1155/2018/6358624
The Cardiogirls are back and this time they are hitting the streets to find out how comfortable the people of Toronto are when we ask them some burning questions on cardiovascular health. How do you think they will do?
Murphy, M. O., & Loria, A. S. (2017). Sex-specific effects of stress on metabolic and cardiovascular disease: are women at higher risk? American Journal of Physiology. Regulatory, Integrative and Comparative Physiology, 313(1), R1-R9. https://doi.org/10.1152/ajpregu.00185.2016
Discrimination, Trauma, Stress and Cardiovascular Disease
General household tasks and child-care have historically been the duty of the women, but with the rise in modern working women and the less progressive change in traditional family roles, women are faced with both the stress of family care and work. Saban et al. (2018) displayed this stress within their research on psychological stress and cardiovascular disease (CVD). Unsurprisingly, the added burden of work and family care (along with finances, trauma and discrimination) increased the risk of CVD in women. Women with these chronic stressors were more likely to have chronic inflammation caused by the immune systems response to stress (2018)! There were even biomarkers in the blood that signal inflammation and stress responses! Unfortunately, this chronic inflammation is a known cause of cardiovascular disease, and its presence within the women sampled is of concern. However, women face many other social issues that increase their lifetime risk of CVD. Let's take a closer look:
Childhood sexual abuse to increase a womanâs risk of CVD 5-fold! Additionally, the occurrence of physical abuse increases a woman's risk of CVD 1.5-fold (Thurston et al., 2014).
The discrimination women face increases the risk of CVD by similar stress mechanisms outlined above. Discrimination is often more severe in African American women who are continuously experiencing the outcome of their two intersecting minority statuses (Albert et al., 2017)
Sexual minority women experience more modifiable risk factors for CVD; however, they do not differ in their rates of diagnosis of CVD (Caceres et al., 2018). Possibly, this is due to under-reporting or stigma associated with women's health and sexual minorities (2018).
Women who did not complete higher education are at a higher risk of fatal CVD independent of other traditional risk factors (such as smoking, sedentary lifestyle, or poor diet) (Lee et al., 2005).
Overall, the increased risk of CVD for women is not a simple relationship! Social factors such as gender-roles, trauma/abuse, discrimination and sexuality, play an important role in increasing women's risk of CVD. We hope this post enlightened you on how social environments can impact women's health! Let us know your thoughts in the comments below âŹïž
P.S. Press keep reading for a full list of references!
References
Albert, M. A., Durazo, E. M., Slopen, N., Zaslavsky, A. M., Buring, J. E., Silva, T., Chasman, D., & Williams, D. R. (2017). Study Design: Cumulative Psychological Stress and Cardiovascular Disease Risk in Middle Aged and Older Women: Rationale, Design and Baseline Characteristics. The American Heart Journal, 192, 1-12. https://doi.org/10.1016/j.ahj.2017.06.012
Caceres, B. A., Brody, A. A., Halkitis, P. N., Dorsen, C., Yu, G., & Chyun, D. A. (2018). Cardiovascular Disease Risk in Sexual Minority Women (18-59 Years Old): Findings from the National Health and Nutrition Examination Survey (2001-2012). Women's Health Issues, 28(4), 333-341. https://doi.org/10.1016/j.whi.2018.03.004
Lee, J. R., Paultre, F., & Mosca, L. (2005). The association between educational level and risk of cardiovascular disease fatality among women with cardiovascular disease. Women's Health Issues, 15(2), 80-88. https://doi.org/10.1016/j.whi.2004.11.004
Saban, K. L., Mathews, H. L., Bryant, F. B., Tell, D., Joyce, C., DeVon, H. A., & Witek Janusek, L. (2018). Perceived discrimination is associated with the inflammatory response to acute laboratory stress in women at risk for cardiovascular disease. Brain, Behavior, and Immunity, 73, 625-632. https://doi.org/10.1016/j.bbi.2018.07.010
Thurston, R., Chang, Y., Derby, C., Bromberger, J., Harlow, S., Janssen, I., & Matthews, K. (2014). Abuse and Subclinical Cardiovascular Disease Among Midlife Women: The Study of Womenâs Health Across the Nation. Stroke (1970), 45(8), 2246-2251. https://doi.org/10.1161/STROKEAHA.114.005928
Chomistek, A. K., Chiuve, S. E., Eliassen, A. H., Mukamal, K. J., Willett, W. C., & Rimm, E. B. (2015). Healthy lifestyle in the primordial prevention of cardiovascular disease among young women. Journal of the American College of Cardiology, 65(1), 43-51. https://doi-org.myaccess.library.utoronto.ca/10.1016/j.jacc.2014.10.024
Itâs the big question⊠âWhat should I eat today to be healthy?â The basis of this question should be simple, but in reality, it just isnât that easy. Understanding how to eat to stay healthy is a confusing topic that is only made more difficult by dieting culture. Despite its complex nature, food consumption is a vital component of womenâs cardiovascular health (Chomistek et al., 2015). Therefore, it is crucial that every woman be given the knowledge to make the most appropriate food choices based on individual circumstances. The most recent evidence does not advocate for gender-specific dietary guidelines (Hoekstra et al., 2009). Consequently, current dietary guidelines for cardiovascular health are universal for men and women.Â
Considerations for a heart-healthy diet:
Eat your fruits and vegetables. Although this might be intuitive, both fruit and vegetable consumption has been associated with a lower risk of cardiovascular disease (CVD) (He et al., 2007). Green leafy vegetables are also strongly encouraged, while fruit juices should be avoided.
Get your whole grains in! Try whole grain oatmeal or brown rice, as a higher consumption of whole grains is associated with a lower risk of CVD (Mellen et al., 2008).
Add in some Alternatives. Vegetable proteins such as tofu, nuts and legumes are a great source of protein and are associated with a lower risk of CVD (Bernstein et al., 2010). Fish is another excellent alternative for red meat. Fish species that are abundant in omega 3 fatty acids have protective effects from cardiac arrhythmias, sudden cardiac death, and CVD incidence (Mozaffarian & Rimm, 2006).
Sodium in moderation. A high sodium intake has been associated with higher blood pressure levels which have been shown to increase the risk for stroke and CVD (Strazullo et al., 2009).
Remember that eating a heart-healthy meal does not mean you have to stop eating what you love. Work with your desires instead of against them! Try to have fun with your food choices to make you feel good in the moment and for the future!
P.S. Press keep reading for a full list of references!
Bernstein, A. M, Sun, Q., Hu, F. B., Stampfer, M. J., Manson, J. E., & Willett, W. C. (2010). Major dietary protein sources and risk of coronary heart disease in women. Circulation, 122(9), 876â83. https://doi.org/10.1161/CIRCULATIONAHA.109.915165
Chomistek, A. K., Chiuve, S. E., Eliassen, A. H., Mukamal, K. J., Willett, W. C., & Rimm, E. B. (2015). Healthy lifestyle in the primordial prevention of cardiovascular disease among young women. Journal of the American College of Cardiology, 65(1), 43-51. https://doi-org.myaccess.library.utoronto.ca/10.1016/j.jacc.2014.10.024
He, F. J., Nowson, C. A., Lucas, M., & MacGregor, G. A. (2007). Increased consumption of fruit and vegetables is related to a reduced risk of coronary heart disease: Meta-analysis of cohort studies. Journal of Human Hypertension, 21(7), 17â28. https://doi.org/10.1038/sj.jhh.1002212
Hoekstra, T., Beulens, J. W. J., & Van Der Schouw, Y. T. (2009). Cardiovascular disease prevention in women: Impact of dietary interventions. Maturitas, 63(1), 20â27. https://doi.org/10.1016/j.maturitas.2009.02.003
Mellen, P. B, Walsh, T. F, & Herrington, D. M. (2008). Whole grain intake and cardiovascular disease: A meta-analysis. Nutrition, Metabolism and Cardiovascular Diseases 18(4), 283â90. https://doi.org/10.1016/j.numecd.2006.12.008
Mozaffarian, D., & Rimm, E. B. (2006). Fish intake, contaminants, and human health: Evaluating the risks and the benefits. JAMA. 296(15), 1885â99.
Strazzullo, P., D'Elia, L., Kandala, N. B., & Cappuccio, F. P. (2009). Salt intake, stroke, and cardiovascular disease: Meta-analysis of prospective studies. The British Medical Journal, 339, 4567. https://doi.org/10.1136/bmj.b4567Â
Try out our berry blast smoothie bowl! A perfect heart-healthy snack that is delicious and totally customizable! The smoothie bowl is packed full of various frozen fruits, topped off with whole grain oats and nuts to satisfy your heart and taste buds!
Female involvement in sports and physical activity has long been undermined within research and health promotion in the past (Oguma & Shinoda-Tagawa, 2004). However, this lack of representation is unfortunate given the importance of physical activity and a healthy lifestyle for women's health. Surely, lifestyle factors (such as physical activity participation, minimal screen time, and avoidance of drugs, smoking, and alcohol) are incredibly influential for minimizing the already enhanced risk of cardiovascular disease (CVD) within women (compared to men). For example, Chomistek et al. (2015) outlined the reduction of all-cause mortality due to cardiovascular disease, along with the incidence of cardiovascular-related health issues, to be minimized when women maintained recommended levels of physical activity! This is excellent news for women given the many unmodifiable factors that are currently contributing to higher CVD rates within the population, such as menopause, early menstruation onset, and contraceptives, to name a few (check out our previous posts for more information about these topics!).Â
Now you may be wondering, what are the recommended levels of physical activity?
Adults are advised to obtain at least 150 minutes of moderate to vigorous aerobic exercise per week, preferably in 10-minute bouts scattered throughout the week!Â
Aerobic activity can include going for a walk, bike ride with friends or family, or having a dance break to your favourite song! Additionally, it is recommended that adults participate in muscle-strengthening activities (such as weight lifting) and avoid prolonged bouts of sitting (Canadian Society for Exercise Physiology, 2021)Â
Oguma and Shinoda-Tagawa (2004) described the impact of physical activity on cardiovascular disease in women as a "dose-response," meaning that the more physical activity you do, the more significant the reduction in CVD risk. However, they also found that inactive women would benefit from even a little bit of exercise. For example, even as little as one hour of walking per week can reduce a woman's risk of developing overall CVD (including decreased risk for stroke and coronary heart disease (Oguma & Shinoda-Tagawa, 2004)!
Overall, physical activity is a great modifiable lifestyle factor that can significantly reduce women's risk of cardiovascular disease! It is important for women to participate in weekly (and possibly daily) physical activity to help reduce their risk of developing CVD, the leading cause of death for women.Â
P.S. Let us know your favourite way to get active in the comments!
P.P.S. Press keep reading for a full list of references!
References
Canadian Society for Exercise Physiology. (2021). Canadian Society for Exercise Physiology. https://csepguidelines.ca
Chomistek, A. K., ScD, Chiuve, S. E., ScD, Eliassen, A. H., ScD, Mukamal, Kenneth J., MD, MPH, Willett, Walter C., MD, DrPH, & Rimm, E. B., ScD. (2015). Healthy Lifestyle in the Primordial Prevention of Cardiovascular Disease Among Young Women. Journal of the American College of Cardiology, 65(1), 43-51. https://doi.org/10.1016/j.jacc.2014.10.024
Oguma, Y., & Shinoda-Tagawa, T. (2004). Physical activity decreases cardiovascular disease risk in women: Review and meta-analysis. Elsevier Inc. https://doi.org/10.1016/j.amepre.2004.02.007
Working from home has made it increasingly difficult to reach 150 minutes of moderate to vigorous physical activity a week. No need to panic! Follow this easy 10-minute workout for an effective and simple way to break up prolonged sedentary time to boost your mood and cardiovascular fitness!
Rotermann, M., Dunn, S., & Black, A. (2015). Oral contraceptive use among women aged 15 to 49: Results from the Canadian health measures survey. Statistics Canada, 26(10), 21-28.Â
Did you know that over 75% of Canadian women will take a form of oral contraceptive or birth control pills at some point in their lives (Rotermann et al., 2015)? Birth control pills' simplicity and reliability have made it the most commonly used form of reversible contraception by women. Despite such widespread use, many women remain unaware of the potential health risks that result from consistent use of oral contraceptives.
Oral contraceptive use has changed significantly over the last 60 years, with progressive efforts to reduce adverse health effects (Williams & MacDonald, 2021). Prior to advancements made in the 1980s, oral contraceptives contained large amounts of estrogen found to be associated with stroke incidence, pulmonary embolism, and heart attacks (Siritho et al., 2003). Modern oral contraceptive doses have lowered estrogen levels significantly and have made it much safer to take but have not eliminated all cardiovascular disease (CVD) risk.
CVD Risks of Oral Contraception
Oral contraceptives have been associated with an increased risk of venous thromboembolism, blood clots in the legs. The risk of venous thromboembolism is twice as high for individuals who use oral contraceptives compared to those who do not. However, the risk of venous thromboembolism with oral contraception remains relatively low (10/10,000 woman-years) and is lower than rates in pregnancy (Rotermann et al., 2015).
Long-term use of oral contraceptives (longer than 3 years) has been linked to increases in systolic blood pressure and cholesterol levels, which are associated with CVD risk in the future (Momeni et al., 2019; Momeni et al., 2020)
It is essential that when deciding to take oral contraceptives, you examine the potential CVD risk factors in accordance with health, lifestyle and family history. Speak to your doctor to ensure that this form of contraception is right for you!
P.S. Press keep reading for a full list of references!
Momeni, Z., Dehghani, A., Fallahzadeh, H., Koohardi, M., Dafei, M., Mohammadi, M. (2019). Effects of low-dose contraceptive pills on the risk factors of cardiovascular diseases among 15-35 year-old women; A retrospective cohort. International Journal of Reproductive Biomedicine, 17(11), 841-850. http://doi.org/10.18502/ijrm.v17i10.5496Â
Momeni, Z., Dehghani, A., Fallahzadeh, H., Koohardi, M., Dafei, M., Hekmatimoghaddam, S., Mohammadi, M. (2020). The impacts of pill contraceptive low-dose on plasma levels of nitric oxide, homocysteine, and lipid profiles in the exposed vs. non exposed women: as the risk factor for cardiovascular diseases. Contraception And Reproductive Medicine, 5(1), 1-6. https://doi.org/10.1186/s40834-020-00110-zÂ
Rotermann, M., Dunn, S., & Black, A. (2015). Oral contraceptive use among women aged 15 to 49: Results from the Canadian health measures survey. Statistics Canada, 26(10), 21-28.Â
Siritho, S, Thrift, A, McNeil, J, You, R, Davis, S., & Donnan, G. (2003). Risk of Ischemic Stroke Among Users of the Oral Contraceptive Pill: The Melbourne Risk Factor Study (MERFS) Group. Stroke, 34(7), 1575-1580. http://doi.org/10.1161/01.STR.0000077925.16041.6BÂ Â
Williams, J. S., MacDonald, M. J. (2021). Influence of hormonal contraceptives on peripheral vascular function and structure in premenopausal females: a review. American Journal of Physiology-Heart and Circulatory Physiology, 320(1), 77-89. https://doi-org/10.1152/ajpheart.00614.2020  Â
Gross-Sawicka, E., & Gorodeski, E. (2020). Early menarche and worse cardiovascular health: an emerging risk factor? Menopause (New York, N.Y.), 28(1), 6-7. https://doi.org/10.1097/GME.0000000000001699
Cardiovascular Disease, Menopause and Menstruation
Given the monthly occurrence of menstruation for women, it may be hard to believe that it is still a taboo subject in so many cultures around the world. However, menstruation is still largely tied to stigma where women are forced to physically and socially conceal their menstruation from others. Johnston-Robledo and Chrisler (2013) regard media to have a particularly active role in the reproduction (pun intended) of this stigma. For example, media often promote concealment of menstruation as a selling point for their products. This is an unfortunate trend given the effects menstruation can have on the health of the female body and her risk to cardiovascular disorder (CVD)! Let's take a closer look at the link between menstruation and cardiovascular disease:
Post-menopausal women have a higher risk of developing cardiovascular disease than women who have not gone through menopause (Gross-Sawicka & Gorodeski, 2020)!
Early onset of menstruation (scientifically, known as menarche), referred to period onset before 10 years old, leads to increased risk of heart attacks, stroke, heart failure, and all cause mortality from CVD (Gross-Sawicka & Gorodeski, 2020)!
Studies have found that the higher risk of CVD due to early onset of menstruation is highest between the ages of 25 and 44 years old (Zheng et al., 2020)! Additionally, those who had later onset of menstruation displayed better cardiovascular health than those who had begun menstruating before the age of 10 (Zheng et al., 2020)!
The pattern of age within the increased risk of CVD and early menarche has been thought to be due to hormonal factors later in life, such as reduced estrogen (Zheng et al., 2020; Gross-Sawicka & Gorodeski, 2020).
Overall, women with an early onset of menarche (<10 years old) and those who have undergone menopause are both at a higher risk of cardiovascular diseases (such as heart attacks, strokes, and heart failure). Unfortunately, these factors can be hard to control and may even be difficult to discuss due to the stigma surrounding menstruation. However, together we can break the stigma and provide a better future for women's health and its dialogue! Keep an eye out for our next post to get involved in breaking the stigma around menstruation!
P.S. Press keep reading for a full list of references!
Gross-Sawicka, E., & Gorodeski, E. (2020). Early menarche and worse cardiovascular health: an emerging risk factor? Menopause (New York, N.Y.), 28(1), 6-7. https://doi.org/10.1097/GME.0000000000001699
Johnston-Robledo, I., Johnston-Robledo, I., Chrisler, J., & Chrisler, J. (2013). The Menstrual Mark: Menstruation as Social Stigma. Sex Roles, 68(1), 9-18. https://doi.org/10.1007/s11199-011-0052-z
Zheng, Y., Wen, T., Shen, Y., & Hu, H. (2020). Age at menarche and cardiovascular health: results from the NHANES 1999-2016. Menopause (New York, N.Y.), 28(1), 18-24. https://doi.org/10.1097/GME.0000000000001653
Hall, M. E., George, E. M., & Granger, J. P. (2011). The heart during pregnancy. Revista espanola de cardiologia, 64(11), 1045â1050. https://doi.org/10.1016/j.recesp.2011.07.009
Nelander, M., Cnattingius, S., Akerud, H., Wikstrom, J., Pedersen, N L., & Wikstrom A. K. (2016). Pregnancy hypertensive disease and risk of dementia and cardiovascular disease in women aged 65 years or older: A cohort study. BMJ Open, 6(1). https://doi.org/10.1136/bmjopen-2015-009880Â
The Influence of Pregnancy on Women's Cardiovascular Health
Throughout pregnancy, the body goes through many necessary changes to support the developing baby. Although size may be the first and most visual, many other important changes cannot be seen, including adaptations to the cardiovascular system. Doctors have called pregnancy the "ultimate stress test" (Nelander et al., 2016) as changes during pregnancy can exacerbate pre-existing conditions or cause new ones, which unfortunately can present serious challenges for maternal health during pregnancy and in the future (Hall et al., 2011).
It is often misunderstood that women are no longer affected by maternal physiological adaptations once pregnancy is over. However, complications and conditions that develop during pregnancy and delivery can have major health effects that can emerge years or decades after giving birth.
Populations at Risk
Women who have a history of gestational diabetes have a 70% higher risk for developing CVD. The increased risk is related to later attaining Type 2 Diabetes, which is experienced by roughly half of all women who've had gestational diabetes within ten years. (Rich-Edwards et al., 2010; Shah et al., 2008)
Women who experience preeclampsia, a hypertensive disorder, during pregnancy are four times more likely to have hypertension in the future and twice as likely to develop heart disease than women who did not have preeclampsia. (Rich-Edwards et al., 2010; Nelander et al., 2016)
Mothers who deliver preterm (<37 weeks of gestation) are around twice as likely to develop CVD compared to mothers whose pregnancies lasted a full term. (Rich-Edwards et al., 2010; Gao et al., 2020)
In conclusion, cardiovascular conditions that develop during pregnancy have a significant influence on women's health in the future. We must focus on implementing interventions to support women's cardiovascular health during pregnancy to benefit mothers in the short and long term.
P.S. Press keep reading for a full list of references!
Gao, L., Li, S., & Moodie, M. (2020). How does preterm delivery contribute to the increased Burden of Cardiovascular Disease? Quantifying the economic impact of cardiovascular disease in women with a history of preterm delivery. Journal of Women's Health, 29(11), 1392-1400. http://doi.org.myaccess.library.utoronto.ca/10.1089/jwh.2019.7995
Hall, M. E., George, E. M., & Granger, J. P. (2011). The heart during pregnancy. Revista espanola de cardiologia, 64(11), 1045â1050. https://doi.org/10.1016/j.recesp.2011.07.009
Nelander, M., Cnattingius, S., Akerud, H., Wikstrom, J., Pedersen, N L., & Wikstrom A. K. (2016). Pregnancy hypertensive disease and risk of dementia and cardiovascular disease in women aged 65 years or older: A cohort study. BMJ Open, 6(1). https://doi.org/10.1136/bmjopen-2015-009880
Rich-Edwards, Janet, McElrath, Thomas, Karumanchi, S. & Seely, Ellen. (2010). Breathing life into the lifecourse approach: Pregnancy history and cardiovascular disease in women. Hypertension, 56, 331-334. https://doi.org/10.1161/HYPERTENSIONAHA.110.156810
Shah, B. R., Retnakaran, R. & Booth, G. L. (2008). Increased risk of cardiovascular disease in young women following gestational diabetes mellitus. American Diabetes Association, 31(8). https://doi-org.myaccess.library.utoronto.ca/10.2337/dc08-0706
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