Mid-Years Women’s Health
Reduce cardiovascular disease risk in women
By Ivy M. Alexander, MS, C-ANP
Adult Nurse Practitioner, Assistant Professor
Adult and Family Nurse Practitioner Programs
Yale University School of Nursing
New Haven, CT
Cardiovascular disease (CVD) is likely to cause death in one of every two women.1, 2 Despite the magnitude of CVD risk, most women are more concerned about their risk of breast cancer than about their risk of CVD.1 Raising awareness of individual risks for heart disease and ways for reducing risk has the potential for saving lives.
CVD or heart disease risk in women increases with age, approximating that of men at age 65.3 Lifestyle changes or treatment can alter many risk factors for CVD in women. (See Contraceptive Technology Update, October 2000, "Check midlife women for cardiovascular disease.")
Work with your patients in altering these risks:
• Smoking: Patients are more likely to attempt smoking cessation if advised to do so by their clinicians. Individuals who attempt cessation are more successful if they use one or more assistance methods such as nicotine replacement therapy (patch or gum), self-help programs, and/or counseling.4 Local American Cancer Society chapters frequently have community-based programs and resources to assist clinicians in helping clients.
• Obesity: About 20% of the U.S. population is obese or significantly overweight.2,5 The best treatment is prevention because sustained weight loss is extremely difficult and often unattainable; about 50% of U.S. women are trying to lose weight.2,3 Successful weight loss is most often achieved through combining diet and exercise programs. Weight loss is associated with reduced blood pressure and improved lipid and glucose levels.2,3,5
• Sedentary lifestyle: Regular exercise has beneficial effects on weight, blood pressure, lipid profile, and glucose levels.2-4,6 Generally, it is safe to recommend physical activity for women who do not have activity intolerance (can walk up two flights of stairs without becoming winded). Those with activity intolerance should be evaluated for existing CVD. Begin an activity program gradually, about 10 to 15 minutes daily, until stamina is increased.
Recommend activities the woman enjoys, such as walking, aerobic dance, or exercise tapes she can do at home.6 Encourage a two- to five-minute warm-up and cool-down period. Have the woman repeat a demonstration of stretches and floor exercises in your office to increase her confidence for doing the exercises correctly at home. The initial goal is to achieve 20 minutes of exercise daily.
• Alcohol: Moderate alcohol consumption (one to three drinks daily) has been associated with reduced CVD risk and lower overall mortality.3 It may reduce lipid levels and decrease coagulation. However, alcohol is generally not recommended due to the risks of overuse and association with hypertension.
• Diet: A successful, healthy diet maintains the ratio of calories from fat at <30% of the total calorie intake. Calories from saturated fat sources should remain at <10% of the total.5 Women should limit the amount of fat from dairy and meat sources to reduce cholesterol. Soy is a popular alternate protein source that also may offer some menopause symptom relief.7 Encourage women to eat fruits, legumes, and vegetables for the bulk of their calorie intake. Legumes mixed with grains can provide low-fat protein in the diet.
Vitamin E, C, and beta carotene may reduce CVD risk by decreasing atherosclerosis.3,5 Research studies found that vitamin E doses of 100 IU daily reduced atherosclerosis progression, and doses of 400 to 800 IU daily for one year reduced future MI in those with pre-existing coronary heart disease (CHD).5 Similarly, among women with existing CHD, aspirin decreases the risk of future events.3 The daily use of low-dose aspirin in women without known CHD remains controversial.
Clinicians also should check for these diseases:
• Hyperlipidemia: Maintaining low-density lipoprotein (LDL) levels <130 mg/dL using exercise, diet, and, if appropriate, medication therapy, is recommended to reduce CVD risk.8 Diet therapy alone can reduce lipids by 10%, and adding drug therapy can further decrease levels by 20%.2 Hormone replacement therapy is recommended for primary CVD prevention to increase high-density lipoprotein (HDL) and decrease LDL if it’s not contraindicated.5
• Hypertension: Controlling blood pressure to maintain normal blood pressures (<140/90) can reduce end-organ cardiac damage significantly. In individuals with comorbid diabetes, treating high normal blood pressure (130-139/85-89) also is recommended.9
• Diabetes: Maintaining blood sugars and hemoglobin A1C levels as close to normal as possible will reduce diabetes risk significantly. Make sure women follow dietary and exercise recommendations along with their medication therapy.
Develop individualized treatment plans for altering lifestyle behaviors. Women are most likely to change their behaviors when perceived benefits outweigh perceived costs and family support for the change is present.6 Motivational readiness for change should be evaluated and incorporated into the treatment plan.6
Learn to identify the different stages of behavior. Women in the precontemplation phase are not intending to make changes. Those at the contemplation level are considering change, so educating those women about personal health outcomes might motivate them toward making changes.
Women in the preparation (making little changes) and action (engaging in the new activity) stages need specific instructions about what to do and how to do it. One of the most frequent barriers to exercise is a perceived lack of knowledge about what to do or lack of skill in physical activity. Similarly, diet changes are difficult for women who are unsure about what to eat. Guide them with specific, concrete information.
Once women reach the maintenance stage, reinforce the positive behavior changes to help sustain their new habits.
References
1. Mosca L, Jones WK, King KB, et al. Awareness, perception, and knowledge of heart disease risk and prevention among women in the United States. Arch Fam Med 2000; 9:506-515.
2. Wild RA, Taylor EL, Knehans A. The gynecologist and the prevention of cardiovascular disease. Am J Obstet Gynecol 1995; 172:1-13.
3. Oparil S. Cardiovascular risk reduction in women. J Women’s Health 1996; 5:23-32.
4. Zhu S-H, Melcer T, Rosbrook B, et al. Smoking cessation with and without assistance: A population-based analysis. Am J Prev Med 2000; 18:305-311.
5. Keller C, Fullerton J, Fleury J. Primary and secondary prevention strategies among older women postmenopausal women. J Nurse-Midwifery 1998; 43:262-272.
6. Marcus BH, Forsyth LH. Tailoring interventions to promote physically active lifestyles in women. Women’s Health Issues 1998; 8:104-111.
7. Soffa VM. Alternatives to hormone replacement for menopause. Alt Ther Health Med 1996; 2:34-39.
8. National Institutes of Health. Second Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults. Bethesda, MD; September 1993 (updated August 1996): No. 93-3096.
9. Deedwania PC. Hypertension and diabetes. Arch Intern Med 2000; 160:1,585-1,594.
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