May 2012 Issue

Nurturing the Heart — RDs Discuss Strategies to Prevent Heart Disease in Pre- and Postmenopausal Women
By Maura Keller
Today’s Dietitian
Vol. 14 No. 5 P. 20

While many women know that eating a low-fat diet and exercising regularly reduces the risk of heart disease, many still believe that the issue of heart health primarily is a man’s concern.

The truth is heart disease is the No. 1 killer of women (and men). It’s this common misconception that’s leading RDs to spread the word about women and heart disease even more as it relates to a healthful diet and lifestyle.

Numbers Don’t Lie
Roughly 8 million women in the United States have heart disease; 267,000 die each year from heart attacks, which kill six times as many women as breast cancer, according to the Women’s Heart Foundation. Even though many people believe mostly men experience a heart attack, each year more women than men die from one. In fact, women are twice as likely as men to die within the first few weeks after suffering a heart attack.

The reason women have believed the misconception that heart attacks and heart disease are conditions unique to men is because “in the past, much of the research on heart disease was conducted on men as the primary focus,” says Carrie Wissemeier, RD, LD, a dietitian at BistroMD, which offers a doctor-designed weight loss plan. “In addition, women may experience less pronounced symptoms than men and may ignore the signs of a heart attack and delay seeking treatment.”

Vandana Sheth, RD, CDE, a spokesperson for the Academy of Nutrition and Dietetics, says it’s been documented that heart attack symptoms can be different for women, and heart attacks can be much more severe in women than in men. After the first heart attack, women are almost twice as likely as men to have a second one within the first six years.

Diet and lifestyle choices play a huge role in maintaining women’s heart health. “Being overweight, eating high-fat foods, drinking more alcoholic beverages, smoking, and minimal physical activity will put a woman at an increased risk for heart disease,” Sheth says. Other factors that affect a woman’s risk of heart disease include age, family history, ethnicity, and medical history. The American Heart Association (AHA) adds pregnancy-related complications, such as preeclampsia and gestational diabetes, along with lupus and rheumatoid arthritis to the potential risk factors.

Menopause and Heart Disease
While it’s established that women are at highest risk of heart disease, premenopausal and postmenopausal women have different levels of risk.

“Premenopausal women have a lower risk for heart disease due to the protective effect of [the sex hormone] estrogen, which raises HDL cholesterol,” Sheth says. “As women transition from pre- to postmenopause, levels of estrogen drop and cardiac risk factors increase. Postmenopausal women have a decrease in the levels of estrogen and lower levels of HDL. That’s why postmenopausal women are at greater risk for heart disease and stroke.”

Wissemeier says estrogen is thought to protect premenopausal women from heart disease because it tends to raise HDL cholesterol. HDL cholesterol carries cholesterol back to the liver where it passes from the body, slowing the buildup of arterial plaque. Higher levels of HDL cholesterol are beneficial, but women also tend to have increased levels of triglycerides compared with men. Therefore, as women age, triglyceride levels continue to rise, whereas HDL levels decrease. This results in a rise in total cholesterol and heightens the risk of heart disease. “Postmenopausal women also face insulin resistance, leading to weight gain, specifically in the abdominal area, which is another risk factor for heart disease,” Wissemeier says.

A big mistake premenopausal women make is not recognizing that they’re at a critical point where they can begin reducing their heart disease risk. Calcium, vitamin D, and omega-3 fatty acids can play a key role in protecting women from heart disease and osteoporosis. That’s why premenopausal women should try to consume at least 1,000 mg of calcium per day.

“According to the AHA, omega-3s have been known to lower triglyceride levels and blood pressure, reduce artery plaque buildup, and decrease risk for heart arrhythmia. Therefore, omega-3s are important in a premenopausal woman’s diet. Food sources of omega-3 fats include salmon, mackerel, albacore tuna, walnuts, flaxseeds, and pumpkin seeds,” Sheth says.

Because much of the emphasis on prevention is in the premenopausal years, postmenopausal women may not realize they still can prevent heart disease—that it’s not too late. “Studies show that the majority of heart attacks in women occur within the first 10 years after menopause, but that doesn’t have to happen,” says Rachel K. Johnson, PhD, RD, an AHA spokesperson and the Bickford Professor of Nutrition at the University of Vermont. “Women can make improvements in their diet and lifestyle that can lower their risk of developing heart disease.”

“Women also may not realize that it’s not just about eating low-fat food or cutting back on sodium,” Sheth adds. “Eating right for heart health includes whole grains; high-fiber foods such as vegetables; oats; beans; soy; heart-healthy fats contained in nuts, avocados, flaxseeds, salmon, and tuna; reducing sodium, and increasing potassium-rich foods. Regular physical activity, lowering alcohol intake, and avoiding smoking are other important factors to include in a heart-healthy regimen.”

Jessica Shapiro, MS, RD, associate wellness dietitian at Montefiore Medical Center in New York, says women over the age of 50 need 2.4 mcg of vitamin B12 daily. “As women age, there’s a decrease in the secretion of hydrochloric acid in the stomach, decreasing the absorption of B12,” she says. “Vitamin B12 is involved with homocysteine metabolism, and elevated homocysteine has been proven to be an independent risk factor for heart disease.”

Furthermore, as a woman ages, her chances of developing high blood pressure increases more than a man’s, which is another risk factor for heart disease. “Women may have had normal blood pressure most of their lives, but after menopause, a woman’s chances of developing high blood pressure rises considerably,” Johnson says. “Women, especially postmenopausal women, should see their healthcare provider regularly to have their blood pressure monitored.”

How RDs Can Help
It’s important for dietitians to recognize and emphasize that premenopausal women are at a critical stage for increased education about their heart health. Here’s what RDs can do to begin counseling these patients:

Stress developing a healthful lifestyle. “Premenopausal women are likely to ignore their health or put it on the back burner due to hectic lifestyles or taking care of families,” Wissemeier says. “[But] women need to make time for a healthful diet for themselves and their families while including regular physical activity. Heart disease is a lifestyle disease, therefore one’s habits greatly factor into the occurrence rates of the disease.”

Suggest the importance of weight loss. “Many premenopausal women think they’ll be able to lose the weight they gain quickly once they’re ready,” Shapiro says. “The reality is they come in to see me after they realize the weight is just not coming off as easily as it used to shortly after age 30. They shouldn’t wait until they have symptoms of heart disease, as it’s easier and less costly to take preventive measures. They should cut back on total calories to create weight loss and engage in regular physical activity, about 30 minutes per day.” A heart-healthy lifestyle includes maintaining a healthful weight and a BMI below 25, staying active, and eating well, Johnson adds.

Recommend a diet low in saturated and trans fats, cholesterol, sodium, and added sugar. Advise women to focus on nutrient-dense foods such as fresh fruits and vegetables, whole grains, and lean meats to improve the quality of their diet.

Advise postmenopausal women to get their cholesterol checked regularly. And suggest they use foods as a tool to help lower triglycerides by decreasing their intake of simple sugars found in soda and sweets.

Provide the right tools. Dietitians can teach clients how to plan menus, grocery shop, read labels, and offer cooking tips, meal/snack ideas, and recipes, Sheth says. Tell patients about the latest smartphone apps for monitoring the healthful foods they eat, and direct them to resources such as the USDA food tracker, she adds.

In the end, all women must not assume heart disease is a man’s problem, especially postmenopausal women who are at higher risk of a heart attack. “These women need to prioritize their health and not brush off warning [signs],” Wissemeier says.

— Maura Keller is a Minneapolis-based writer and editor.


Top 6 Heart Attack Symptoms in Women
Chest pressure and pain typically have been the most common heart attack symptoms in men, but this isn’t the case for women. Here are the top six heart attack symptoms most characteristic in women:

1. fatigue

2. shortness of breath with or without chest discomfort

3. indigestion or upper abdominal pain

4. breaking out in a cold sweat, nausea/vomiting, or lightheadedness;
5. back, jaw, or throat pain

6. pain or discomfort in one or both arms (especially the left arm)

— Source: American Heart Association