Prevention of cardiovascular risk factors in women: The lifestyle paradox and stereotypes we need to defeat

Primary and secondary cardiovascular prevention is multifactorial and based on smoking cessation, the correct dietary regimen, regular physical activity, weight management and the control of cardiovascular disease, including hypertension, dyslipidaemia and diabetes (Table 1).1 The prevention of cardiovascular disease must also be cost-effective.2 There are some specific issues in the prevention of cardiovascular disease in women, particularly counteracting the physiological effects of a reduction in oestrogen, which starts slowly, but progressively, many years before the codified time of menopause.3 Oestrogens modulate the balance between vasoconstrictors (endothelin, the renin–angiotensin–aldosterone system and catecholamines) and vasodilators (NO, NO prostacyclin, cAMP and adenosine), leading to a modulation of endothelial function, which has a better profile in young women than in similarly aged men. Oestrogens mediate some genomic effects, leading to the inhibition of the proliferation of smooth muscle cells and the deposition of collagen and elastin, conferring a real protective effect on the cardiovascular system. Consequently, a reduction in oestrogen leads to weight gain (associated with an increase in adipose tissue and a reduction in muscle mass), insulin resistance, an increase in adrenergic tone, oxidative stress and blood pressure, a reduction in NO levels and unfavourable changes in lipid profiles. Some authors have suggested that oestrogens are the “fountain of youth”, but it should be taken into account that the oestrogen-mediated benefits to cardiovascular health only occur before the detrimental effects of ageing are established.4 Traditional and emerging cardiovascular risk factors in women. Traditional and emerging cardiovascular risk factors in women. Lifestyle approaches to the prevention of cardiovascular disease in women are particularly important, not only to counteract the physiological reduction in oestrogen with age, but also to control the negative effects of additional cardiovascular risk factors peculiar to women, specifically, preterm delivery, hypertensive disorders of pregnancy and gestational diabetes, the effects of which are life-long.5 Breast cancer treatment, autoimmune disease and depression, which are more often identified in women, also affect cardiovascular morbidity and mortality.6 A lifestyle protective towards the cardiovascular system should be characterized, in addition to smoking cessation, by dietary approaches to favour the control of blood pressure and glucose/lipid metabolism via weight management and regular physical activity. A correct dietary approach favours fruits, vegetables, fibre, fish, grains, nuts, legumes and seeds over sugar and detrimental fats. Therefore a daily Na+ intake <1.5 g, cholesterol <150 mg, unsaturated fat <7% of the total energy intake, and very low alcohol consumption are recommended.7 However, although healthy, this approach is expensive and may not be applicable those in most need of intervention. Physical activity is strongly recommended throughout life, but it becomes crucial in post-menopausal women. The effect of the reduction in natural oestrogen on the cardiovascular system may be counteracted by regular aerobic physical activity (e.g. Nordic walking or swimming) for 150 minutes/week.8 In these patients, regular exercise balances the cortisol to dehydroepiandrosterone sulphate ratio, which is a marker of health status after the menopause, controlling weight gain and ameliorating glucose and cholesterol profiles.9 Modern women have multiple roles that are both time- and energy-consuming. In the so-called developed countries, there is a trend towards uniformity in working patterns and activity between the sexes, although family responsibilities are often left to women. These joint obligations lead to an increase in psychosocial stressors (e.g. anxiety, depression and marital stress), which are known to further increase the overall cardiovascular risk.10 Conversely, modern guidelines for the prevention of cardiovascular disease suggest an holistic approach, in which lifestyle has a pivotal role. However, the correct lifestyle based an adequate diet, regular physical activity and weight management is both costly and time consuming and is a tough challenge. Accordingly, women rarely follow such a lifestyle, and this is strongly influenced by their income level, social role, education and culture. An understanding of the mechanisms contributing to worsening cardiovascular risk factors in women (particularly young women) is crucial in developing a better prevention programme and to reduce cardiovascular disease morbidity and mortality. Traditional atherosclerotic cardiovascular and non-traditional, but emerging, risk factors – combined with the general lack of awareness of cardiovascular disease as the primary cause of mortality in women and the expectations of women’s role in the real world – generate a undeniable lifestyle paradox. This paradox must be evaluated in any population-oriented cardiovascular risk prevention programme focusing on women (Table 1).11 The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. The author(s) received no financial support for the research, authorship, and/or publication of this article.