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Major Risk Factors

Smoking

Cigarette smoking has been described as "the most important individual health risk in this country." Approximately 26 million American women smoke. Although the smoking rate for women dropped 8 percent between 1965 and 1988, women who smoke today are apt to smoke more heavily than they did in the past.

Surprising as it may seem, smoking by women in the United States causes almost as many deaths from heart disease as from lung cancer. Women who smoke are two to six times as likely to suffer a heart attack as nonsmoking women, and the risk increases with the number of cigarettes smoked per day. Smoking also boosts the risk of stroke.

Cardiovascular disease are not the only health risks for women who smoke. Cigarette smoking greatly increases the chances that a woman will develop lung cancer. In fact, the lung cancer death rate for women is now higher than the death rate for breast cancer, the chief cause of cancer deaths in women for many years. Cigarette smoking is also linked with cancers of the mouth, larynx, esophagus, urinary tract, kidney, pancreas, and cervix. Smoking also causes 80 percent of cases of chronic obstructive lung disease, which includes bronchitis and emphysema.

Smoking is also linked to a number of reproductive problems. Women who smoke are more apt to have problems getting pregnant and to begin menopause at a slightly younger age. Further, cigarette use during pregnancy poses serious risks for the unborn. Babies of women who smoked during pregnancy tend to weigh less at birth than babies of nonsmokers. Smoking while pregnant also increases risks of bleeding, miscarriage, premature delivery, stillbirth, and sudden infant death syndrome, or "crib death." Moreover, young children who are exposed to a parent's cigarette smoke have more lung and ear infections.

There is simply no "safe way" to smoke. Although low-tar and -nicotine cigarettes may reduce the lung cancer risk to some extent, they do not lessen the risks of heart diseases or other smoking-related diseases. The only safe and healthful course is not to smoke at all.

High Blood Pressure

High blood pressure, also known as hypertension, is another major risk factor for coronary heart diseases and the most important risk factor for stroke. Even slightly high levels double the risk. High blood pressure also boosts the chances of developing kidney disease.

Nearly 58 million Americans have high blood pressure, and about half of them are women. Older women have a higher risk, with more than half of all women over the age of 55 suffering from this condition. High blood pressure is more common and more severe in black women than it is in white women. Use of birth control pills can contribute to high blood pressure in some women.

Blood pressure is the amount of force exerted by the blood against the walls of the arteries. Everyone has to have some blood pressure, so that blood can get to the body's organs and muscles. Usually, blood pressure is expressed as two numbers, such as 120/80, and is measured in millimeters of mercury (mmHg). The first number is the systolic blood pressure, the force used when the heart beats. The second number, or diastolic blood pressure, is the pressure that exists in the arteries between heartbeats. Depending on your activities, blood pressure may move up or down in the course of a day. Blood pressure is considered high when it stays above normal levels over a period of time.

High blood pressure is sometimes called the "silent killer" because most people have it without feeling sick. Therefore, it is important to have it checked each time you see your doctor or other health professional. Blood pressure can be easily measured by means of the familiar stethoscope and inflatable cuff placed around one arm. However, since blood pressure changes so often and is affected by many factors, your health professional should check it on several different days before deciding if your blood pressure is too high. If your blood pressure stays at 140/90 mmHg or above, you have high blood pressure.

Although high blood pressure can rarely be cured, it can be controlled with proper treatment. If your blood pressure is not too high, you may be able to control it entirely through weight loss if you are overweight, regular exercise, and cutting down on alcohol, table salt, and sodium. (Sodium is an ingredient in salt that is found in many packaged foods, baking soda, and some antacids.)

However, if your blood pressure remains high, your doctor will probably prescribe m medicine in addition to the above changes. The amount you take may be gradually reduced, especially if you are successful with the changes you make in your lifestyle. While few people like the idea of taking any medicine for a long time, the treatment benefits are real and will reduce the risk of stroke, heart attack, and kidney disease. If you are prescribed a drug to control high blood pressure and find you have any uncomfortable side effects, ask your doctor about changing the dosage or possibly switching to another type of medicine.

During pregnancy, some women develop high blood pressure for the first time. Between 10 and 20 percent of first-time mothers develop a high blood pressure problem during pregnancy called preeclampsia. Other women who already have high blood pressure may find that it worsens during pregnancy. If untreated, these conditions can be life-threatening to both mother and baby. Since a woman can feel perfectly normal and still have one of these conditions, it is important to get regular prenatal checkups so that your doctor can discover and treat a possible high blood pressure problem.

High Blood Cholesterol

High blood cholesterol is a third important risk factor for coronary heart diseases that you can do something about. Although young women tend to have lower cholesterol levels than young men, between the ages of 45 and 55, women's cholesterol levels begin to rise higher than men's. After age 55, the gap between women and men becomes still wider. Today, about one-third of American women have blood cholesterol levels high enough to pose a serious risk for coronary heart diseases. The higher your blood cholesterol level, the higher your heart disease risk. For all adults, a desirable blood cholesterol level is less than 200 mg/dL. A level of 240 mg/dL or above is considered "high" blood cholesterol. But even levels in the "borderline-high" category (200-239 mg/dL) boost the risk of heart disease.

The body needs cholesterol to function normally. It is found in all foods that come from animals--that is, all meats and dairy products. However, the body can make all of the cholesterol that it needs. Over a period of years, extra cholesterol and fat circulating in the blood settle on the inner walls of the arteries that supply blood to the heart. These deposits make the arteries narrower and narrower. As a result, less blood gets to the heart and the risk of coronary heart disease increases.

Ask your health professional to check your blood cholesterol level once every 5 years. This simple test involves taking a small blood sample and measuring the amount of cholesterol. The cholesterol level is expressed as, for example, "215 mg/dL" or 215 milligrams of cholesterol per deciliter of blood. Be sure to ask what your cholesterol number is and whether you should take steps to lower it. Before age 45, the total blood cholesterol level of women averages below 220 mg/dL. But between the ages of 45 and 55, women's average cholesterol levels soar to between 240 and 260 mg/dL. Women between 45 and 74 years of age who have a cholesterol level over 240 mg/dL are more than twice as likely to develop coronary heart disease as women with levels below 200 mg/dL.

Total blood cholesterol is the first measurement used to identify persons with high blood cholesterol. As you read above, a blood cholesterol level of 240 or more means you have "high" blood cholesterol. But even "borderline-high" levels (200-239) boost your risk of coronary heart disease. If your total blood cholesterol is in the high or borderline-high category and you have other risk factors for coronary heart disease, your doctor will want a more complete "cholesterol profile" before making a decision about treatment. Specifically, your doctor will measure your LDL and HDL levels after an overnight fast.

Cholesterol travels in the blood in packages called lipoproteins. Cholesterol packaged in low density lipoprotein (LDL) is often called "bad cholesterol" because LDL carries most of the cholesterol in the blood and if not removed, cholesterol and fat can build up in the arteries. Another type of cholesterol, which is packaged in high density lipoprotein (HDL), is known as "good cholesterol." That is because HDL helps remove cholesterol from the blood, preventing it from piling up in the arteries.

A "cholesterol profile" includes measurements of both HDL and LDL levels. An LDL level below 130 mg/dL is desirable. LDL levels of 130-159 mg/dL are "borderline-high." Levels of 160 mg/dL or above mean you have a high risk of developing coronary heart disease. As with total cholesterol, the higher the LDL number, the higher the risk. On the other hand, the lower your HDL number is, the greater your risk for coronary heart disease. Any HDL level below 35 mg/dL is considered too low. After studying your LDL- and HDL-cholesterol levels and other risk factors for coronary heart disease, your doctor may recommend a specific treatment program for you.

For many people, a change in eating habits is the only step needed to lower blood cholesterol levels. Cutting back on foods rich in fat, especially saturated fat, and in cholesterol, can lower both total and LDL-cholesterol. Weight loss for overweight persons also will lower blood cholesterol levels. Losing extra weight, as well as quitting smoking and becoming more active, also may help boost your HDL-cholesterol levels. Although we don't know for sure that raising HDL levels in this way will reduce the risk of coronary heart disease, these measures are likely to be good for your heart in any case.

While changing the way you eat is the first and most important action you can take to improve your blood cholesterol levels, your doctor may also suggest that you take cholesterol-lowering medications. This recommendation will depend on how much your new diet lowers your blood cholesterol and whether you have any other risk factors for coronary heart disease. If your doctor does prescribe medicines, you must also continue your cholesterol-lowering diet because the combination may allow you to take less medicine. Also, because diet is still the safest treatment, you should always try to lower your cholesterol levels with diet changes before adding medication.

Triglycerides are another type of fat found in the blood and in food. Triglycerides in food are made up of saturated, polyunsaturated, and monounsaturated fats. The liver also produces triglycerides. When alcohol is consumed or when excess calories are taken in, the liver produces more triglycerides.

A number of studies have found that some people with coronary heart disease have high triglyceride levels. However, more research is needed to determine whether high triglycerides cause narrowing of the arteries or are just associated with other risk factors like low levels of HDL-cholesterol and being overweight.

Extremely high levels of triglycerides can cause a dangerous inflammation of the pancreas called pancreatitis.

To reduce blood triglyceride levels, doctors recommend a low-fat, low-calorie diet, weight control, increased exercise, and no alcohol. Occasionally drugs are needed.

Other Risk Factors

Overweight

Overweight (obesity) is a proven risk factor for cardiovascular diseases. People who are obese--more than 30 percent overweight--are more likely to develop heart-related problems even if they have no other risk factors. According to an important study of cardiovascular diseases called the Framingham Heart Study, overweight in women is linked with coronary heart disease, stroke, congestive heart failure, and death from heart-related causes.

The Framingham Heart Study found that the more overweight a woman was, the higher her risk for heart disease. This was true for women of all ages, but especially for women under age 50. Among women younger than 50, the heaviest group was two and a half times more likely to develop coronary heart disease than the group with desirable weight. Overweight women under age 50 had more than four times the stroke rate of the group with desirable weight.

Overweight contributes not only to cardiovascular diseases, but to other risk factors as well. For example, overweight women under age 50 are three times as likely to develop high blood pressure as women of desirable weight. Overweight women also are more apt to have high blood cholesterol levels and diabetes. Fortunately, these conditions often can be controlled with weight loss and regular exercise.

What is a healthy weight for you? Currently, there is no exact answer. Researchers are trying to develop better ways to measure healthy weight. In the meantime, here are some guidelines to follow. Check the "What Should You Weight?" table to find out if your weight is within the range suggested for your height. (Ranges are given because women of the same height may have equal amounts of body fat but different amounts of muscle and bone, which affects weight.) Weights above the suggested ranges are thought to be unhealthy for most people.

Research also suggests that body shape as well as weight affects heart health. "Apple-shaped" individuals with extra fat at the waistline may have a higher risk than "pear-shaped" people with heavy hips and thighs. If your waist is larger than the size of your hips, you may have a higher risk for coronary heart disease.

Diabetes

Diabetes, or high blood sugar, is a serious disorder that raises the risk of coronary heart disease. More than 80 percent of people who have diabetes die of some type of cardiovascular disease, usually heart attack. The risk of death from coronary heart disease is doubled in women with diabetes. Compared with nondiabetic women, diabetic women are also more apt to suffer from high blood pressure and high blood cholesterol. Besides helping to cause coronary heart disease, untreated diabetes can contribute to the development of kidney disease, blindness, problems in pregnancy and childbirth, nerve and blood vessel damage, and difficulties in fighting infection.

Diabetes is often called a "woman's disease" because after age 45, about twice as many women as men develop diabetes. The type of diabetes that develops in adulthood is usually "noninsulin-dependent diabetes mellitus," or NIDDM. This type of diabetes, in which the pancreas makes insulin but the body is unable to use it well, is the most common form of the disease. For unknown reasons, the risks of heart disease and heart-related death are higher for diabetic women than for diabetic men.

While there is no cure for diabetes, there are steps one can take to control it. Eighty-five percent of all NIDDM diabetics are at least 20 percent overweight. It appears that overweight and growing older promote the development of diabetes in certain people. Losing excess weight and boosting physical activity may help postpone or prevent the disease. For lasting weight loss, get regular, brisk exercise and eat a diet that is limited in calories and fat, especially saturated fat.

Stress

In recent years, we have read and heard much about the connection between stress and coronary heart disease. In particular, we have heard that "type A" behavior--aggressiveness, a need to compete, a constant concern about time--is linked to the development of heart disease. Some studies have shown such a relationship in men. But recent research on type A behavior in women shows no link between this kind of behavior and coronary heart disease.

Another factor that has often been connected to women's heart disease is employment outside the home. The "price of liberation" for working women, according to many media reports, is a high level of stress leading to soaring rates of coronary heart disease. But research from the Framingham Heart Study shows no difference in rates of coronary heart disease between housewives and employed women.

But it is too early to rule out stress as a risk factor for women. Certainly, some common ways of coping with stress, such as overeating and heavy drinking, are bad for your heart. On the other hand, stress-relieving activities such as exercise can lower your risk of heart disease. Researchers will need to study larger groups of women over time to find out whether certain behaviors, personality types, or stressful situations are linked to the development of coronary heart disease in women.

Birth Control Pills

Studies show that women who use high-dose birth control pills (oral contraceptives) are more likely to have a heart attack or a stroke because blood clots are more likely to form in the blood vessels. These risks are lessened once the birth control pill is stopped. Using birth control pills also may worsen the effects of other risk factors, such as smoking, high blood pressure, diabetes, high blood cholesterol, and overweight.

Much of this information comes from studies of birth control pills containing higher doses of hormones than those commonly used today. Still, the risks of using low-dose birth control pills are not fully known. Therefore, if you are now taking any kind of birth control pill or are considering using one, keep these guidelines in mind:

Smoking and "the pill" don't mix. If you smoke cigarettes, stop smoking or choose a different form of birth control. Cigarette smoking boosts the risks of serious cardiovascular problems from birth control pill use, especially the risk of blood clots. This risk increases with age and with the amount smoked. For women over 35, the risk is particularly high. Women who use oral contraceptives should not smoke.

Pay attention to diabetes. Glucose metabolism, or blood sugar, sometimes changes dramatically in women who take birth control pills. Any woman who is diabetic, or has a close relative who is, should have regular blood sugar tests if she takes birth control pills.

Talk with your doctor. If you have a heart defect, if you have suffered a stroke, or if you have any other kind of cardiovascular disease, oral contraceptives may not be a safe choice. Be sure your doctor knows about your condition before prescribing birth control pills for you.

Alcohol

Over the last several years, a number of studies have reported that moderate drinkers--those who have one or two drinks per day--are less likely to develop heart disease than people who don't drink any alcohol. Alcohol may help protect against heart disease by raising levels of "good" HDL cholesterol. On the other hand, it may also raise blood pressure which could lead to stroke.

If you are a nondrinker, this is not a recommendation to start using alcohol. And certainly, if you are pregnant or have another health condition that could make alcohol use harmful, you should not drink. But if you're already a moderate drinker, evidence suggests that you may be at a lower risk for heart attack.

But remember, moderation is the key. Heavy drinking can definitely cause heart-related problems. More than two drinks per day can raise blood pressure, and recent research shows that binge drinking can lead to stroke. It is well-known that people who drink heavily on a regular basis have higher rates of heart disease than either moderate drinkers or nondrinkers.

Keep in mind, too, that alcohol provides no nutrients--only extra calories. Most drinks contain 100-200 calories each. Women who are trying to control their weight may want to cut down on alcohol and substitute calorie-free iced tea, mineral water, or seltzer with a squeeze of lemon or lime.

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