By Annette M. Boyle
BOSTON — During the past 15 years, female veterans have developed risk factors for cardiovascular disease (CVD) at ever-younger ages, challenging many providers’ concept of the population at risk for heart disease.
“Historically, the focus in the medical community has been on older men when it comes to cardiovascular disease preventions. However, cardiovascular disease is the No. 1 killer of women, as well,”said Varsha Vimalananda , MD, MPH, Center for Health Quality, Outcomes and Economic Research (CHQOER) at the Edith Nourse Rogers Memorial VAMC in Bedford, MA, and endocrinologist at Boston University School of Medicine.
Research conducted by Vimalananda and her Boston University colleagues provides a wake-up call to providers who may not consider women veterans at significant risk of heart disease.
“We know that half of women with two risk factors at age 50 will develop cardiovascular disease in their lifetime,” Vimalananda told U.S. Medicine. “Forty percent of women seeking care at VA facilities meet this criterion currently.”
Women aged 35-44 had two or more CVD risk factors at about half the rate of their male counterparts, 11% vs. 20%. Among those 20 years older, however, the gap had significantly narrowed. In 2010, 38% of women aged 55-64 had two or more risk factors in 2010 compared with 52% of veteran men, for a relative risk of 0.73.
“We found that, since 2000, the age of onset of these risk factors has decreased — newer cohorts of veteran women are developing disease at younger ages than older cohorts did,” Vimalananda noted.
As the women aged, the prevalence of several risk factors rose markedly. The researchers found that, in 2010, 13% of the youngest group of women veterans, those 35-44, had hypertension. That rate more than doubled (28%) among 45-54 year olds and then more than tripled — to 42% — in the oldest group.
Hyperlipidemia followed a very similar trajectory — 14% to 28% to 43% for those age intervals. The prevalence of diabetes also increased 450% as female veterans got older, from 4% in the youngest women to 18% in those 55-64.
For the recent study, published in the Journal of General Internal Medicine, Vimalananda and her colleagues conducted serial cross-sectional studies on data from the VA Diabetes Epidemiology Cohort, which includes information about all patients treated by the VA since 1998. The researchers analyzed the records of all veterans aged 35-64 who had received two or more services from the VA in 2009-2010 and in 1999-2000. The final data set included 255,891 women and 2,271,605 men.1
In 2000, 20% of veteran women in the oldest age group had hypertension, less than half the rate seen in 2010. Hyperlipidemia affected about 12% of women aged 55-64 in 2000, compared with 43% a decade later. Among the youngest women, the prevalence of hypertension rose threefold, and the prevalence of hyperlipidemia increased 700% over the decade.
All groups had obesity rates below 10% and diabetes rates below 8% in 2000. In 2010, the researchers found that obesity rates were about the same in men and women, rising from 14% to 18% in women and from 14% to 17% in men. In the study, however, they noted that other research had found overall obesity rates of 30% and higher rates among female veterans than male, based on height and weight charts.
The authors noted that “the prevalence of each condition increased substantially across the decade in all age groups, with increases of more than fivefold in rates in several categories.” For some risk factors and cohorts, the increase over time exceeded the increase in prevalence associated with age.
“This portends a significant burden of CVD among women veterans and the need for the VHA to be prepared to recognize and treat these patients,” Vimalananda said. “Both providers and women patients must recognize and discuss the very real risk of cardiovascular disease. This requires a bit of a frameshift in how many of us imagine the at-risk population looks.”
As many women veterans receive their primary healthcare through women’s health clinics, Vimalananda recommended that providers in those settings become comfortable addressing the prevention of cardiovascular disease, possibly employing different motivations and programs than those used for male veterans.
While treating identified risk factors for cardiovascular disease is important, female veterans and their physicians also should focus on preventing the onset of conditions such as obesity, diabetes, hyperlipidemia and hypertension. Open discussion of CVD risks and prevention strategies, including weight management, provide a good starting point, as does participation in the MOVE! Program, she noted.
At the same time, recognition that women face different barriers to healthy lifestyles can increase effectiveness of interventions. For instance, women more often have childcare and elder-care responsibilities that compete for the time they have available to focus on their own health, Vimalananda pointed out.
“Some research has shown that messages focused on well-being are more effective in motivating women to weight loss than are messages focused on improving one’s appearance. Given compelling findings such as these, we need to investigate whether gender-specific interventions to prevent CVD would be more effective than gender-neutral ones,” she explained.
1 Vimalananda VG, Miller Dr, Christiansen CL, Wang W, Tremblay P, Fincke BG. “Cardiovascular Disease Risk Among Women Veterans at VA Medical Facilities.” Journal of General Internal Medicine. 2013 July;28(Suppl 2):517-23.