Should women worry about heart diseases?

SOME SHOULD, BUT ODDS ARE YOU'RE NOT ONE OF THEM.

Recently a bunch of old friends and I were discussing our upcoming fortieth birthdays. As women sometimes do, we checked out the jiggle in our thighs and the wrinkles under our eyes, remembering what we had all looked like in college together. But then we started comparing numbers: blood pressure, cholesterol, fat grams in our diets. Suddenly I felt less like a 30-something woman and more like, well, an old man. My grandfather is the person I most associate with conversations like this. After he retired, he and his buddies would sit around and argue about which fat-free cheese tasted best and who had lowered his cholesterol level the most.

It's not that my friends and I are hypochondriacs. The secret has been out for a while that heart disease kills just as many women in this country as men. Indeed, for the past few years a virtual industry of books, magazine articles, and television shows has been educating the female half of the population to think as carefully as men should about what they eat and how they react to stress.

No doubt a lot of good has come from spreading the word. Women with chest pain are now less likely to dismiss their discomfort as indigestion, and their doctors are more likely to make a correct diagnosis and begin proper treatment. But this heightened awareness has a downside: Many women are unnecessarily alarmed about their risk of heart disease.

The truth is, not all female hearts are vulnerable. And even though just as many women as men die from heart disease, they do so much later in life. Heart disease is the leading cause of death in men age 45 and older, but it doesn't move into that number one position for women until age 65. In fact, between age 45 and 54, men have five times as many heart attacks as women do. The average woman's risk barely rises until she reaches menopause. Beyond that, women's heart disease rates continue to lag behind those of men for a decade or so, not peaking until the late sixties or seventies.

Because of this sharp curve, a minor controversy has been brewing between two groups of heart disease experts. The official recommendation from the American Heart Association and the National Cholesterol Education Program is that women should follow the same low-fat diet advised for men and have their cholesterol levels monitored regularly. But a rival group of doctors, dubbed "the snails" by the editor of the physicians' journal Annals of Internal Medicine, says that young women have little to gain from this vigilance and may even have something to lose: their peace of mind. According to the snails, women under 45 shouldn't be included in cholesterol-screening programs. Some even question whether they need to be as concerned as men about the fat in their diets.

And so women are left wondering, Does it do my heart any good to take the skin off chicken or to swap ice cream for frozen yogurt? More to the point: Does what I eat in my thirties raise my risk of having a heart attack when I'm 70?

IN 1989 JOHN GROUSE, a lipids researcher at Bowman Gray School of Medicine in North Carolina, raised hackles when he questioned whether America's low-fat proselytizing was relevant for all women. Despite the hue and cry his skepticism generated, he hasn't changed his mind. "My feeling now is more or less where I left it at the time," says Crouse, a professor of medicine and public health sciences. "I don't think there's any strong evidence that healthy young women would profit from a low-fat diet."

For one thing, he points out, premenopausal women rarely get heart disease. Why? Because they're naturally protected by their own estrogen. This essential hormone helps keep total blood cholesterol levels low --including bad cholesterol low-density lipoprotein, or LDL), the type that builds up on artery walls and leads to heart disease -- while helping to maintain a high level of good cholesterol (high-density lipoprotein, or HDL), which carts LDL away from the arteries and to the liver for disposal. Before age 45 most women have cholesterol counts within the perfectly acceptable range of 185 to 207.

And estrogen has more than a one-dimensional effect on the heart. "It stretches the arteries, which makes them more accommodating to a blockage," says Rita F. Redberg, a researcher on women and heart disease at the University of California at San Francisco. It may also reduce the incidence of coronary spasm in the artery walls, an event that sometimes precedes a heart attack.

How thoroughly does estrogen protect? "Just look at the numbers," says Redberg. According to the AHA, only 1.3 in every 100,000 women between the ages of 25 and 34 die each year of coronary heart disease. From age 35 to 44 that number rises to seven in 100,000. Even spanning the perimenopausal and menopausal years -- 45 to 54 -- the fatality rate is only 31.6 in 100,000, which is well under one-tenth of 1 percent.

Once women enter menopause they begin to lose their gender advantage. As estrogen levels decline, cholesterol levels go up and arteries stiffen. But some experts say women still have plenty of time to make changes before their odds of actually developing heart disease rise significantly. "The evidence shows that a young woman with no inherited risk factors can reverse any risk she's engendered if she changes her habits at menopause," says Stephen B. Hulley, a UCSF epidemiologist.

Not only do women have time on their side, some studies suggest that high cholesterol is not a reliable predictor of their heart disease rates. The famous Framingham Heart Study found that women under 75 with cholesterol readings over 295 had the same or lower risk of heart disease as men whose cholesterol was 204. A study in Scotland showed that women aged 45 to 64 whose cholesterol levels were over 278 had a lower risk of coronary heart disease than men with cholesterol below 193. And recently UCSF researchers analyzed the data from nine separate studies and saw that healthy women whose high cholesterol wasn't treated were no more apt to end up with heart disease than those who lowered their cholesterol through diet or drugs.

Even health experts who insist that high cholesterol is an issue for women are starting to concede that the magic number 200 may be meaningless. While it seems to accurately predict an increased heart risk for men, for women the HDL count is more important. With a high enough HDL, a woman with a total cholesterol count of 240 could be in better shape, heartwise, than someone with a number of 180. That means doctors who look only at total cholesterol may incorrectly label some women as high risk.

To muddy the waters even more, just as many uncertainties surround the treatment for high cholesterol. "The NIH doesn't even know whether a low-fat diet makes a difference for postmenopausal women," says Crouse. "They're currently doing a 15-year study, the Women's Health Initiative, which will help resolve that problem. So right now we've got one arm of public health saying you must eat a low-fat diet and another spending $628 million to see if that's true." As for cholestrol-lowering drugs, they seem to work for men, but there's considerable controversy about whether they're appropriate for women, particularly premenopausal ones.

All of these question marks leave some doctors unsure of whether young women should even be screened for high cholesterol. "Consider a 20-something woman who has a cholesterol count of 280 but no other risk factors for heart disease," says Hulley. "She's not likely to have a heart attack for another half century, but suddenly you've turned this healthy young woman into a patient. Her efforts to change her diet probably won't be enough to bring her cholesterol way down. So then she may be put on drugs whose long-term side effects aren't known. And, of course, she becomes very anxious about her heart risks, which may be completely insignificant." In other words, wonders Hulley, what's the point?

Indeed, the U.S. Preventive Services Task Force had pretty much the same idea in 1995 when it came out against routine cholesterol screening for women under age 45. The American College of Physicians followed suit last year, citing Hulley's argument in a nutshell: Why prescribe drugs to a group of women whose heart disease risk is low?

OF COURSE, not everyone advocates the laissez-faire approach. Listen to Mary Malloy, co-director of the UCSF'S lipid clinic, and you might think Hulley was sentencing women to a lifetime of clogged arteries. Malloy's office is just a few blocks from Hulley's -- they're colleagues at UCSF -- but her thinking on heart disease could not be farther from his. She's not a fanatic about cholesterol screening; if a baseline check earlier in life shows you're not at high risk, it's fine to wait until menopause to resume testing, she says. But she's a bit exasperated with what she sees as a too-casual attitude toward heart disease prevention among Hulley and his fellow snails.

It might not give you a heart attack when you're young, she says, but a high-fat diet could certainly set you up for trouble down the line. True, there's time to shift gears at menopause, but why lock yourself into a game of catch-up when the stakes are so high?

The strongest argument Malloy and other prevention advocates make may be a psychological one. It's not realistic, they say, to expect women to make serious dietary changes at a point in life when most people have become rather set in their ways. Who wants to bid adieu to Haagen-Dazs or juicy porterhouse steaks after 30 years of enjoying their company?

And some evidence indicates that if you've been eating badly all your life, your arteries will be in worse shape than someone who's been eating lowfat all along. In a recent study, called the Pathobiological Determinants of Atherosclerosis in Youth, researchers looked at the autopsy reports of more than 1,000 men and 300 women, ages 15 to 34, who died from an accident, a homicide, or a suicide. They found a direct correlation between the subjects' cholesterol levels (men and women alike) and the health of their arteries. Those with high blood cholesterol, particularly LDL, had more advanced lesions in their arteries: calcium deposits and scar tissue that block blood flow and can set the scene for a heart attack.

Besides, it's not as if a low-fat diet is bad for you. Keeping fat intake low (particularly the saturated type) has numerous health advantages, from helping to keep off unwanted pounds to lowering the risk of colon cancer and possibly breast cancer (although that evidence is still sketchy).

Even Crouse, in spite of his doubts, supports public health messages encouraging everyone to eat low-fat, if only because of the way people live. "Scientifically, it makes sense to tell women not to worry. But you can't have a woman enjoying ham and cheese while her husband has to stick to fruit and fish. And I do firmly believe a low-fat diet is a good idea for men. So from a public policy standpoint, it makes sense to tell everyone to eat the same things."

CLEARLY, THERE ARE NO RIGHT or wrong answers here, only a compelling argument for moderation. As the matter stands, no one really knows whether the food you eat when you're young can raise your risk for heart disease later in life. Even if it does, cholesterol may turn out to be less than a major player, at least where women are concerned. Homocysteine, for instance, is fast gaining ground as a culprit in heart disease, and the only way to lower excess levels of this amino acid is by getting enough B vitamins, including folic acid.

Until scientists get a clearer picture of how this all works, the best advice is probably to eat reasonably and have a baseline cholesterol check sometime after age 18. If that number is normal and your HDL is high, chances are both indicators will remain that way until menopause. If your cholesterol is high but you have no other risk factors, taking steps to reduce your dietary fat couldn't hurt -- and might even help. But if doing so makes you break a sweat every time you pass an ice cream store, there's no reason to torture yourself.

Perhaps Redberg puts it best. "If it's not going to bother me, I'll take the low-fat approach," says the 40-year-old physician. "But if that means I'm not going to enjoy my meal, I'll go ahead and put the butter on my bread. I don't think it's worth being miserable for 30 years. But it is worth being prudent."

Who's at Risk?
If you're premenopausal, your own estrogen most likely protects you from heart disease. But if any of the following applies to you, you're considered at risk; the more that apply, the greater the danger.
YOU SMOKE. This habit is the biggest heart attack risk factor for women.

YOU HAVE A FAMILY HISTORY of premature heart disease (your father, brother, grandfather, or uncle developed it before age 55, or your mother or another first-degree relative had it before age 65).

YOU'RE OVER 54, or you're going through premature menopause, and you aren't on estrogen replacement therapy.

YOU DON'T EXERCISE. Studies show that sedentary people are almost twice as likely to develop heart disease as physically active ones.

YOU HAVE DIABETES OR HIGH BLOOD PRESSURE.
YOU'RE OBESE. People who are more than 30 percent overweight are prone to heart disease, even if they have no other risk factors.

YOUR HDL IS BELOW 35. An HDL count above 60 is thought to protect against heart disease, but anything between 35 and 60 is considered okay.

ILLUSTRATION

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BY BETH WEINHOUSE

Beth Weinhouse is a writer in Oxford, Mississippi.

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