Heart disease and the feminine mystique

Despite the fact that heart disease is the number one killer of women in America and stroke the leading cause of disability, women often don’t identify with the very real dangers the disease holds for their gender, according to Robert Wood Johnson Foundation Clinical Scholar Lisa Rosenbaum, MD.

“We all know men drop dead of heart attacks … we don’t think of women dropping dead of a heart attack,” the University of Pennsylvania cardiologist noted of the masculine attributes often attached to heart disease.

Furthermore, women tend to fear other diseases, notably breast cancer, more than heart disease. The HealthyWomen 2010 survey, in partnership with the National Stroke Association and the American College of Emergency Physicians, found that women believe breast cancer is five times more prevalent than stroke, and 40 percent of those surveyed were ‘only somewhat’ or ‘not at all’ concerned about experiencing a stroke. Yet, stroke is significantly more prevalent in women than in men, and stroke kills twice as many women as breast cancer each year.

“There’s a certain sort of female solidarity around breast cancer,” Rosenbaum stated. In a perspective piece published earlier this year in the New England Journal of Medicine, Rosenbaum wrote about an encounter with a middle-age woman with high blood pressure and hyperlipidemia. When Rosenbaum asked the new patient what was the number one killer for women, she noted the patient “answered in a way that sticks with me: ‘I know the right answer is heart disease,’ she said, eyeing me as if facing an irresistible temptation, ‘but I'm still going to say breast cancer.'”

Rosenbaum is quick to say breast cancer is a valid concern, but the emotions linked to the disease go beyond just the facts. She pointed to the controversy surrounding mammography as a clash between data and identity at the social level. Despite a recommendation from the U.S. Preventive Services Task Force to decrease mammography frequency for most women under age 50 based on decades of data, Rosenbaum wrote, “So intense was the outrage over these evidence-based recommendations that a provision was added to the Affordable Care Act specifying that insurers were to base coverage decisions on the previous screening guidelines.”

No matter where you stand on mammography, most healthcare professionals are united in agreeing lifestyle modifications and appropriate use of medications have been proven to prevent heart disease and save lives. However, Rosenbaum contends that facts alone aren’t enough. Instead, she said the healthcare community needs to find a way to tap into the emotional aspects of heart disease as successfully as has been done with breast cancer.

In the her perspective piece, Rosenbaum wrote that although the first decade of educational campaigns such as Go Red for Women “led to a near doubling of women’s knowledge about heart disease, in the past few years, such efforts have failed to reap further gains.”

She told Medical News, “Our default in medicine is to give people facts, and then we don’t know what to do when we hit the wall. We know how to disseminate facts … we don’t know how to change feelings.”

Complicating the issue with heart disease is that in so many cases it is preventable, and therefore comes with built-in guilt. Risk factors, which have been well publicized, include smoking, obesity, high blood pressure, high cholesterol, and sedentary lifestyle. “All of these are embedded with a sense of not taking care of yourself,” Rosenbaum said. “You should have done something differently.”

Conversely, breast cancer is imbued with a sense of having a terrible disease visited upon a victim, which is true. Also, because breast cancer kills more women at a younger age than heart disease, there are multiple media images of beautiful, strong heroines fighting and surviving … or succumbing … to a disease that attacks a body part that is so uniquely feminine. Rosenbaum pointed out Angelina Jolie’s message about breast cancer resonated with women across the nation who saw the actress as a lovely, brave, fierce role model.

Again, she stated, it isn’t ‘bad’ that breast cancer has pushed its way to the front of female consciousness. It’s smart … and perhaps it’s the type of message the field of cardiology should consider to reach more women.

However, Rosenbaum said it isn’t fair to ask healthcare providers to try to change identity beliefs in a brief office visit. Instead, she said the subject requires research regarding social values and group identity. Ultimately, Rosenbaum added, cultural messaging will likely come from a variety of sources including media outlets.

Today, she said, “Our biggest challenge is translating what we know into better health of our population. The next phase of evidence based-medicine should be as much about figuring out how to communicate that evidence to our patients … to do that we have much to learn from the methodological approaches of the social sciences.”

Rosenbaum added the starting point to address women’s perceptions of heart disease should be to conduct focus groups to evaluate where emotional beliefs currently stand and assess the impact of framing messaging in different ways. “This is decades worth of work,” she stressed, “to ultimately understand not just how they feel and where those feelings come from, but to evaluate whether there are appropriate interventions that help women adopt more heart-healthy behaviors.”

While heart disease might have a decidedly masculine feel, there’s no reason why research can’t point to ways to soften the message and appeal on an emotional level to women, as well. After all, women are often identified with their capacity to love … the trick will be finding the right words to help a woman celebrate her big heart while being cognizant of the dangers that come with having an enlarged one.