Women in Crisis:
Obesity and Cardiovascular
Disease
New Cardiovascular Horizons 2009
Jane Nelson Worel MS, APNP
Meriter Heart Hospital, Madison, Wisconsin

Disclosures
• No financial relationships to disclose
• No “off label” medication
recommendations

Objectives
♥ Create awareness regarding the incidence
of cardiovascular disease in women.
♥ Increase understanding of the risk factors
for CVD and gender differences.
♥ Outline the obesity epidemic and the role
obesity plays in the development of CVD
and its risk factors.
♥ Provide recommendations: how to impact
overweight/obesity and reduce CVD risk.

Women and Cardiovascular
Disease
♥ Worldwide,
cardiovascular disease
(CVD) is the largest
single cause of death
among women.
♥ One in three women will
die of CVD.
♥ 38.2 million women (34%)
are living with CVD.

CVD Mortality Trends in the US:
1979-2004
American Heart Association Heart Disease and Stroke Statistics
2008 Update
520
500
480
Deaths in Thousands
460
440
KK insert chart
420
400
380
79 80 85 90 95 00 04
Ye a rs
M ales Fem ales
Source: NCHS and NHLBI

Women and Heart Disease Fact Sheet
Death Rates for Diseases of the Heart per 100,000 Women, 2002
Age adjusted to the 2000 U.S. Population; International Classification of
Diseases (ICD–10) codes: I00–I09, I11, I13, I20–I51.

CVD and Other Major Causes
of Death: Females
500,000
400,000 Alzheimer
CLRD
Deaths 300,000
Cancer
200,000 Other CVD
Stroke
100,000 Heart Disease
0
All Ages <85 85+
(United States: 2004)
Source: NCHS and NHLBI

Leading Causes of Death in US,
2003
Female Male
Heart Disease 28% 28%
Cancers 22% 24%
Stroke 8% 5%
Lower respiratory diseases 5% 5%
Alzheimer’s disease 4% 2%
Diabetes 3% 3%
Accidents 3% 6%
Influenza/pneumonia 3% 2%
Source: CDC, NCHS, Health, United States, 2006

Are Women Aware ?
♥ Percentage of women aware that heart disease is the
leading cause of death in women:
♥ 1997: 30%
♥ 2000: 34%
♥ 2003: 46%
♥ 2007: 59%
♥ In the latest survey, only 13% viewed heart disease as
their leading health concern.
♥ There is a gap in women personalizing the messages.
♥ Awareness levels are lower in Black and Hispanic
women, who are often at even higher risk because of the
prevalence of blood pressure and diabetes.
Sources: CDC/NCHS; Mosca et al Circulation 2004.

Awareness of Leading Cause of
Death Among Women
source: Mosca, et al National Study of Women’s Awareness, Preventive Action
and Barriers to Cardiovascular Health, Circulation, 2006
Response All White Black Hispanic Other
percentages n=1008 n=565 n=210 n=171 n=53
Breast Ca 12 10 19 14 23
Cancer 22 19 26 33 23
Heart 55 62 38 34 43
Disease
Other 7 5 14 12 4
Don’t know 4 4 3 8 8

Risk Factors, Gender and
Excess Weight

Case Study - Carol H.
♥ PT: 70-yr- old White woman, retired librarian
♥ CC: Evaluation of CV risk due to abnormal lipids
♥ HPI: TG high, very low-fat diet for years
♥ PMH: Asthma, PAT, HTN
♥ Lifestyle Hx: Tobacco use, none; alcohol use, rare; walks 3x/wk;
very low-fat, high carbohydrate diet
♥ FH: Mother – deceased at age 82; diabetes, CVA and CAD
♥ Current medication: Diltiazem SR, Advair
Physical Examination Laboratory Results
Ht: 5’ 4” TC: 210 mg/dL Cr: 0.8 mg/dL
Wt: 157 lb
BMI: 27 kg/m2 TG: 250 mg/dL TSH: WNL
BP: 122/70 mm Hg HDL: 39 mg/dL LFTS: WNL
HR: 67 bpm LDL: 121 mg/dL
Glucose: 104 mg/dL

Risk Factors for CVD
Modifiable Non-modifiable
♥ Physical Inactivity ♥ Age
♥ Psychosocial Factors ♥ Family history
♥ High Blood Pressure ♥ Gender
♥ Diabetes / Metabolic Syndrome
♥ High Cholesterol and Triglycerides, Low HDL
♥ Cigarette Smoking and exposure to
secondhand smoke
♥ Diet high in saturated fat and calories and low
in fresh fruits, vegetables, whole grains & fish
♥ Overweight/Obesity

Case Study - Carol H.
Summary of CV Risk Factors
GOALS:
♥ BP< 120/80 (optimal) ♥ Woman age 75yr
♥ Total Cholesterol < 200 ♥ HTN on therapy
mg/dL
♥ LDL Cholesterol< 100 ♥ Total Cholesterol 210
mg/dl (optimal) mg/dL
♥ HDL > 50 mg/dL ♥ LDL-C 121 mg/dL
♥ Triglycerides < 150 mg/dL ♥ HDL 39 mg/dL
♥ Blood Sugar < 100 mg/dL ♥ Triglycerides 250 mg/dL
♥ BMI = 19-24 kg/m2
♥ No tobacco use ♥ Fasting glucose 104 mg/dL
♥ Daily exercise 30 min ♥ Overweight: BMI 27 kg/m2
♥ Non-smoker
Source: American Heart Association
♥ Exercises 3 times per week

Women and Awareness of CVD
Risk Factors
Source: Mosca, et al National Study of Women’s Awareness, Preventive Action and
Barriers to Cardiovascular Health, Circulation, 2006
All White African Hispanic
American
BP < 120/80 48% 52% 40% 37%
HDL-C > 50 37% 42% 27% 2%
mg/dl
LDL-C <100 21% 24% 12% 14%
mg/dl
Blood sugar 31% 32% 29% 27%
< 100 mg/dl

Obesity and Coronary Heart Disease
Mortality
Nurses’ Health Study: Women who never smoked
6
5
4
3
2
1
0
<19 19.0-21.9 22.0-24.9 25.0-26.9 27.0-28.9 29.0-31.9 >32.0
Body Mass Index (kg/m ) 2
P<0.001 for trend
Source: Manson JR, et al. N Engl J Med. 1995;333:677-685.

Overweight and Obesity
♥ Growing epidemic in U.S.
♥ Being overweight increases risk of :
♥ High blood pressure
♥ Cholesterol abnormalities
♥ Diabetes
♥ Heart Disease

Definitions
Body Mass Index (BMI) describes relative
weight for height: weight (kg)/height (m2)
♥ Ideal BMI 19-24 kg/m2
♥ Overweight = 25–29.9 BMI
♥Obesity = > 30 BMI
♥ Severe Obesity = > 40 BMI

Source:Clinical Guidelines on the Identification, Evaluation,
and Treatment of Overweight and Obesity in Adults
www.nhlbi.nih.gov/guidelines/obesity

Obesity Trends* Among U.S. Adults
BRFSS, 1990, 1998, 2007
(*BMI ≥30, or about 30 lbs. overweight for 5’4” person)
1990 1998
2007
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% 30%

Obesity Trends* Among U.S. Adults
BRFSS, 2007
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Overweight and Obesity – Prevalence Among US
Women
Source: CDC, National Center for Health Statistics, NHANES.
Weight 1988 to 1994 1999 to 2000
Category Prevalence (%) Prevalence (%)
Overweight 51.2 62
(BMI > 25)
Obesity 26 34
(BMI > 30)
Severe Obesity 4 6.3
BMI > 40)

Obesity and CVD Risk

NHANES III Prevalence of Hypertension*
According to BMI
BMI <25 BMI 25-<27 BMI 27-<30 BMI >30
50
41.9
40 37.8
32.7
Percent
30 27 27.7
22.1
20 14.9 15.2
10
0
Men Women
*Defined as mean systolic blood pressure ≥140 mm Hg, mean diastolic ≥90
mm Hg, or currently taking antihypertensive medication.
Brown C et al. Body Mass Index and the Prevalence of
Hypertension and Dyslipidemia. Obes Res. 2000; 8:605-619.

Hypertension and Lifestyle Modification
Modification Recommendation Systolic Reduction
(expected)
Weight Goal of BMI 18-25 5-20 mm Hg per
reduction Waist <35inches 10kg wt loss
DASH Fruits, vegetables, 8-14 mm Hg
low-fat dairy
products, less fat
Sodium <2.4 g every day 2-8 mm Hg
restriction
Physical 30 mins of aerobic 4-9 mm Hg
activity 4x per week
Reduced 1 serving per day 2-4 mm Hg
ETOH

Hypertension Guidelines
Classification & Management-JNC 7 2003.
SBP DBP Diet/Ex No Compelling
Compelling Indication
Indication
Normal < 120 < 80 Encourage
and
Prehtn 120-139 or 80-90 Yes Drug for
Compelling
Indication
Stage I 140-159 or 90-99 Yes Diuretics Drug for
Compelling
Indication
Stage II 160+ 100 Yes 2 drug Drug for
combo Compelling
Indication

NHANES III Prevalence of
High Blood Cholesterol* According to BMI
BMI <25 BMI 25-<27 BMI 27-<30 BMI >30
50
40
Percent
30.5 29.6
30 27
21.6 22
19.1
20
13 13.4
10
0
Men Women
*Defined as >240 mg/dL.
Brown C et al. Body Mass Index and the Prevalence of
Hypertension and Dyslipidemia. Obes Res. 2000; 8:605-619.

NHANES III Prevalence of
Low HDL-Cholesterol* According to BMI
BMI <25 BMI 25-<27 BMI 27-<30 BMI >30
60
50
40.6
Percent
40
31.1
27.1 28.5
30 23.7
18.2
20 16.6
9
10
0
Men Women
*Defined as <35 mg/dL in men and <45 mg/dL in women.
Brown C et al. Body Mass Index and the Prevalence of
Hypertension and Dyslipidemia. Obes Res. 2000;8:605-619.

Obesity and Diabetes = “Diabesity”

Diabetes, Women and CVD
Risk
• 23.6 million Americans with diabetes (8 % of the
population).
• 11.5 million Women over the age of 20 have diabetes
(10.2% of all women).
• 68% of diabetics die of CHD and 16% die of stroke.
• Diabetes increases CAD risk 3-7 fold in women vs. 2-3
fold in men.
• Women with Type 2 Diabetes develop heart disease at a
much younger age compared to non-diabetic women.
Source: CDC National Diabetes Fact Sheet, 2007

Risk of Fatal CAD in Diabetic vs.
Non-Diabetic Adults
4.5
4
3.5
3
Relative Risk 2.5
of Fatal CAD 2
Men
1.5
1 Women
0.5
0
Alameda Chicago NHANES Rancho New
City, Ga Bernardo Haven
Source: Davidson MB. Diabetes Mellitus: Diagnosis and
Treatment. 4th ed. 1998

American Diabetes
Association Guidelines
♥ Optimal fasting blood sugar < 100 mg/dL
♥ Impaired fasting glucose 100 - 125 mg/dL:
also called “prediabetes”
♥Women in this category can benefit greatly
by making changes in their diet and
increasing physical activity
♥ Criteria for diabetes
♥Fasting glucose 126 mg/dL or higher

Lifestyle and Diabetes
♥ Research shows that diabetes can be prevented, or at
least postponed, by improving diet, losing weight, and
increasing physical activity levels.
♥ People at risk for diabetes who follow a diet and exercise
plan (with only a modest weight loss) can decrease their
risk of developing diabetes by more than 50%. Diabetes
Prevention Program (DPP)
Source: NEJM, Feb. 2002

DPP: Lifestyle Intervention
WC Knowler, et al NEJM Feb. 2002

DPP: Incidence of Diabetes
WC Knowler et al.NEJM Feb. 2002

Obesity and the Metabolic
Syndrome
♥ Increasing prevalence of obesity in
women, from 12.2% in 1991 to 20.8% in
2001.
The Metabolic Syndrome 3 of 5 factors:
♥ Waist circumference > 35 in.
♥ Triglyceride > 150 mg/dL
♥ Fasting glucose > 100 mg/dL
♥ HDL < 50 mg/dL
♥ BP > 130/85 mmHg or on antihypertensive therapy

Case Study – Carol H.
Does She Have Metabolic Syndrome?
Risk Factor Category Cut Carol’s Data
Point
↑Waist circumference Not available
Woman >88 cm (> 35 in) (BMI 27)
↑TG ≥150 mg/dL or on Rx 250 mg/dL
↓HDL-C
Woman <50 mg/dL or on Rx 39 mg/dL
↑BP ≥130 or ≥ 85 mm Hg 122/70 mm Hg on
or on Rx Rx
Fasting glucose ≥100 mg/dL or on Rx 104 mg/dL
Grundy SM, et al. Circulation. 2005;112:285

Obesity and the Metabolic
Syndrome
• Women spend 1/3 of lives in menopause.
• Menopause related to decreased physical
function in women.
• Decreased physical functioning -> wt.
gain, insulin resistance and hypertension.
• Decreased estrogen -> androidal body
habitus w/ increased abdominal fat and
increased risk of metabolic syndrome.

From the National Institutes of Health-National Heart, Lung, and Blood Institute Women's
Ischemia Syndrome Evaluation (WISE) study, event-free survival by metabolic status was
recently reported in women
Shaw, L. J. et al. J Am Coll Cardiol 2006;47:S4-S20

Physical Activity
Estimated percent of Americans > 18 yrs who
report no leisure-time activity (2004)
50 46 45
40 37
34
31
% of 30 26 28 25
population 20 Men
Women
10
0
White Black Hispanic Asian
Source: Heart and Stroke Stats 2008

Where Does Exercise Come In?
EVERYWHERE!
• Exercise helps lower blood pressure.
• Exercise helps prevent diabetes.
• Exercise helps lower LDL (bad cholesterol)
and raise HDL (good cholesterol).
• Exercise helps weight management.
• Exercise helps manage stress.
• Exercise helps bone health.

Health Benefits of Weight Loss
• Decreased cardiovascular risk
• Decreased glucose and insulin levels
• Decreased blood pressure
• Decreased LDL and triglycerides,
increased HDL
• Decreased severity of sleep apnea
• Reduced symptoms of degenerative joint
disease
• Improved gynecological conditions

Weight Loss:
Calories In and Calories Out!
Modest decreases in
calorie intake and
increases
in calorie expenditure
make a difference!

Do You Know How Food Portions Have
Changed in 20 Years?
National Heart, Lung, and Blood Institute
Obesity Education Initiative

BAGEL
20 Years Ago Today
140 calories How many calories
3-inch diameter are in this bagel?

BAGEL
20 Years Ago Today
140 calories 350 calories
3-inch diameter 6-inch diameter
Calorie Difference: 210 calories

Maintaining a Healthy Weight is a Balancing Act
Calories In = Calories Out
How long will you have to rake leaves in order to
burn the extra 210 calories?*
*Based on 130-pound person

Calories In = Calories Out
If you rake the leaves for 50 minutes you will
burn the extra 210 calories.*
*Based on 130-pound person

CHEESEBURGER
20 Years Ago Today
333 calories How many calories are
in today’s cheeseburger?

CHEESEBURGER
20 Years Ago Today
333 calories 590 calories
Calorie Difference: 257 calories

Maintaining a Healthy Weight is a Balancing Act
Calories In = Calories Out
How long will you have to lift weights
in order to burn the extra 257 calories?*
*Based on 130-pound person

Calories In = Calories Out
If you lift weights for 1 hour and 30 minutes,
you will burn approximately 257 calories.*
*Based on 130-pound person

SPAGHETTI AND MEATBALLS
20 Years Ago Today
500 calories How many calories do
1 cup spaghetti with sauce you think are in today's
and 3 small meatballs portion of spaghetti and
meatballs?

SPAGHETTI AND MEATBALLS
20 Years Ago Today
500 calories 1,025 calories
1 cup spaghetti with sauce 2 cups of pasta with sauce
and 3 small meatballs and 3 large meatballs
Calorie Difference: 525 calories

Maintaining a Healthy Weight is a Balancing Act
Calories In = Calories Out
How long will you have to houseclean in order
to burn the extra 525 calories?*
*Based on 130-pound person

Calories In = Calories Out
If you houseclean for 2 hours and 35 minutes,
you will burn approximately 525 calories.*
*Based on 130-pound person

FRENCH FRIES
20 Years Ago Today
210 Calories How many calories are in
2.4 ounces today’s portion of fries?

FRENCH FRIES
20 Years Ago Today
210 Calories 610 Calories
2.4 ounces 6.9 ounces
Calorie Difference: 400 Calories

Maintaining a Healthy Weight is a Balancing Act
Calories In = Calories Out
How long will you have to walk leisurely in
order to burn those extra 400 calories?*
*Based on 160-pound person

Calories In = Calories Out
If you walk leisurely for 1 hour and 10 minutes
you will burn approximately 400 calories.*
*Based on 160-pound person

SODA
20 Years Ago Today
85 Calories How many calories are
6.5 ounces in today’s portion?

SODA
20 Years Ago Today
85 Calories 250 Calories
6.5 ounces 20 ounces
Calorie Difference: 165 Calories

Maintaining a Healthy Weight is a Balancing Act
Calories In = Calories Out
How long will you have to work in the garden to
burn those extra calories?*
*Based on 160-pound person

Calories In = Calories Out
If you work in the garden for 35 minutes,
you will burn approximately 165 calories.*
*Based on 160-pound person

TURKEY SANDWICH
20 Years Ago Today
320 calories How many calories are in
today’s turkey sandwich?

TURKEY SANDWICH
20 Years Ago Today
320 calories 820 calories
Calorie Difference: 500 calories

Maintaining a Healthy Weight is a Balancing Act
Calories In = Calories Out
How long will you have to ride a bike in order to
burn those extra calories?*
*Based on 160-pound person

Calories In = Calories Out
If you ride a bike for 1 hour and 25 minutes,
you will burn approximately 500 calories.*
*Based on 160-pound person

Thank you for participating in
Portion Distortion!
For more information about Maintaining a Healthy Weight
visit www.nhlbi.nih.gov

Weight Loss Diets
Which Works Best?
Pounds Lost Trial; Harvard School of Public Health
Diet Type Components Calorie Activity
Reduction
20% cal fat
Low fat, ave 750 cal/d 90 min/wk
15% cal protein
protein 65% cal cho
20% cal fat
Low fat, high 750 cal/d 90 min/wk
25% cal protein
protein 55% cal cho
40 % cal fat
High fat, ave 750 cal/d 90 min/wk
15% cal protein
protein 45% cal cho
40% cal fat
High fat, high 750 cal/d 90 min/wk
25% cal protein
protein 35% cal cho

Weight Loss Diets
Which Works Best?
Pounds Lost Trial; Harvard School of Public Health
♥ Saturated fats were replaced by unsaturated and monosaturated
fats in all diets; whole grains, fruits and vegetables replaced simple
carbohydrates.
♥ Wt. loss similar across groups: ave. 13 lbs at 6 months and
maintained a 9 lb loss for 2 years.
♥ Waist circumference similar across groups: ave. loss 2 inches.
♥ Attendance at counseling sessions linked to greater adherence and
lbs lost.
♥ CVD risk factors improved at 6 months and 2 years in all groups.
LDL decreased most in low fat groups. HDL cholesterol increased
most in the high fat groups. Trigs improved in all groups. Fasting
insulin decreased in all but highest CHO group.

National Obesity Guidelines: Step I Diet
nhlbi.nih.gov/guidelines/obesity
Nutrient Recommended Intake:
Calories: Approximately 500 to 1,000 kcal/day reduction from usual intake
Total fat: 30 percent or less of total calories
Sat fat: 8 to 10 percent of total calories
Monos: Up to 15 percent of total calories
Polys: Up to 10 percent of total calories
Cholesterol: <300 mg/day
Protein: Approximately 15 percent of total calories
Carbohydrate: 55 percent or more of total calories
Sodium chloride: No more than 100 mmol/day approx 2.4 gm sodium
Calcium: 1,000 to 1,500 mg/day
Fiber: 20 to 30 g/day

Recommendations for Physical
Activity
♥ National Obesity Guidelines
♥ 30-60 min of moderate activity most days of week
♥ Moderate activity: “somewhat hard”
♥ Steps/day
♥ Pedometer – 10,000/day or “lifestyle activity”
♥ Similar benefits in wt. loss and CVD risk reduction as
structured exercise programs.
Source: RE Anderson et al JAMA 1999

Case Study – Carol H.
TLC Treatment
Nutrition
• Diet counseling - refer to dietitian
• Fat from mono and polyunsaturated fats
• ↑Fruits and vegetables – 5/d (2 fruits & 3 vegs daily)
• Watch portions – especially simple carbohydrates
• Set weight loss goal - 10 lb, 3-4 lb/mo over 3 months
Physical activity
• Start from 3x/wk, 30 min
• Increase walking frequency to most days
• Consider a pedometer – 10,000 steps/d

Case Study – Carol H.
3-Month Follow-Up Visit
Risk Factor Goals Baseline 3-Months TLC
TC mg/dL <200 210 190
TG mg/dL <150 250 180
HDL mg/dL >40 39 40
LDL mg/dL <130 or 100 121 110
Non-HDL mg/dL <160 or130 171 150
FBG mg/dL <100 104 99
Wt lbs 130 157 147
BMI kg/m2 <25 27 25
BP mm Hg <140/<90 122/70 110/60
Phys activity 30 min 7x/wk 3x/wk 10,000 steps/d

Internet Resources
• National Heart Lung and • Small Step
Blood Institute www.smallstep.gov
www.nhlbi.nih.gov
• Preventive Cardiovascular
• Heart Truth Campaign Nurses Association
www.nhlbi.nih.gov/health/heart www.pcna.net
truth/
• American Obesity Society
• American Heart Association www.obesity.com
(AHA)
www.americanheart.org • US Dept. of Health and
Human Services, Office on
• AHA Go Red for Women Women’s Health
www.goredforwomen.org www.womenshealth.gov
• WomenHeart: National
Coalition for Women with
Heart Disease
www.womenheart.org

Remember to:
• Discuss CVD risks with women to increase
awareness!
• Encourage women to know their personal risk
factors.
• Counsel patients to include both diet and
exercise changes for healthy wt. loss and CVD
risk reduction.
• Use all health team members to assist patients
with lasting wt. loss.
• Be a good example and take time for healthy
habits yourself!

Thank you for your time and
attention!