Cardiovascular Disease

1. Women’s Perception of Cardiovascular
Disease Risk Varies by Hyperlipidemia
History: Data from the Making Effective
Nutritional (MENU) Choices Study
Andrea E. Cassidy-Bushrow, PhD, MPH, Gwen Alexander, PhD,
Frank R. Lawrence, PhD, Henry Ford Hospital; Jennifer B. McClure,
PhD, Group Health Research Institute; Debra P. Ritzwoller, PhD,
Kaiser Permanente Colorado; Sharon J. Rolnick, PhD,
HealthPartners Research Foundation; Dennis D. Tolsma, MPH,
Kaiser Permanente Georgia; Christine Cole Johnson, PhD, MPH,
Henry Ford Hospital.
17th Annual HMO Research Network Conference

2. Background
Cardiovascular disease (CVD) traditionally
considered an “older man’s disease”
American Heart Association Go Red For
Women campaign launched in 2004 to
increase women’s awareness of CVD
Increasing numbers of women now aware
that CVD is #1 cause of death of women

3. Background
• Over half of CVD attributable to hyperlipidemia
• Recognition of hyperlipidemia as CVD risk
factor lacking
• Women with hyperlipidemia worry more about
CVD than those without
• However, >1/3 of women with hyperlipidemia do
not worry about CVD
• Hyperlipidemia diagnosis and treatment
particularly challenging in women
• Variable screening rates in young women
• Contraindicated treatments (statins) for women
of child-bearing potential

4. Purpose
To examine if the perceived risk of
CVD varies by hyperlipidemia status
in women, overall, and by age

5. MENU Choices Study
• Web-based, 5-site randomized intervention trial
• Encouraged increased intake of fruit and vegetables
• “Healthy” population target group
• Optimized use of technology (email and internet)
• “Real world” application
Longitudinal study (baseline, 3, 6, 12 month measures)
Three intervention arms:
• Untailored website
• Tailored website
• Tailored website + Behavioral counseling via email

6. MENU Study Sample
• Eligibility:
• Age 21 – 65 years
• No contraindication to increasing fruit and
vegetable intake
• Access to internet for personal use
• Working email account checked ≥1/week

7. Recruitment methods
• Recruitment spanned 09/2005 – 03/2006
• African Americans over-sampled at 2 sites and Hispanics
over-sampled at 1 site
• Single mailing of invitation letter included:
• Business-style envelope with Health Plan logo, metered mail, sent
locally
• Web address and unique sign-on code
• $2 bill to gain “attention”
$20 incentive for completing each follow-up survey
Online enrollment including eligibility, consent, email
verification, baseline and follow-up surveys
Letter and automated email prompts

8. Measures
• Hyperlipidemia history defined as:
• Self-reported diagnosis and/or
• Reported use of anti-hyperlipidemics
Perceived personal risk of CVD measured
on ordinal scale (1) not at all to (5)
extremely likely

9. Analytic sample
• Restricted to women (N=1,729)
• Exclusions
• Pre-existing CVD
• Missing data
Final analytical sample 1,693 women

10. Statistical Analysis
• Association of hyperlipidemia with
perceived risk of CVD estimated using
Bayesian proportional odds models
• To account for potential residual
confounding, a propensity-score approach
utilized as a sensitivity analysis (variables
used: age, diabetes, body mass index
(BMI), marital status, hypertension, family
history of CVD)

11. Results
Hyperlipidemia No Hyperlipidemia
N 382 (22.6%) 1311 (77.4%)
Age (years) 51.0±8.6 43.0±10.6
<High-school education 43 (11.2%) 102 (7.8%)
Married/living with partner 253 (66.2%) 903 (68.9%)
African-American 112 (29.7%) 286 (22.2%)
BMI (kg/m2) 31.0±7.0 28.0±6.8
Child <18 in home 106 (27.7%) 636 (48.5%)
Currently smoke 45 (11.8%) 129 (9.8%)
Physically active 198 (51.8%) 788 (60.1%)
Family history CVD 157 (41.1%) 332 (25.3%)
Data are N (%) or mean±standard deviation

12. Results
40
35
Proportion (%)
30
25
20
15
10
5
0
Not at all Little Somewhat Lot Extremely
Percieved risk of CVD
Hyperlipidemia No Hyperlipidemia
After adjusting for age, BMI and race, women with
hyperlipidemia had a mean increase in perceived CVD risk
of 1.2 (95% CI posterior mean = 0.6, 1.7; P=0.001) compared
to women without hyperlipidemia

13. Results
Results similar, although somewhat
attenuated in propensity-score matched
group (mean increase of 0.61; 95% CI
posterior mean = 0.23, 1.0; P=0.001)

14. Conclusions
• Women with hyperlipidemia perceive a
greater personal risk of CVD than women
without hyperlipidemia
• However, nearly 40% of women with
hyperlipidemia consider themselves at no to
little risk of CVD – an important and
modifiable knowledge gap

15. Future Directions
As a result of the Go Red For Women campaign,
many studies investigated CVD awareness/
knowledge only in women
Direct comparison to the experiences of men still
needed/warranted
MENU study conducted in mid 2000’s, at time
Go Red For Women campaign was starting
A more contemporaneous study may reveal a
dwindling gap between risk factor presence and
perceived risk of disease

16. Collaborating Sites
Group Health Cooperative: Jennifer McClure, PhD
Seattle Julie Richards, Paula Sandler
Roy Pardee
HealthPartners: Cheri Rolnick, PhD
Minneapolis Mary Kelley, MPH, Ann Hanson
HFHS/HAP: Christine Cole Johnson, PhD, Gwen Alexander, PhD
Detroit George Divine, PhD, Nancy Oje-Tebbe
Sarah Claud, MPH, Heidi Kromrei,MA
Rick Krajenta, Noel Maddy
KP Colorado: Deb Ritzwoller, PhD, Anna Sukhanova
Denver Melanie Stopponi, MPA, Nikki Carroll
KP Georgia: Dennis Tolsma, MPH
Atlalnta Jody Calvi, MPH
U Michigan Center for
Health Communications*: Vic Strecher, PhD
Ed Saunders, Carola Carlier
Janine Konkel, Mike Nowak
Consultants: Mick Couper (UM Inst Soc Research)
Marci Campbell, PhD, UNC
Ken Resnicow, PhD, U Michigan
Jerianne Heimendinger, PhD, RD
Fran Thompson, PhD, RD
Tom Hurley, PhD
*Plus project team members, pilot testers and UM HMRL staff