Elsevier

Women's Health Issues

Volume 13, Issue 4, July–August 2003, Pages 167-174
Women's Health Issues

Article
Cardiovascular disease risk in lesbian women

https://doi.org/10.1016/S1049-3867(03)00041-0Get rights and content

Abstract

Lesbians may be a higher risk subpopulation of women for cardiovascular disease due to the prevalence of risk factors and attitudes about weight. In a survey of 648 women, we compared various cardiovascular risk factors between 324 lesbians age 40 and older residing in California and their heterosexual sisters closest in age. Compared with their sisters, the lesbians had a significantly higher body mass index, waist circumference, and waist-to-hip ratio (WHR). The lesbians were also more likely to have ever smoked, but were as likely as their sisters to be current smokers. They were significantly less likely to have eaten red meat in the past year, but did not differ significantly from their sisters on the other nutritional variables. They were more likely, however, to report a history of weight cycling. With regard to exercise, the lesbians were significantly more likely to exercise at least weekly. Yet the two groups did not differ in the number of times per week exercised, the length of the exercise session, nor the exercise vigor.

This is the first study to report waist circumference measurements and WHR for lesbians. Our findings suggest that lesbians, as a group, may have greater abdominal/visceral adiposity and, thus, a metabolic profile placing them at higher risk for cardiovascular disease. Future studies of cardiovascular risk in lesbians should measure low-density lipoprotein, C-reactive protein, and identifiers of the metabolic syndrome, namely blood pressure, triglyceride and high-density lipoprotein levels, and fasting glucose. Interventions designed to reduce abdominal/visceral adiposity in lesbians should also be examined in future studies.

Introduction

Although male gender is associated with a higher risk for cardiovascular disease, women also suffer greatly from this disease. Approximately 50% of women in the U.S. die from a cardiovascular condition.1 The diagnosis is often more difficult in women2 and the risk profile differs somewhat from men.3 Most women remain unaware of the extent of the problem and their individual risk. To address this lack of awareness, the National Heart, Lung, and Blood Institute (NHLBI) has mounted a national campaign entitled “The Women's Heart Health Initiative” to inform women about their risk for cardiovascular disease.4

The traditional risk factors for cardiovascular disease are: male gender (until age 60), increasing age (≥55 for females and ≥45 for males), family history of early cardiovascular disease (before age 65 for first-degree female relative and 55 for male relative), hypertension, cigarette smoking, sedentary lifestyle, dyslipidemia (especially elevated low-density lipoprotein [LDL]), obesity, and diabetes.5 Besides these traditional risk factors, recent attention is being paid to metabolic and inflammatory markers predictive of subsequent cardiovascular disease. The metabolic syndrome, characterized by atherogenic dyslipidemia, prothrombotic state, insulin resistance, hypertension, and abdominal obesity,6 enhances the risk of cardiovascular disease beyond that conferred by elevated LDL.7 Insulin resistance due to excess body weight appears to be responsible for the genesis of the metabolic syndrome.8 Elevated C-reactive protein (CRP), a marker of systemic inflammation, also predicts subsequent cardiovascular disease. Again, overweight and obese individuals have been found to have higher CRP levels.9

The role of metabolic factors in cardiovascular disease has been of interest for some time due to the observation that diabetes is a risk factor for cardiovascular disease, especially in women. Also, a high triglyceride level is often a better serum marker of atherogenic dyslipidemia than high LDL in women age 50–69 and women with type 2 diabetes. Of particular concern to women is the fact that these metabolic and inflammatory variables may be more pronounced in the presence of estrogen. Estrogen is associated with increased fibrinogen (thrombus formation) and increased CRP (inflammation).3 Not all women, however, share the same risk for cardiovascular disease. Health disparities exist, resulting in a higher risk among minority women. For example, heart disease mortality is approximately 31% higher in black women than in white women. The prevalence of stroke is also higher among black than white women. It is believed that higher rates of hypertension, lack of physical activity, and obesity play a role in this difference. Metabolic risk factors, such as insulin resistance and abdominal/visceral adiposity, are currently being studied by NHLBI in black and Hispanic families where the prevalence is so high. Also, the NHLBI has committed to a strategic plan that seeks to “identify the needs of minority target audiences who are at greater risk for cardiovascular disease”.10

One subpopulation of women not specifically named in the NHLBI strategic plan, yet possibly at higher risk for cardiovascular disease, is lesbians. In 1999, the Institute of Medicine issued a report calling for further research into the prevalence of risk factors for cardiovascular disease among lesbians, as well as for population-based studies to determine the incidence of cardiovascular disease.11 Published surveys suggest that certain cardiovascular risk factors may be more prevalent in lesbians than in the general population.5

More recent publications in the field of lesbian health further illuminate this concern, especially with regard to the cardiovascular risk factors of excess weight, cigarette smoking, and poor nutritional habits. A recently published meta-analysis of seven large surveys revealed higher rates of cigarette smoking and excess body weight among lesbians.12 Data from the Women's Health Initiative (WHI) study also suggest that there may be dietary differences between lesbian and heterosexual women that would place lesbians at higher risk.13

With regard to weight in lesbians, two issues are emerging. One is that studies have consistently shown lesbians to have a higher body mass index (BMI) when compared with the national averages for women.12, 14, 15 and when compared with heterosexual women.13, 16, 17, 18 The higher BMI observed in lesbians has not yet been reported along with body composition measurements. Hence, it is unknown whether this increased BMI reflects increased lean body mass or adiposity. Reporting waist circumference and waist-to-hip ratio (WHR) measurements, both clinical markers of abdominal/visceral adiposity, would be helpful. Indeed, increased adiposity, or more specifically increased abdominal/visceral adiposity, would be of concern with regard to health risk.19 The second issue regarding weight in lesbians is that previous studies have shown lesbians to be less concerned about weight issues than heterosexual women.20, 21, 22 They are also less likely to perceive themselves as overweight when they in fact are.12 If lesbians do turn out to be at higher risk for cardiovascular disease due to higher visceral adiposity, then their relative lack of concern about weight issues could form a possible barrier to intervention. To further test the hypothesis that lesbians are at higher risk for cardiovascular disease, we compared them to their heterosexual sisters on the following variables: body measurements, cigarette smoking, nutrition, dieting, and exercise.

Section snippets

Design

The design for this study was a matched (lesbian with heterosexual sister) cross-sectional mail-back anonymous survey. Previous work on lesbians' sisters makes them a well-defined, appropriate control group.18

Sample and setting

In the study, we distributed the surveys to English-speaking women, who identified themselves as lesbians age 40 and older throughout the state of California. A combination of adaptive sampling techniques was used to identify the lesbians, but essentially this was a large convenience

Sample characteristics

Lesbians and their heterosexual sisters differed significantly with regard to age, education, full-time employment, personal income, living alone, and geographic area. The lesbians were slightly older (49.7 years vs. 48.9 years, p < .01), more educated (17.5 years vs. 15.4 years, p < .001), and more likely to be employed full-time (70% vs. 56%, p < .001). As such, their personal income was significantly higher (p < .001). Although most participants resided with others, the lesbians were more

Body measurements

This is the first study to report waist circumference measurements and WHR for lesbians. In our study, these measurements were significantly higher for the lesbians when compared with their heterosexual sisters. As previously noted, waist circumference and WHR are independent risk factors for coronary heart disease in women.19 The average value for waist circumference for the lesbians was 34.2 inches, near, but not above, the 35-inch cutoff point associated with an increase in cardiovascular

Acknowledgements

We would like to thank all the participants who took time to complete the surveys. This research would not be possible without them. We also had the assistance of a number of wonderful research assistants including: Katherine Culberg, RN; H. Rachel Davids, MD; Stacey Hopper, RN, MS, ANP; Toni King, RN, BS; Melissa Moffat, BA; Desi Owens, MS, MSW; Maria Pedrosa, BS; Erin Rowley, BA; Beatrice Sanchez, MPH; and Farley Urmston, BA. The funding for this study was from the California Breast Cancer

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