AHA Forecast: CV Risk Factors in Women, Girls Headed in Wrong Direction

The number of women in the United States living with cardiovascular disease is expected to rise over the next 25 years, with multiple modifiable risk factors also threatening the health of girls in their teens and younger, according to a forecast of CVD and stroke trends from the American Heart Association (AHA).

Without interventions to turn things around, hypertension, diabetes, and obesity rates all will likely increase, along with the prevalences of CVD, coronary heart disease , heart failure, stroke, and atrial fibrillation, the scientific statement, published last week in Circulation, suggests.

Speaking with TCTMD, committee chair Karen E. Joynt Maddox, MD, MPH (Washington University School of Medicine, St. Louis, MO), said the goal was to take “a 30,000-foot view” of where things are headed and where there are opportunities to make changes by using historical trends from the National Health and Nutrition Examination Survey, the 2015 to 2019 Medical Expenditure Panel Survey, and census estimates.

“Unfortunately, a lot of the trends that we’ve seen over the past decade we are projecting will continue over the next 30 years, unless of course we do something different about it,” she said.

The forecast focused on how disease prevalence might change based on expected shifts in suboptimal levels of the elements comprising the AHA’s Life’s Essential 8: diet quality, sleep quality, physical activity, exposure to cigarette smoking, body mass index, levels of fasting blood glucose, total cholesterol, and blood pressure. It also included the composite of total CVD.

Risk factors among women estimated to increase between 2020 and 2050 include:

• Hypertension (48.6% to 59.1%)
• Diabetes (14.9% to 25.3%)
• Obesity (43.9% to 61.2%)

Women of color are expected to see even greater increases, with projections suggesting that Hispanic women will see the most increase in hypertension while Asian women will see the greatest rise in obesity.

For all CVD risk factors, Black women will continue to have the highest prevalence rates, with hypertension and obesity each impacting more than 70% of the population, and diabetes affecting more than one in four.

Unfortunately, a lot of the trends that we’ve seen over the past decade we are projecting will continue over the next 30 years, unless of course we do something different about it. Karen E. Joynt Maddox

For all women, the prevalence of coronary disease is projected to increase from 6.85% to 8.21%, heart failure from 2.45% to 3.60%, stroke from 4.14% to 6.74%, atrial fibrillation from 1.58% to 2.31%, and total cardiovascular disease and stroke from 10.7% to 14.4%.

Among girls ages 2 to 19 years, obesity is expected to increase by more than 12% by 2050, meaning that nearly 32% of that population will be affected. According to the committee, inadequate physical activity and poor diet are the largest contributors. Poor diet prevalence was highest overall in women between the ages of 20 and 44, but those women also had the lowest prevalence of inadequate physical activity compared with other groups. Women age 80 and over had the greatest prevalence of poor sleep, but the lowest prevalence of smoking.

Girls of color will experience greater increases in risk factors similar to those of women of color, with Black girls expected to have the highest prevalence of hypertension and diabetes and Hispanic girls expected to have the greatest prevalence of obesity.

Changing the Projections

Big changes will be needed to get risk factors for women and girls on the right track, but revamping the food ecosystem and working toward control of blood pressure are probably the two biggest things that could be done to alter the committee’s projections, Joynt Maddox said.

“While it seems simple to say that we should all eat better and move more, that turns out to be incredibly hard to do and isn’t just about individual choice,” she added.

Even when parents and caregivers are careful about children’s diets at home, aggressive marketing of fast food and sugary foods and drinks to children can make it difficult to maintain healthy choices when at school or out with friends.

“We don’t do a very good job about controlling high blood pressure,” Joynt Maddox noted. “That’s another place where it sounds so simple, but in reality that requires a pretty different approach to thinking about: what’s someone’s blood pressure at home? What is it in the office? What would be the right next step? Can I empower patients to understand what medications they’re on? Can I choose the one with the fewest side effects? It becomes much more complicated when you actually try to do it.”

The projections suggest that while suboptimal diet, inadequate physical activity, and current smoking all will improve somewhat over time, inadequate sleep will worsen. The committee says it will be important to identify and address environmental and physiological drivers of worsening sleep trends in women such as screen time, stress, and hormonal changes.

One risk factor expected to decrease is cholesterol, which the projections show in decline across age, race, and ethnicity. This trend, they say, has been demonstrated in multiple prior studies and may be explained by increased screening for hypercholesterolemia and a shift toward risk-based approaches instead of targeting specific lipid levels.

“Despite these declines, ongoing attention should be paid to ensuring that women are equitably treated with statins and other lipid-lowering therapies, particularly because treatment benefits women and men to a similar degree,” Joynt Maddox and colleagues write. “Furthermore, the decline in hypercholesterolemia in concert with a rise in obesity, other CVD risk factors, and CVD overall may relate to a shift in American diets toward highly processed, high-sugar foods and suggests a need for more attention in this area.”

The document also focuses on the reproductive lifespan with an eye toward getting a better handle on the projected rise in adverse health behaviors and factors in younger women, as well as those in menopause and beyond. Reversing the trends of CVD in women, the committee says, “would positively affect families, the workplace, and society as a whole.”

It Can Be Done

To TCTMD, Joynt Maddox said while the scope may seem overwhelming, opportunities for change that are most effective are ones that help patients feel empowered to help themselves rather than telling them they are doing things wrong.

In a prior forecast, Joynt Maddox and others noted that simulation studies suggest that just a 10% reduction in the prevalence of hypertension, hypercholesterolemia, diabetes, and obesity could cut rates of incident CVD and stroke events, including death, by 17% to 23%.

“People are smart and thoughtful, and generally when engaged in a person-to-person relationship [they can] sit down and say with a clinician, ‘What changes could I make to make myself a little healthier?’ That feels much more achievable than taking it all on at once,” she said. “So, it’s about recognizing that small changes can make a big difference.”