Female & fit for life.

True or false:

1. Coronary heart disease kills ten times more middle-aged women than breast cancer.

2. Fatigue, nausea, or dizziness can be warning signs of a heart attack.

3. A woman aged 45 or older should have her blood sugar tested every five years.

May 9 is not just Mother's Day. It's also the beginning of National Women's Health Week. Yet most women still don't know all they should about protecting their health. Here's a rundown of the latest research on foods, vitamins, exercise, and more.

How'd you do on our mini-quiz?

1. False. Women shouldn't underestimate their risk of heart disease. But coronary heart disease kills ten times more women than breast cancer only if you look at women aged 75 or older (see "Heart Disease vs. Breast Cancer," p. 5).

2. True. In a 1997 survey, 90 percent of women didn't know these less common signs of a heart attack.

3. False. Experts recommend that women get their blood sugar tested at least every three years (see "What to Check & When," p. 7). Diabetes rates are climbing, but many women don't routinely get blood sugar tests.

To get the latest on women's health, we talked to one of the leading researchers in the field.

Q: What have we learned from the last decade's worth of research on women?

A: We've made a lot of progress in women's health. Life expectancy for women is close to 80 years now. We've seen many treatment advances.

But in the last decade, obesity and sedentary lifestyles have become even greater public health problems. Two-thirds of adult Americans are now overweight or obese. And probably 75 percent of Americans get less than the recommended amount of exercise.

It's been estimated that more than 400,000 deaths per year in the U.S. are attributable to obesity and sedentary lifestyle. And the epidemic of obesity in childhood portends a tremendous burden of disease in the future.

Q: So we're losing ground?

A: Yes, in some areas. People have become complacent about heart disease and stroke because of the dramatic declines in the death rates for both over the last 30 years. But that may change.

We've clearly made progress detecting and treating high cholesterol and high blood pressure and treating cardiovascular disease. But with three risk factors--body weight, physical activity, and diabetes--going in the wrong direction, that progress is being threatened.

Q: So heart disease isn't the only worry?

A: No. We're concerned because diabetes is so closely linked to overweight and a sedentary lifestyle. Diabetes has been called the epidemic of the 21st century. The prevalence has more than doubled over the last 30 years.

And it's not just diabetes, but the burden of illness from diabetes--the eye disease, kidney disease, and nerve damage--and the fact that diabetes greatly increases the risk of heart disease and stroke.

Q: Are women at greater risk than men?

A: Yes. Diabetes is a particular problem for women because cardiovascular events--like heart attack or stroke--are five to seven times more likely in women with diabetes than in women without the disease, but only two to three times more likely in men with diabetes.

About 75 to 80 percent of deaths among people with diabetes are due to cardiovascular disease. Diabetes could become a public health crisis over the next couple of decades.

Q: Do women think that they won't get heart disease?

A: While that's a common misconception, they're not immune. The risk of heart disease in women lags behind that of men by about 10 to 15 years. But heart disease is still the leading cause of death in women.

In fact, heart disease and stroke kill more women each year than men, mostly because women tend to die at older ages, when cardiovascular disease is most prevalent.

Heart Attack & Stroke

Q: What can lower the risk of a heart attack or stroke?

A: Our Nurses' Health Study suggests that more than 80 percent of heart attacks, strokes, and diabetes cases in women could be prevented by simple behavioral changes--not smoking, 30 minutes a day of moderate-intensity exercise, maintaining a healthy weight, and eating a healthy diet. That's a pretty striking statistic.

Q: What kind of healthy diet?

A: We gave the nurses higher diet scores if they consumed more fish, fruits, vegetables, whole grains, and fiber. They also got higher scores if they ate less trans fat and more poly-unsaturated fats, which you get from foods like fish, vegetable oils, salad dressings, and nuts, rather than saturated fats, which come from foods like red meat, butter, cheese, and ice cream.

And the nurses got points if they had a low glycemic load. That means they ate fewer refined carbohydrates that are rapidly digested and absorbed--foods like low-fiber cereals, white bread, white rice, cakes, and cookies. Even white potatoes tend to be rapidly digested and absorbed.

Q: Should people avoid those foods entirely?

A: No. You can eat them in small quantities. But the evidence is mounting that a diet with a high glycemic load increases the risk of heart disease, stroke, high blood pressure, and diabetes. That's probably because it causes a rapid rise in blood sugar, which raises blood insulin levels. It's a particular problem in people who are overweight or who are already insulin resistant.

Q: How do you know if you're insulin resistant?

A: You have at least three of the five risk factors for what we call the metabolic syndrome: abdominal obesity, higher-than-optimal triglycerides, blood pressure, or fasting blood sugar, and low HDL ["good"] cholesterol (see "Insulin Alert").

High triglycerides and low HDL are stronger risk factors for heart disease in women than in men. There's a new recommendation for women to get their HDL above 50. It used to be 45.

Obesity

Q: Do carbohydrates that raise blood sugar cause obesity?

A: There's only limited evidence for that. Most studies suggest only a small correlation between glycemic load and body weight, so I don't think there's a conclusive relationship.

Q: What do you think of the low-carb craze?

A: I think it's an oversimplification. Not all carbs are bad. While refined carbs should be restricted, avoiding whole grains is not going to confer good health. Although an Atkins-type diet may help with short-term weight loss, we have concerns that, in the long term, a very high intake of saturated fat and red meat would be unhealthy.

Q: Might whole grains help women avoid extra pounds?

A: Yes. We recently reported that women who had a higher intake of whole grains--or who increased their intake of whole grains--gained less weight than women who had a very low intake of whole grains. That's plausible because whole grains make people feel full.

Type 2 Diabetes

Q: What's the best way to prevent diabetes?

A: By far, the smartest strategy is to lose excess weight and exercise. That has the greatest impact on your risk.

Q: What else affects risk?

A: Several studies suggest that high magnesium intake may lower the risk of diabetes. But it's hard to know whether it's the magnesium per se or the fruits, vegetables, and whole grains that are higher in magnesium that are linked to a lower risk.

Q: What about iron?

A: We've recently found that higher iron levels and red meat intake may increase the risk of diabetes. That's biologically plausible, because iron can create free radicals and can damage the pancreas, where insulin is produced. Also, the risk of diabetes is high in people with iron overload, a disorder called hemochromatosis.

It's possible that something other than the iron in meat may explain the link with diabetes. But since red meat has been linked to a higher risk of colon cancer, diabetes just adds one more reason to minimize meat intake.

Q: How little do you recommend?

A: No more than one serving of red meat per week would be a reasonable guideline. Also, we recently reported that having at least three cups of coffee per day is linked to a lower risk of diabetes.

Q: Does that mean three "tall" coffees at Starbucks?

A: No. When we say one cup, we mean six ounces. We're talking about 120 to 150 milligrams of caffeine per cup. A 'tall' drink at Starbucks is 12 ounces. A 'venti' is 20 ounces. So our three cups works out to 1 1/2 tall coffees or slightly less than one venti. And we're not talking about Frappuccinos or other high-calorie drinks.

Q: What would explain the link?

A: We don't know. It could be caffeine, which burns extra calories, raises metabolic rate, and is linked to slightly lower body weight. But it's also possible that the magnesium, potassium, and antioxidants in coffee beans may play a role.

Q: Did you find a lower risk with decaf?

A: We found a slight reduction in risk. But tea drinkers also had only a small reduction in risk, so the relationship may be complicated.

Q: Should people drink more coffee to prevent diabetes?

A: It would be premature to recommend that. But if you already drink coffee, there's no need to stop based on diabetes risk. Just keep in mind that five or six cups a day--even less in some people--can increase heart rate, disturb sleep, and may slightly increase blood pressure. And pregnant women should avoid drinking more than one cup a day.

Q: Does coffee prevent Parkinson's disease?

A: A few studies have found a lower risk of Parkinson's with a higher intake of caffeine. While it suggests a direction for future research, we're not advocating that people have a cappuccino to prevent Parkinson's.

Breast Cancer

Q: Does weight gain promote breast cancer?

A: It's a major risk factor. Even a moderate weight gain of 20 to 25 pounds since the age of 18--which is quite common in the U.S.--can increase the risk of breast cancer.

Q: What about alcohol?

A: The evidence has mounted that moderate alcohol intake is linked to a higher risk of breast cancer. Even women who have an average of one drink a day have a slightly increased risk. Two drinks a day has been linked to a nearly 40 percent increase.

Q: What can lower the risk of breast cancer?

A: Exercise and weight control. Overall, studies suggest that moderate-to-vigorous-intensity exercise for 30 to 60 minutes a day can lower the risk of breast cancer by 20 to 30 percent. Exercise may lower the risk of colorectal cancer even more.

Q: What's moderate-to-vigorous?

A: Running would be vigorous. Brisk walking counts as moderate. That means walking a mile in 15 to 20 minutes. We found a 30 to 40 percent lower risk of heart disease, stroke, and diabetes with 30 minutes of brisk walking per day. Those are really major benefits from a level of activity that can be achieved by nearly everyone.

Q: Doesn't the government recommend an hour a day?

A: That's for maintaining a healthy weight. If you were to reduce calorie intake plus exercise moderately for 30 minutes a day, you could achieve similar weight control as you would by exercising for an hour.

Regular physical activity also reduces the risk of osteoporosis, fractures, and gallbladder disease. It's the closest we've come to a magic bullet.

Q: So brisk walking is strenuous enough?

A: Many women don't like very vigorous or sweat-inducing exercise, and now we know that they don't need to run marathons. The notion of 'no pain, no gain' is clearly outdated.

But they shouldn't just walk. Everyone should add at least two episodes a week of strength training for 15 to 20 minutes each. It boosts metabolic rate, increases muscle mass, and improves bone density.

Q: Why do women need more muscle mass?

A: To boost metabolic rate and prevent the gain in fat--or adipose tissue--that occurs with aging. And it's important for women to improve their bone density because they have a greater risk of fracture than men. Women need muscle strength for activities of daily living. And we have some evidence that strength training can improve balance and reduce the risk of falls.

Q: And it's not just more exercise, but less sifting, that matters?

A: Yes. Sedentary behavior--particularly watching TV--is linked to obesity and diabetes. That's independent of the time spent in recreational physical activity. In other words, get up and walk around the office. Stand up or walk around while talking on the phone.

Vitamins, etc.

Q: Should women take vitamins?

A: The only supplements I recommend to my patients at this time are a multivitamin plus calcium and vitamin D to prevent osteoporosis. The Women's Health Initiative is testing whether calcium and vitamin D can lower the risk of fractures and colorectal cancer. So we'll have conclusive answers within a year and a half.

In the meantime, postmenopausal women should get between 1,000 and 1,500 milligrams of calcium a day in their food or, if that's not possible, in a supplement. A multivitamin is also a good investment in health, especially if you have concerns about having a balanced diet.

Q: What about antioxidants?

A: Several trials, including our WACS--Women's Ant ioxidant Cardiovascular Study--are still under way. WACS is testing vitamin E, vitamin C, beta-carotene, and folic acid in women at high risk for heart disease. But I recommend avoiding megadoses of any vitamins or minerals.

Overall, the research on antioxidants has been disappointing. Taking megadoses of vitamins E and C and betacarotene hasn't conferred clear benefits. And taking megadoses of an isolated carotenoid like beta-carotene may even increase cancer risk, perhaps by reducing the availability of other carotenoids.

Q: Do we now know that postmenopausal estrogen doesn't protect the heart?

A: That's right. And it may raise the risk of stroke, memory loss, and breast cancer. Postmenopausal estrogen or combination estrogen and progestin can still be used in the short-term treatment of hot flashes and menopausal symptoms. But hormones shouldn't be used long term to prevent chronic disease.

Q: Should most women take aspirin?

A: At this point, we don't routinely recommend aspirin for women at low risk of heart disease because we don't know if the benefits outweigh the risk of gastrointestinal bleeding and even hemorrhagic stroke. Results from the Women's Health Study--a trial testing low-dose aspirin and vitamin E in low-risk women--should be available within a year, so stay tuned.

Q: What if you are at high risk of heart disease?

A: The evidence is very strong that aspirin is beneficial if you're at high risk or if you've had a heart attack, stroke, angina, angioplasty, bypass, or a diagnosis of heart disease. Aspirin is also recommended for women with diabetes if they have at least one other heart disease risk factor, which is true for most women with diabetes.

Q: Do cholesterol-lowering statins like Lipitor work in women?

A: There's been increasing evidence that statins reduce the risk of both heart disease and stroke in women as well as in men. Certainly any woman with a history of heart disease--regardless of her cholesterol level--and even a woman who has moderately elevated cholesterol and other risk factors--should talk to her doctor about taking statins.

Q: Should all women have a blood test for C-reactive protein (CRP)?

A: Not quite yet. CRP is a measure of low-level inflammation. It and other novel markers for heart disease may help us identify high-risk individuals. But it will take a few years before we know which people will benefit the most from these tests. In the meantime, women can ask their doctors if it makes sense to get tested.

Heart Disease vs. Breast Cancer

"One in three American women dies of heart disease, making it the #1 killer," says the National Heart, Lung, and Blood Institute. "That's the Heart Truth."

Women are more likely to die of heart disease than anything else, and most women should do more to protect their hearts. But when graphs like the one above suggest that women are nine times more likely to die of heart disease than breast cancer, they're not quite telling the whole truth. In fact:

* When you look at deaths from coronary heart disease (that's the kind that people can prevent by lowering their cholesterol, blood pressure, etc.), a woman's lifetime risk drops to six times higher than her risk of dying of breast cancer, not nine times.

* For women under age 55, breast cancer deaths are slightly more common than heart disease deaths. And from ages 55 to 74, heart disease deaths are two to four times higher than breast cancer deaths. Only once women pass age 75 do heart disease deaths dwarf breast cancer deaths by a factor of ten to one.

Insulin Alert

If you have any three of these five risk factors, you probably have the
metabolic syndrome (also known as insulin resistance), which raises
your risk of heart disease and diabetes. The underlying cause: too much
weight and too little exercise.

1. Abdominal Obesity              Women:   more than 35-inch waist
                                  Men:     more than 40-inch waist *

2. Triglycerides (mg/dL)          150 or higher

3. HDL cholesterol (mg/dL)        Women:   under 50
                                  Men:     under 40

4. Blood pressure (mm Hg)         systolic:    130 or higher or
                                  diastolic:   85 or higher

5. Fasting  blood sugar (mg/dL)   110 or higher **

* For some men, a 37- to 39-inch waist can be a risk factor.

** Recent recommendations classsify a fasting blood sugar of 100 to 125
mg/dL as "pre-diabetes."

Source: National Heart, Lung, and Blood Institute.

What to Check & When

Are you missing some key screening tests? Here's a checklist for women
who are at average risk. Anyone at high risk may need tests more freq
uently or at a younger age.

                                     Get Tested
To Protect Your   Get A              Every           Optimal Is

Heart & Brain     Blood pressure     1-2 years       Under 120/80
                  reading

Heart             Cholesterol test   5 years         LDL: under 100
                  (fasting):                         HDL: 60 or higher
                  LDL, HDL, and                      Triglycerides:
                  triglycerides                      under 150

Bones             Bone density       At age 65       Higher than -1 SD
                  measurement

Blood sugar       Blood sugar test   3 years, if     Under 100 mg/dL
                  (fasting)          45+

Breast            Mammogram          1-2 years, if
                                     40+

Cervix            Pap smear &        1-3 years
                  pelvic exam
Colon             A. Fecal occult    1 Year, if
                  blood test         50+
                  and
                  flexible           5 years, if
                  sigmoidoscopy      50+
                  or
                  B. Colonoscopy     10 years, if
                  or                 50+
                  C. Double-         5 years, if
                  contrast barium    50+
                  enema

Thyroid           TSH test           5 years, if     0.2 to 4.7
                                     35+             mcU/mL

Eyes & Ears       Eye and hearing    2-4 years, if
                  exam               40-64
                                     1-2 years, if
                                     65+

Skin              Mole exam          1-3 years if
                                     20-39
                                     1 year, if
                                     40+

Teeth             Dental exam        1-2 per year

Source: Adapted from the American Cancer Society and
www.4woman.gov/screeningcharts/screenings-general.pdf.

JoAnn Manson MD, is Chief of Preventive Medicine at Boston's Brigham and Women's Hospital, professor of medicine at Harvard Medical School, and professor of epidemiology at the Harvard School of Public Health. She is the co-author of The 30-Minute Fitness Solution: A Four Step Plan for Women of All Ages (Harvard University Press, 2001). Manson spoke with Nutrition Action Healthletter's Bonnie Liebman by telephone.