Healthy Behaviors Linked to Lower Risk of Subclinical Atherosclerosis in Middle-aged Women

Middle-aged women who don’t smoke and have a healthy diet and physical activity habits have a lower prevalence of subclinical atherosclerosis, according to new research.

“This work highlights the growing recognition that the midlife is a critical window for cardiovascular disease prevention and strongly supports the need for lifestyle interventions aimed at promoting these modifiable health behaviors in midlife women,” lead author Dongqing Wang, MPH, and senior author Ana Baylin, MD, DrPH (both from University of Michigan School of Public Health, Ann Arbor), told TCTMD in an email. “We believe that the importance of a healthy lifestyle cannot be overstated, especially for midlife women undergoing the menopausal transition.”

For their study, published this week in the Journal of the American Heart Association, the researchers used self-reported data on smoking, diet, and physical activity from 1,143 women aged 42-52 years in the Study of Women’s Health Across the Nation to develop a six-point Healthy Lifestyle Score (HLS).

Average HLS over 10 years was inversely associated with common carotid artery (CCA) intima-media thickness as well as CCA adventitial diameter (P < 0.01 for both). Specifically, compared with those with the lowest scores (0-2), those with the highest scores (4-6) had a 0.024-mm smaller CCA intima-media thickness and a 0.16-mm smaller CCA adventitial diameter. Lower HLS was also linked to more carotid plaque in adjusted models (P = 0.024), but this was not maintained after adjusting for physiological risk factors.

Smoking had the strongest effect on all three measures of subclinical carotid atherosclerosis (P < 0.01 for trend for all). Compared with those who smoked at some point during follow-up, nonsmokers had a 0.047-mm smaller CCA intima-media thickness, a 0.24-mm smaller CCA adventitial diameter, and a 49% lower risk of having a higher carotid plaque index.

“We were surprised by the finding that the vast majority of women at this life stage did not have the healthiest possible lifestyle available to them, which again highlights the need for active lifestyle intervention in this group,” Wang and Baylin said.

Additionally, the “relatively weak” links that unhealthy diet and physical activity habits had to subclinical atherosclerosis in comparison to smoking were unexpected. “Because smoking is measured more accurately than diet and exercise, [it’s possible that] the associations for diet and exercise are somewhat attenuated,” the authors suggest. “When exposures are measured with a lot of error, which is the case for diet and exercise, the associations are always attenuated. That still does not account for the fact that smoking is probably a stronger risk factor than diet and exercise, but can explain why the associations between diet and exercise do not look larger.”

Nevertheless, Wang and Baylin urged clinicians to “emphasize to their midlife female patients the importance of improving overall lifestyle (including abstinence from smoking, eating a healthy diet, and engaging in regular physical activity), even if their patients are apparently healthy without clinically diagnosed cardiovascular disease.”

They called for prospective studies that follow middle aged women for decades. “From [these] type of studies, we can further investigate how specific health behaviors during the menopausal transition could impact cardiometabolic outcomes in the future,” Wang and Baylin said, noting that targets like dietary patterns, beverage intake, sleep hygiene, and stress management are good targets for exploration.