Women are Underrepresented in Research. Why Should You Care?

As a woman, you have unique health needs and experiences that can differ from those of men. If women are underrepresented in research studies, the results may not accurately reflect their health outcomes or address their health concerns. This could lead to inaccurate diagnoses, ineffective treatments, and missed opportunities for preventative care.

Women comprise half of the population, and their voices and experiences should be equally represented in research studies. It is a matter of fairness and equity that women have the same opportunities as men to participate in research that impacts their health and well-being.

Research is critical for advancing our understanding of diseases, treatments, and health outcomes. Our knowledge in these areas may be limited if women are underrepresented in research studies. This can slow down progress in medical advancements and result in missed opportunities for discoveries and breakthroughs that could benefit everyone.

It’s our mission at Rumblings to ensure you have the science-based facts and education you need to understand what can impact your health so that you can take informed actions. We feel it is crucial for all women to care about underrepresentation in research because it can directly impact our health and well-being.

So this month, we interviewed women’s health expert and assistant professor at the University of Minnesota, Manda Keller Ross, Ph.D., DPT. Dr. Keller Ross shares her research background and interest in women's health in this interview. She discusses the gender gap in research, particularly in heart disease risk in women, which has been historically studied more in men. She focuses on studying the influence of menopause symptoms on blood pressure regulation and heart disease risk in women. Additionally, she highlights the barriers women face when participating in research and the importance of addressing the diversity in experiences and physiology among women. Lastly, she emphasizes the need for more women to participate in research to improve preventative strategies and treatments for women.

Rumblings Interview with Dr. Keller Ross.

Can you tell us a little bit about yourself, your background, and how you became interested in the research that you’re currently doing?

I am a mother of three young girls (8, 7, and 5 yrs), a scientist, and an educator. I have been studying blood pressure regulation and heart disease risk for about 10 years. In the last seven years, our laboratory has transitioned to studying primarily women’s health due to the dearth of information regarding heart disease risk in women and, in particular, how age and menopause influence this risk. The majority of the research in the area of heart disease has primarily been on men, and women have been traditionally underrepresented in medicine and science, particularly women with a non-white racial and ethnic background. This also means we have less available information regarding safe and effective therapies for women who are at risk for or have already developed heart disease. Our laboratory hopes to close this knowledge gap and be able to better understand some of the early risk factors of heart disease for women to identify effective preventative and therapeutic strategies to reduce heart disease risk for women.

We know that there are many age-related changes that women go through that increase their health risk, but is there a particular reason why you decided to focus on research related to menopause?

From what the literature suggests, prior to menopause, men have a greater prevalence of high blood pressure and increased heart disease risk compared with women. After the typical age of menopause, around 50-51 years, this risk increases substantially in women and surpasses that of men. This means that there is something in particular about the loss of sex hormones (estrogens and progesterone) in women that contributes to this greater risk. There is also evidence that menopause symptoms can be associated with heart disease, particularly hot flashes, night sweats, and difficulty sleeping. Our lab focuses on the influence of these symptoms and how the age of menopause influences blood pressure regulation to contribute to these greater risks.

Why is research on women’s health so important?

Women are important and have traditionally been ignored in research and science. For example, women participate in clinical trials much less than men for many reasons; however, this means that many drug trials are conducted only in men, but these same medications are given to women. Much of what we know about physiology was determined in men. Now we are playing catch-up to understand women’s physiology. It’s frustrating, but we are trying to be part of the solution.

What are the barriers for women to participate in research?

Women often carry several responsibilities simultaneously, and participating in research is not often at the top of their priority list. Women are working; they may be primary caretakers and are often not able to get the time off, cannot afford to take the time off, or need to be with their children. We have opened up our laboratory on the weekends for studies to help reduce this barrier, but often childcare is an issue. We have tried to set up childcare at the University for parents, but we have not been successful as there are some liabilities with this process. In addition, there is a lack of information provided to people in general about research and clinical trials, and information about menopause is often not shared with women unless women inquire directly with their physicians. There are often additional barriers for people of color, particularly the African American community, who have been traditionally exploited in research, and as scientists, we need to do a better job of connecting with their communities and building strong relationships and trust before engaging them in research.

Are there certain subsegments of women where we particularly need more research information, and why is that necessary? Can’t we generalize women’s research to all women?

Yes, there are definitely subsegments of women that we particularly need additional knowledge on regarding their health and strategies for disease prevention and treatment. We cannot generalize across subpopulations of women because life experiences have a strong impact on our physiology. One of the strongest examples that I can provide is racial stress. Non-white communities have experienced macro- and micro-aggressions for centuries, and we haven’t even really begun to understand how that has impacted their physiology. We know diverse communities are often at a greater risk for high blood pressure, heart disease, and kidney disease, just to mention a few, but we don’t have a clear understanding of why. These factors are often erroneously discussed in the literature as being connected to genetic or physiological differences, but we, as scientists, need to incorporate how life experiences, such as the trauma and stress surrounding racial discrimination, influence risk factors for these diseases.

Why is it important for women to participate in research studies from a researcher's perspective? What benefits can women experience by participating in research?

The majority of the knowledge we have obtained from the research, including clinical trials, drug trials, etc., has come from studies conducted in mostly men, in particular white men. This knowledge gets generalized to the community when it doesn’t always apply to women. Over the last 20 years, we have identified many breakthroughs in how the physiology of men and women are different. Sex hormones, including estrogen, progesterone, and testosterone, influence our muscles, heart, lungs, and blood vessels differently, and men and women have varying levels of these hormones. Thus, it is important for women to participate in research so that we can delineate differences in physiology between men and women, which will lead to improved preventative strategies and treatments for women.

Another important benefit of women participating in research is that they would contribute their experiences to the depth and breadth of knowledge on women. This knowledge will lead to better treatments for them, their daughters, and generations to come. If women do not participate in research, we can’t make strides in understanding risk factors that are specific to women and develop tailored treatments to prevent/reduce heart disease risk in women.

How can women learn about research studies they may be eligible to participate in?

• There are national websites that women can browse for research studies, such as clinicaltrials.gov

• Women can learn about studies at the University of Minnesota’s StudyFinder website: studyfinder.umn.edu

• Women can learn more about our lab and studies occurring in our lab by visiting: https://med.umn.edu/rehabmedicine/research/labs/cardiovascular-rehabilitation-lab.

What questions should women ask before participating in a study?

• What is the purpose of the study?

• What procedures are involved in the study?

• What are the risks of the study?

• How long does the study last, how many visits are there, and how long is each visit?

• Is there compensation for being a part of the study?

What should we do to advocate for getting more women involved in research?

We should educate women on what we know and do not know about women’s health and the consequences of that lack of knowledge. In addition, we should build relationships with the community and discuss the importance of their participation in research.

What is your hope for the future if we could close the gap in women’s health research?

My hope for the future is that we significantly reduce the risk of high blood pressure, heart disease, and mortality in women; that women know their risks and how to reduce their modifiable risk factors for these diseases; that women feel there is a space and place for them in research and clinical trials; and that women feel comfortable enough to talk to their family, friends and health care providers about menopause and advocate for themselves.

Thank you to Dr. Keller-Ross for taking the time to highlight the progress made in recent years to include more women in medical research and acknowledging that there is still a way to go to ensure equal representation in research. As moms, daughters, sisters, and friends, we need to spread the word and advocate for women to be included in research studies and to raise awareness of the importance of why our representation matters to our health and health care.

Learn more about Dr. Keller-Ross, The Cardiovascular and Rehabilitation Lab, and The effects of menopause on cardiovascular health in women study by clicking the links.

What Women Can Do to Care for Heart Health After 50

Turning 50 is a wake-up call for many of us.

During our 30s and 40s, we may not have prioritized our health while raising kids and building careers. The good news is it’s not too late.  

It’s our mission at Rumblings to ensure you have the science-based facts and education you need to understand your health risks and be your own best health advocate while also providing you with tools to put knowledge into action.  

This month, we’re focusing on heart health—the number one killer of women.

After menopause, heart disease risk in women increases, yet, only 56 percent of women identify cardiovascular disease as the most significant health problem facing them today.

Preventive cardiologist Dr. Courtney Jordan Baechler*, spoke to a group of Rumblings women about heart health, prevention, treatment, and what midlife women can do to improve overall health.

Not all of you could attend the in-person event, so we took what we learned and provided additional information to ensure you have the facts, resources, and tools to live well, flourish, and take great care of your heart as you age. The information below summarizes our 60-minute discussion. It is not a comprehensive list of everything you can do as it only covers the conversation and questions asked during the evening.

No matter where you’re at in your health journey, there is never a more critical time to take care of yourself.

Understand that current heart health recommendations for prevention and treatment are based primarily on men's research. 

It wasn’t until 1993 that women were mandated to be included in medical research reversing a restriction since 1977 that prevented women of childbearing potential from participating in clinical research. It created a two-decade gap in new medical knowledge on women. Women, as a result, may be misdiagnosed and mistreated more often than men, partly because scientists know far less about the female body.

Today women still only represent about 25 to 35 percent of subjects in clinical trials. We have a long way to go to ensure women are equally represented in research and that the knowledge used to create prevention and treatment recommendations represent us. This is critical to understand so you can have conversations with your medical providers and advocate for your health.

Today's underlying assumption in medical research is that not every trial will have 50 percent women subjects. We need to expect that women are 50 percent of all National Institutes of Health (NIH) funded trials. If not, we need to understand why participating doesn’t work for women and work to solve this systemic issue. Health care has been traditionally designed for families with a stay-at-home spouse with well-covered insurance, and that doesn’t work for most US families today.  

We need all women to advocate for greater inclusivity of women in medical research, as research informs the care women receive.

What can you do?

• Arm yourself with knowledge. Watch Ms. Diagnosed — an award-winning film following the stories of real women whose lives and families have been disastrously affected by this basic inequity in medical care that women receive.

• Stay up-to-date on women’s research. Read patient stories and sign-up for electronic communications from trusted research institutions like the Penny Anderson’s Cardiovascular Center at the Minneapolis Heart Institute Foundation, where Dr. Jordan Baechler works.    

•  Support research with women through financial contributions as you’re able.

Know your heart disease risk.

After menopause women’s risk for developing heart disease is similar to men's risk. The most significant risk factor for developing heart disease is age.

As we age, several risk factors to monitor and discuss regularly with your care provider include:

• High blood pressure which has no symptoms, and many people don’t know they have it, can lead to heart disease and stroke. 

• Being overweight or having obesity raises your risk of heart disease. Women often complain about weight gain during and after menopause.

• Arrhythmias, like atrial fibrillation, are fluttering feelings in your chest (palpitations).

• High cholesterol increases with age. Cholesterol is a waxy, fat-like substance made by the liver or found in certain foods. Your liver makes enough cholesterol to meet your body’s needs, but we may eat foods that increase cholesterol in our blood.

• High LDL (low-density lipoprotein) cholesterol is considered the “bad” cholesterol because it can cause plaque buildup in your arteries, reducing blood flow to the heart.

• Having diabetes causes sugar to build up in the blood. The risk for heart disease for adults with diabetes is higher than for adults without diabetes.

• Eating a poor diet.

• Physical inactivity.

• Drinking too much alcohol.

• Using tobacco. No amount is considered healthy. 

It’s imperative you know your risk and what to do about it.

What can you do?

• Know your blood pressure. Have it checked regularly. Ask for your numbers and understand the levels healthy for you.  Keep track of them or get a blood pressure monitor to check it yourself between visits to your doctor.  

• Calculate your BMI ( body mass index), which is a measure of fat based on height and weight. It’s a measurement used to calculate risk. However, it’s not a perfect measurement because it does not consider muscle mass, bone density, overall body composition, and racial and sex differences. If your BMI is outside the normal weight range, talk to your health care provider to determine if you should be concerned.  

• Use a risk calculator to determine your risk and talk to your medical provider or other health professionals about managing your risk.

Be aware of signs and symptoms of a heart attack that may differ from the symptoms men experience.  

A heart attack may not feel the same in women as in men. Dr. Jordan Baechler stated women might experience an overwhelming sense of depression, nausea, shoulder pain, teeth pain, anxiety, or jaw pain. However, the most common symptoms are similar to what men experience: chest pressure, tight chest, neck or jaw pain, feeling like an elephant sitting on the chest, or numbness, usually on the left side. The critical thing to realize is that whatever you’re experiencing if it is significantly disproportionate to anything you’ve ever experienced before, you need to get evaluated.

What can you do?

• Familiarize yourself with the common symptoms of a heart attack.

Talk to your primary care physician to ensure close attention is paid to your heart health as you get older.

You are an equal partner with your primary care providers. Make sure you know everything they are doing to manage your overall health and health risks.  Ask questions about tests and procedures to ensure you understand what they’re for, what you’ll learn from them, and how the outcomes will inform future recommendations and care.

What can you do?

• Restate! If you feel you are not getting the answers you deserve or feel dismissed, the best thing you can do is restate what your providers are saying back to them. Doing so may stop bias or dismissiveness from happening. For example, say, ”So you’re confident I am not having a heart attack or blood clot or (insert any symptom).”

Discuss the following lab tests with your primary care providers to better understand your heart health and disease risk.

The lipid panel includes total cholesterol, LDL cholesterol, HDL cholesterol, and triglycerides. The goal is to have total cholesterol of less than 200, but it does not automatically mean you need treatment. Today providers are looking at LDL cholesterol (most associated with coronary artery disease and blockages in your arteries), with less than 130 considered healthy. However, lower is better, and if you have disease most providers want it below 70. Having an LDL less than 70 is difficult to do without medication, no matter how clean you’re eating. HDL is the good cholesterol, and a desirable level is greater than 50. Triglycerides are an indicator of how well you eat and your genetics. If your triglycerides are high, it could indicate your simple or processed carbohydrate intake is too high. A triglyceride level less than 150 is considered healthy.

Know your fasting blood sugar. A healthy level of fasting blood sugar is 99 mg/dL or lower. Anything between 100 to 125 mg/dL indicates you have pre-diabetes and could benefit from lifestyle changes starting with eating and physical activity.

Hemoglobin A1c is a simple blood test that measures your average blood sugar levels over the past three months. It’s one of the most commonly used tests to diagnose prediabetes and diabetes and manage diabetes if you have it.

You can consider advanced testing such as a calcium score which is an x-ray of your coronary arteries that tells you if you have plaque or not. A calcium score does not tell us whether there is a narrowing of the arteries; that is what an angiogram does. More doctors are recommending a calcium score test to quantify risk as a way to determine if a medication like a statin may be beneficial. If you’re healthy and post-menopausal, should you get a calcium score? It’s a personal decision on how informed you like to be and whether or not you would take action, such as taking a statin if one is recommended. It’s an earlier way to detect plaque and disease and a new tool in the toolbox. For some people, it’s helpful. The results compare you to other people of the same gender and age. You get a percentage on how you rank 0-100.

If you have palpitations, you want to mention this to your doctor to potentially get a monitor to assess the cause and any underlying concerns.

Consider a stress test if you have symptoms. No data indicates you need to have one without symptoms. 

What can you do?

• Have a conversation with your primary care provider to determine what tests are right for you.

• When contemplating a test like a calcium score, good questions to ask yourself are:

  •  Do you want to know your risk? 

  • Will the results change your personal decision?

  • Do you want that information or not? Knowledge is power, but if knowing the facts will keep you up at night, it may not be worth it. It may be better for you to focus on lifestyle behaviors to reduce your risk. 

  • If you have no symptoms, a calcium score may be unnecessary as it most like won’t change the recommendations from your provider other than medication recommendations. If you are someone who may feel stressed or anxious from knowing your score or has no desire to take a statin, you may not want to know your calcium score.

• Talk to your provider about your numbers.

Understand how inflammation impacts heart health.

Inflammation is not a good thing. Understanding the impact of inflammation on disease is changing the future of how we think about and treat diseases like cardiovascular disease.  Cholesterol is one inflammatory marker. It will be interesting to see how much emphasis is put on cholesterol in the future. Dr. Jordan Baechler predicts that more emphasis will be placed on inflammation and less on cholesterol levels over the next 20 years. 

The best way to detect and measure inflammation is with a high sensitivity C-reactive protein blood test (hs-CRP).  This test is becoming more common, and Dr. Jordan Baechler orders it frequently for her patients. It’s another way to help quantify the risk for heart disease. The results will indicate your risk for developing blockages in your arteries. inflammatory conditions increase your risk of developing coronary artery disease, so the better the inflammation is managed, the less likely you will develop future heart blockages.

What can you do?

• Focus on the food you eat. People can see inflammation improvements by changing the foods they eat. Dr. Jordan Baechler has seen patients make food modifications and seen significant changes in inflammation. Start by getting a minimum of 5-11 servings of fruits and vegetables every day. If you’re looking for more guidance on what and how much to eat, Dr. Jordan Baechler recommends the following eating patterns which vary in how strict the recommendations are:

o   The Mediterranean Diet is a good style of eating and an excellent place to start.

o   The Anti-inflammatory Diet is plant-based with fish and one to two items of other nonplant protein portions a week. The recommendations are a little stricter than a Mediterranean diet, yet has more options than a vegan diet.

o   The Vegan Diet includes no animal products. Work with a registered dietitian nutritionist to ensure you’re getting adequate nutrition for good health and energy..

Get off the fad diet craze roller coaster.

Food recommendations overlap between diseases. Everyone is unique and there is not a one size fits all heart-healthy eating pattern recommendation.

Unfortunately, there is a lot of conflicting information online about the best way to eat. For example, some recommendations given for heart health do not always work for weight loss and obesity which are risk factors for developing cardiovascular disease.

Dr. Jordan Baechler gets asked frequently about ketogenic diets and advises her patients that the American version of the diet is often too high in processed fats and can be hard on your heart. She believes a ketogenic diet when followed strictly for long periods can raise the risk of heart disease.

What can you do?

• See a registered dietitian nutritionist to tailor recommendations for you, your lifestyle and your health risks. Dietitians are trained in medical nutrition therapy and behavior change. They can help you modify your eating patterns for life.  

• Consider following one of the three eating patterns listed above that have research behind them and show heart health benefits.

• To manage your weight as you age, you may need to consider increasing the good fat and reducing refined carbohydrates you eat in order to be successful in the long term.  A registered dietitian can help you make these modifications successfully.

Eat well, move more, don’t smoke, drink moderately, manage stress, sleep and be kind to yourself.

Changing habits can be challenging. Ask yourself the following questions:

• Where are you at?

• How can you do a little better?  

The goal is to start small. Quality of life is very important. Dr. Jordan Baechler recommends practicing the 80/20 rule (she does this too)— 80% of the time try to adhere to a healthful way of living. Find a balance that works for you. Every day is another day.

Evidence suggests making four critical changes—move 30 minutes a day, eat a minimum of five servings of fruits and vegetables, don’t use tobacco, and drink alcohol in moderation — you may get an extra decade of high-quality life. Only five percent of Americans do these four things. How are you doing with these behaviors?

It’s also important to manage stress by practicing calm. Most of us don’t do this, we’re constantly in a flight or fight state which takes a toll on our overall health and well-being. 

More and more research is emphasizing the critical importance of sleep to overall health. Ensure you wake up feeling rested. Usually, this means getting six to eight hours of sleep for most people. If you’re struggling to sleep or sleep well seek help earlier. You don’t want to suffer for two years before you get help. There are options that can help such as supplements, acupuncture, movement, food, etc.

Although not directly related to heart health, strength training with weights is important for building lean body mass which is especially important in midlife to prevent muscle loss. Lean body mass is also important for losing and maintaining weight as women age.  

The message is that we can all do a little better, one small change at a time. Don’t beat yourself up if you aren’t perfect today. Tomorrow is a new day.

What can you do?

• Move a minimum of 30 minutes a day. You can do It all at one time, or spread movement breaks throughout the day.  Join the Rumblings Move in May Challenge by downloading 40 ways to be active and follow us on social media for support and encouragement as we add more movement in our days throughout the month.

• Consider strength training with weights to build lean muscle and help manage weight as you age.

• Eat a minimum of five fruits and vegetables a day. Although our March Fruit and Veggie Challenge is over, you can still download 40 creative tips for eating more fruit and veggies in your day.

• Don’t use tobacco products.

• Limit alcohol to one drink a day for women and two drinks a day for men.  

• Practice calm— meditation, yoga, staring at a candle, prayer, etc.— in whatever way works for you for a minimum of 10-minutes a day.

• Sleep a minimum of six to eight hours a night. Wake up rested.

Chose foods key to a heart-healthy diet.

Research from Tufts University found that ten foods are estimated to cause nearly half of all US deaths from heart disease each year: eating too few nuts/seeds, seafood Omega-3, vegetables, fruit, whole grains, and polyunsaturated fats, and too much sodium, processed meat, sugary beverages, and processed red meat. This research also suggests that whole-fat dairy consumption can be part of a healthy diet, especially those with probiotic-containing unsweetened and fermented dairy products such as yogurt and certain aged and unpasteurized cheeses.  

If you’re trying to manage your blood cholesterol, natural compounds can be found in certain plant-based foods like fruits, vegetables, whole grains, legumes, nuts, seeds, and some vegetable oils have a valuable role.  Eating them helps limit the amount of cholesterol your body can absorb. These natural compounds in plants are called sterols, stanols, or phytosterols.  They can also be found in foods like margarine, cheeses, milk, cereals, and snacks that have been fortified with them. Check the labels for sterols, stanols, or phytosterols, and aim for 2 grams a day.

What can you do?

• Reach for nuts/seeds as snacks and toppings

• Aim for two Omega-3-containing seafood servings a week like salmon, sardines, Atlantic mackerel, cod, herring, lake trout, or canned tuna.

• Eat a minimum of five servings of fruits and vegetables a day

• Substitute whole grains for processed grains

• When eating dairy, choose unsweetened probiotic-containing yogurt and aged, unpasteurized cheeses like Swiss, provolone, gouda, cheddar, Edam, Gruyere, feta, caciocavallo, Emmental, and parmesan. Eat them sparingly.

Before taking dietary vitamins or supplements, work with a registered dietitian nutritionist and your medical providers to determine which ones can benefit you.

Supplement recommendations require an individualized approach based on deficiencies, medications, activity levels, and food consumed. Dr. Jordan Baechler prefers you get nutrients from your food first. 

In terms of heart health, there are no supplements that have been shown in studies to help clinically reduce heart disease risk. However, she is a fan of supplements when indicated. Supplements should be used as a complement to your food and medication regimen, not as a replacement. This is especially critical once the disease has developed.

There was a question about coenzyme Q10 (CoQ10) and statin use. CoQ10 is an antioxidant that your body produces naturally. Your cells use CoQ10 for growth and maintenance. Levels naturally decline as you age and are found to be lower in those who take certain medications, like statins. Statins are metabolized in your mitochondria and can deplete natural CoQ10 in your body. A supplement can help replace what is lost and there are minimal side effects to taking it. CoQ10 has also been seen to be helpful for those with heart failure. Dr. Jordan Baechler recommends starting with 200 mg a day if you’re on a statin or if your blood systolic blood pressure is over 130.

What can you do?

• Talk to your medical providers about the dietary supplement, vitamin needs, or medications specifically for you as you age This could include statins, CoQ10, and other vitamins and minerals. It can be helpful for your provider to analyze your blood levels and determine together with you what combination of supplements is right for you. 

Know what to consider if you’re advised to take a statin or aspirin.

Statins are the number one drug prescribed to lower cholesterol. Statins are intended to be used to stabilize plaque so you don’t have a heart attack or stroke, and that requires you to be on them for the rest of your life. There are no long-term effects of statin use that we know of today. Dr. Jordan Baechler feels safe having people on them, including her family members.

Before prescribing a statin, your doctor will consider all your risk factors for heart attacks and strokes. Eighty percent of people do great on statins and have no adverse effects. However, about 20 percent of people complain about side effects such as headaches, nausea, or muscle aches. If you experience side effects, talk to your doctor to review your risk factors for heart attack and stroke to see if it is recommended to discontinue the medication. Most patients’ complaints disappear as a result of stopping medications.

If you feel strongly you don’t want to be on a statin, you shouldn’t be on a statin. The mind is extremely powerful.  There was a trial done at the Minneapolis Heart Institute Foundation where people were blinded between statin and placebo and had equal side effects. At the end of the day, it doesn’t matter. If you don’t want to be on it, you don’t want to be on it.

It’s your body so you can decide when and if you want to be on or off a statin. There are other non-statin cholesterol-lowering medications you can discuss with your physician if statins don’t feel like the right choice for you.  

The use of aspirin in preventing heart disease as we age is common. However, aspirin recommendations have changed, and it is no longer recommended unless you have a diagnosis of heart disease. If you have established heart disease, your doctor may recommend 81 mg of aspirin daily. Aspirin use is a good topic to discuss with your doctor.    

What can you do?

• Discuss cholesterol-lowering medication options with your medical provider.

• If you have side effects from statins, talk to your physician about alternative types of cholesterol-lowering medications.

• If you have established heart disease, discuss the benefits and risks of daily low-dose aspirin

Discuss hormone replacement therapy (HRT) to manage menopausal symptoms with your provider.

There is an increased heart disease risk with hormone replacement therapy. However, not sleeping — a common occurrence during and after menopause — also increases your risk for heart disease. Work with your physician to decide the right option for you individually. If using HRT, Dr. Jordan Baechler recommends using the lowest dose possible to manage symptoms rather than using it to get hormone levels back to premenopausal levels.

Bioidentical hormone replacement therapy is one option to discuss with your provider. These hormones are from plant estrogens that are chemically identical to human-produced hormones may be slightly better than traditional hormone replacement therapy.  They are however more expensive.

What can you do?

• If you have menopausal symptoms, discuss low-dose hormone replacement therapy or bioidentical hormone replacement therapy with your medical providers.

There are many things you can do to prevent disease and reduce risks. Knowledge is power, and small changes add up. Take it one step at a time, and soon you’ll find yourself flourishing in midlife.

If you are facing other midlife challenges, we want to hear from you so that we can provide the expertise and answers to your questions through similar events, online webinars, newsletters, and future books.

If you want to read more about heart health, check out 5 Actions to Improve Heart Disease Risk and How to Care for Your Heart After 50.

* Dr. Jordan Baechler serves as medical director of health equity and health promotion at the Minneapolis Heart Institute Foundation.   Her previous roles included an appointment as assistant commissioner for the Minnesota Department of Health.  Before that, she served as Vice President of the Penny George Institute for Health and Healing, Allina Health’s prevention, wellness, and clinical service line.  She served as a consultant to the Statewide Health Improvement Plan for the clinical workgroup in Minneapolis.  She has been one of the authors of the Healthy Lifestyle Guideline for the Institute for Clinical Systems Improvement. She serves on the MN Department of Health Prevention of Cardiovascular and Stroke Committee.  Her leadership roles have included general board member for the YMCA of the Greater Twin Cities, MDH Maternal mortality and Review Committee member, and a policy advocate for the American Heart Association of MN and co-chair of the Twin Cities Go Red campaign 2020-2021.  She is passionate about helping individuals, families, and communities to find their highest state of well-being—body, mind, and spirit.

How to Care for Your Heart After 50

This is part two of a two part series of a conversation with Courtney Jordan Baechler MD, MS, a preventive cardiologist and a Medical Director at the Minneapolis Heart Institute Foundation. Part one can be found here. Edited and condensed for readability. 

Disclaimer: Nothing in this post is intended to diagnose or be a substitute for medical treatment. Always consult with your healthcare provider before taking any supplements, particularly if you have any medical conditions or take prescription medications. 

As part of the Minneapolis Heart Institute Foundation’s (MHIF) women’s health event called Hope, Health and Humor: At-Home Edition, we had Courtney Jordan Baechler MD, MS join us for a small outdoor gathering of women and a conversation about women’s heart health. This conversation is critical for women over 50 because many women think that heart and vascular disease only impact men at this age. However, once women reach menopause the level of risk, number of events, severity of heart disease, and even death rates are the same. Yet, our symptoms may be different, are often not taken seriously, and we’re not researched as much as men. 

Karyn: Social connection is one of the foundational principles at Rumblings, and there is more and more research showing social isolation, loneliness and the impacts on health being as great as smoking, obesity and other health risks. Are you starting to see this impact in your practice as well?

The Inner Heart Trial was a study across 52 countries and 6 continents. It looked at causes of blockages in the arteries and also if there was anything else that we did not yet know. It found that one-third of all blockages in coronary arteries result from poor mental health: from social isolation, anger, depression, anxiety, and anything in the mental wellbeing category. As strong as abdominal obesity, smoking, and high blood pressure. It’s a really big deal. There are many non-pharmaceutical or non-medicine based things you can do. At Minneapolis Heart Institute, we talk about Tai Chi, social connection, sleep, nutrition, music therapy, and acupuncture for example. It’s fascinating that across all generations we have a world that is quite lonely. Even if you’re on social media all the time, people don’t feel connected in an intimate sense with their friends. We have a tremendous interest in ways to be well other than just seeing a doctor and getting drugs. 

Karyn: Are there certain lab tests, heart tests or calcium scores that we should be asking for as we get older?

It really depends on what you will do once you have the information. The analogy that I use are genetic tests you may get when you are pregnant, especially if you are considered at ‘advanced maternal age’. Are the results of the test going to change your behavior or will they just worry you? I have pretty strong beliefs about doing the tests that we do for the right reasons. For example, a calcium score is determined by what is basically an x-ray of your heart to look at calcium production. A calcium score is not usually covered by insurance. It is the first sign of build-up in the arteries, and it will compare you against women of the same age. A calcium score of 0 - meaning no buildup in your arteries - is rare. Everything else in our mind is considered heart disease, even if it’s the beginning of heart disease with a buildup of 10 percent. Then the recommendation of the guidelines is to prescribe a statin drug. From a cardiologist perspective, once that happens, we do not pass go without being on a statin medication. The recommendation is to repeat the calcium test in 5 years to see if it has changed. There is not a lot of data to suggest whether or not a repeat test should be done or if the score changes for many people. 

I have some patients that tell me their calcium score is single-handedly the most impactful things that caused them to change their behaviors on what they eat, when they exercise, how they sleep and moderate their stress. If that is going to happen and it will drive you to do the things that we need to do for health, then it’s super helpful. But, 85% of coronary artery disease or blockage in the arteries are lifestyle based and preventable. Even if you get lucky and get that ‘0’ [score], it doesn’t change the need to do those things. It’s definitely very trendy right now, but it depends how your brain works and what kind of information is helpful to you. 

There are other things we do that are more commonly covered by insurance. A high-sensitivity C-reactive protein (hs-CRP) is a blood marker for inflammation. There has been an association between higher CRP levels and heart disease. When I am risk-stratifying someone and they have a very low high-sensitivity CRP level, it indicates that their body’s sensation of inflammation is low. My prediction is that in 20 years, heart disease will be much more about inflammation. Inflammation in the body leads to high blood sugar, which leads to more diabetes. Inflammation leads to high cholesterol, which  itself is an inflammatory marker. Inflammation also leads to high blood pressure and the list goes on. This is one of the few ways to test for inflammation and most preventive cardiologists will do that as this blood marker can be lowered with statins. 

Some other markers I usually get are Lipoprotein A (Lipo A) and Apolipoprotein B (Apo B), which are ways to look at the cholesterol breakdown to look at size and stickiness of the cholesterol. These things are a little more genetic in nature. We do not have any drugs as of yet, that can change those numbers. It can be helpful to reassure someone who has a strong family history or is nervous about their levels. 

There are more advanced [tests] to gather even more information about the cholesterol breakdown, many of them are not super helpful beyond the 3 that I get on most of my patients. 

Most of the studies that we have are on [the effect of] drugs, not lifestyle. We are hoping to change that. Today, the way that we use statins in our society is that everyone should be on them, and most physician’s intent is that you should be on them until you die. I try to tell patients they get to choose what they want to take, as nothing we put in our bodies is perfect. If a patient tells me they want to do everything possible to decrease their risk of having a heart attack or stroke, and they want to do everything by the book; for most people that will mean a statin, and they’re doing ok. 

Other patients may say they want to do everything else but that, and there is a lot that can be done on the behavioral side. I have many patients that have a pristine diet, they move a lot, they really moderate stress and how they manage it. They sleep well, social connection is a huge part of their life - they have a purpose. They choose not to be on statins and they’re doing ok. It’s about tradeoffs and thinking through what will work best for you long-term. I have people who do both and they’re doing pretty well. 

Karyn: What about supplements? Are there supplements that we should be taking?

I am definitely a fan of supplements for a specific reason and not just taking them because your friend does and they work for her. CoQ10 and Vitamin D are two that I use routinely.

For instance, if I have someone on statins, I always put people on 100mg of CoQ10 twice per day. In Europe, this is standard of care. Statins deplete mitochondria, which are the energy producers of our cells and CoQ10 helps to replete them. For some patients, I have found they are much less likely to get muscle and joint aches. There have been trials that have found it doesn’t matter, but for some it seems to help. Trials have shown that CoQ10 lowers blood pressure. I have people looking for natural ways to lower blood pressure to try it first, and it’s great for energy. 

It is important to ask your primary care provider about checking your Vitamin D levels.  Vitamins A, D, E, and K are fat soluble, so you can get too much, but 85% of Minnesotans are low. In the Winter, 5000 IU per day is recommended. The sweet spot for Vitamin D levels is in the 50-70 ng/mL range. I will see people come in as low as 10 ng/mL. We call Vitamin D the ‘happy vitamin’ because people feel off without it if they are low, but too much can be toxic. 

For [high] triglycerides I use fish oil. There are studies on lowering triglycerides with 1000mg, 3 times per day. It’s a big dose, and it has to be the right type of fish oil - Nordic Naturals is a good one. Fish oil is also good for mental health. I use red yeast rice for lowering cholesterol. I have found that most people’s cholesterol will go down with a 2400 mg supplement, but there are no studies to show if it reduces risk for heart attacks or strokes.

I have many supplements that I may recommend for individuals with anxiety, stress, or problems sleeping. For palpitations, stress, or help falling asleep I use L-theanine. I will use melatonin to help people stay asleep.  Depending on the time and reason for a patient visit, I will sometimes recommend Ashwagandha during menopause as women’s bodies adjust to the new normal. 

Everything is connected in our bodies. Sometimes our heart feels off because our gut flora is off. I may put people on probiotics for a month to see if we can refresh their natural flora. I always try to introduce them one at a time so that you don’t have too many different things at once to try to figure out if it is working. 
Karyn: I’m pleasantly surprised to hear you say that there are supplements you recommend. I’ve always been hesitant to tell my healthcare providers about the supplements I take, but now I definitely will. I have always felt that supplements have helped me to feel my best. 

Karyn: Let’s talk about how the gap in women’s cardiovascular health research impacts recommendations for women. What can we do to advocate for getting more research on women’s heart health?

We’re 35 years behind in research on cardiovascular disease compared to men. Women weren’t even allowed to participate in studies due to regulations set by the Food and Drug Administration (FDA) for a long time*. There is less research funding for women in all areas—whether it’s how women respond to valve surgery, bypass surgery, stent placements, if we’re more or less likely to have a procedure after a heart attack, or are we more likely to die. I firmly believe that closing this gap will be a woman-led solution. Currently, 12% of cardiologists are women. As that number grows, we’ll have more women physicians and researchers leading the efforts. Women being engaged participants in designing where and how they want to receive care, what that care looks like, and what the wellness efforts and how they want to be treated will also be critical components too. 

Not only are we not small men, but the way that care was designed was predominantly for well insured white men with a wife to take care of them. Men tend to enroll in studies immediately, while women are more likely to take time to consider participating. Boston Scientific has done great research on how to get women to participate in more research studies by designing brochures to resonate with women and taking an extra step to continue to reach out to them. Once women have a chance to ask questions and speak with their trusted network of friends, they are more likely to participate. This approach is considered ‘soft’ academics, and is not how it’s often done, but it will be a big part of the solution to get more participants. 

Women’s heart disease rates started to go up in the 1950s, correlating with women entering the workforce, and slowly their rates began to equal that of men. We don’t want women working to change, but the idea that we [as women] can do everything all the time for everyone with the idea that we’ll take care of ourselves last is a cultural value that has to change before we can actually thrive. We have a lot of work to do on that. 

Karyn: We do have a lot of work to do. But, I think we can do it. I believe marketers are realizing women in our age group have tremendous buying power and by hiring millennials that focus on marketing to other millennials, they’re missing out on a huge marketing opportunity. I also hope with more women who are reaching midlife and increasing numbers in professions that were traditionally male dominated, we’ll see rapid change. 

I graduated from medical school in 2004 and ours was the first class with 51% women. These changes are recent. 

Karyn: Is there a difference between a standard cardiologist and a preventive cardiologist and how do you get to see a preventive cardiologist? 

Preventive cardiologists usually do extra training and it takes more years [in school]. They would usually have extra training on lipid and cholesterol profiles and in areas of nutrition, exercise, stress. A focus on the different types of lifestyle contributors to give a more holistic view of health. At the Minneapolis Heart Institute, we are planning to start a prevention fellowship within our cardiology fellowship. As of now, it is mostly a certificate, but what you can expect is someone who is focusing on prevention. It doesn’t have to be primary prevention, it can be about preventing a second event after someone has had a heart attack or stroke. 

*In 1977, the FDA issued a guideline banning most women of ‘childbearing potential’ from participating in clinical research studies. In 1993, the FDA issued a new guideline and formally rescinded the 1977 policy that banned most women from participating in studies. The Congress made this policy law in 1993. Source: U.S. Department of Health & Human Services Office on Women’s Health.

5 Actions to Improve Women’s Heart Disease Risk After 50

This is part one of a two part series of a conversation with Courtney Jordan Baechler MD, MS, a preventive cardiologist and a Medical Director at the Minneapolis Heart Institute Foundation.

Women know that preventing breast cancer is a big health issue. While that is very important, and much has been done to shed a light on the value of early detection and treatment, it remains true that heart disease is still the leading cause of death in women. We don’t talk enough about how research on women’s heart health is decades behind that of men, how our symptoms are often not taken seriously, what we can do to prevent heart disease and cardiovascular events, and how we should treat it. We want to help change the narrative around women and heart disease. It all starts with having more conversations about this topic.  

As part of the Minneapolis Heart Institute Foundation’s (MHIF) women’s health event called Hope, Health, and Humor: At-Home Edition, we had Courtney Jordan Baechler MD, MS join us for a small outdoor gathering of women and a conversation about women’s heart health. This conversation is critical for women over 50 because many women think that heart and vascular disease only impact men at this age. However, once women reach menopause the level of risk, number of events, the severity of heart disease, and even death rates are the same. Yet, our symptoms may be different, are often not taken seriously, and we’re not researched as much as men. 

This gathering took place a few days after Rebecca’s husband had a stroke. Because of how healthy and young he was, it drove home that we need to start having conversations about heart health, cardiovascular events, and doing everything we can to take care of ourselves as we age.

Karyn: Dr. Baechler, tell us about yourself.

I’m a preventive cardiologist. I did the National Institutes of Health (NIH) scientist track, and added extra time onto my fellowship in cardiology to study the primary and secondary prevention of heart disease. I hit a wall during my intern year and thought the [healthcare] system was totally broken. How was I going to practice for the rest of my life in a sick-based system? There was no focus on nutrition, stress, exercise, ability to fill your prescriptions - nothing. It led me to pursue my interest in preventive medicine. I obtained a Master’s degree in Epidemiology and Public Policy to learn more about population health. I spent years running the Penny George Institute for Health and Healing. I’m a huge believer in the mind, body, spirit approach of Eastern medicine meets Western medicine. I currently run the Women’s Science Center at the Minneapolis Heart Institute Foundation and I see patients part-time through the Minneapolis Heart Institute. 

Karyn: What are the age-related changes that women go through that begin to increase our risk for heart disease?

Until menopause, women have a much lower risk of developing heart disease. After menopause, our risk increases to be the equivalent to the risk men experience for having a heart attack or stroke. 

I’m sure many women have heard of the Women’s Health Initiative and the research on hormone replacement therapy. There was an idea that if we put women on hormones so that menopause wouldn’t happen, that would fix things. It turns out the risk of having a heart attack and the risk of having a stroke was higher. It was back in 2004 when we first started getting this information. 

Here are some of the reasons our risk increases after menopause:

When we age, our blood vessels start to stiffen and we can develop high blood pressure. Our metabolism starts to slow and we tend to develop more central obesity and fat in our bellies. These things happen as we age, and there are things that we can do to counteract them. From a perspective of our metabolism slowing down, we can also be at higher risk for developing Type 2 diabetes because of the way our body responds to insulin and sugar in general. 

Our sleep changes. Sleep is the cornerstone of everything, and it helps to clear our brains. There is lots of data on the importance of sleep and our overall immune system and helping us to be well.

Most of these things appear to be true for men too, there just is a protective effect for women prior to menopause. We’re 35 years behind in doing research on women. We don’t know why that is, but can speculate that society has cared about keeping women healthy while we’re reproducing and then we have less perceived ‘value’ after we’re done with being able to reproduce. 

Karyn: You know, it’s really interesting that even Rebecca and I have found that there is so much information out there for women who are in childbearing years and for fertility. When you look for resources on health for women who are over 50 there is nothing. Everything that you Google is almost entirely about how to dress, how to be more attractive, or is about anti-aging. It’s fascinating, and not in a good way. We have work to do to change that!

Karyn: What symptoms should women be aware of, and when should they seek immediate care? What symptoms are different for women than for men?

Women are much more likely to have atypical symptoms. They are more likely to get jaw pain, arm numbness, nausea, vomiting, and also depression. They do get shortness of breath, and chest pain is still the most common symptom in women. However, women are much more likely to have all of the symptoms compared to men. I always tell women that you know your body best. Hands down, patient-wise, women are more in tune with their bodies. If you are experiencing something that is different and is not going away, you should get it checked out. Physicians should be grateful that you are proactive and focused on prevention. If everything turns out fine, then that is great!

Karyn: When we see our doctors, our primary care providers, what kinds of things should we ask them about to make certain we’re paying close attention to our heart health as we get older? 

One of the things that is critical for women to be aware of when seeing your physician is that you should have information about anything being done. As a patient, you should be told what your blood pressure is. You should be told what your heart rate is. And, you should understand what your medical providers are doing. Are they listening to your respiratory rate? Are they taking your temperature? All of those things are critical pieces of information that you want to be personally tracking. 

Blood pressure and heart rate are things that change over time. For example, if you’ve always had a heart rate in the 60s and now your rate is consistently in the 80s or 90s, you need to know about it. And, they should tell you that it’s better to be a little bit lower consistently. 

Body Mass Index (BMI), which is one way to look at weight, is another indicator that doesn’t get talked about much with your physician. Is your weight or BMI contributing to your level of risk and what is a healthy BMI? How do you compare to your peers? Physicians will usually tell you if there is something wrong, but they should also tell what they are looking for and why.

You should definitely get your cholesterol checked. There are advanced cholesterol profiles that we can do to tell whether the cholesterol is ‘sticky’ which can increase your risk. A cardiologist would also look at inflammation and other things. Most importantly, have a conversation with your primary care doctor about your family history and your lifestyle. Ask them about your risk of having a heart attack or stroke in the next 10 years. 

These are basic things that let you know where you fall in terms of risk and then based on these measures, does your doctor recommend that you see a cardiologist to do further testing and why or why not? Ask them what other specific things you could be doing to optimize your health. These are the conversations you want to have with the person taking care of you. 

Karyn: It is so important to have a relationship with a care provider that knows you and is willing to be a partner in your care. 

It is unfortunate but very common to be put on medication without ever being evaluated for all of these other things. It is important in those situations to ask why you are being prescribed something so you can be informed. 

Part two of the conversation with Courtney Baechler MD, MS discusses how to take care of your heart.