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Faculty of Nursing, University of Alberta, Edmonton, Alberta, CanadaHeart and Stroke Strategic Clinical Networks, Alberta Health Services, Edmonton, Alberta, Canada
Section for Renal Medicine, Department of Clinical Intervention, Science, and Technology, Karolinska Institute and Karolinska University Hospital, Stockholm, Sweden
Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, CanadaFaculty of Medicine, University of Ottawa, Ottawa, Ontario, CanadaReplica Analytics, Ottawa, Ontario, Canada
§ These authors contributed equally to this work as last authors.
Louise Pilote
Correspondence
Corresponding author: Dr Louise Pilote, Center for Outcomes Research and Evaluation, Division of Clinical Epidemiology and General Internal Medicine, McGill University Health Centre Research Institute, 5252 Boulevard de Maisonneuve, Montréal, Québec H3A 1A1, Canada. Tel.: +1-514-934-1934, ext 44722; fax: +1-514-843-1676.
§ These authors contributed equally to this work as last authors.
Affiliations
Centre for Outcomes Research and Evaluation, McGill University Health Centre Research Institute, Montréal, Québec, CanadaDivisions of Clinical Epidemiology and General Internal Medicine, McGill University Health Centre Research Institute, Montréal, Québec, Canada
Evidence differentiating the effect of biological sex from psychosociocultural factors (gender) in different societies and its relation to cardiovascular diseases is scarce. We explored the association between sex, gender, and cardiovascular health (CVH) among Canadian (CAN) and Austrian (AT) populations.
Methods
The Canadian Community Health Survey (CCHS) (n = 63,522; 55% female) and Austrian Health Interview Survey (AT-HIS) (n = 15,771; 56% female) were analyzed in a cross-sectional survey design. The CANHEART/ATHEART index, a measure of ideal CVH composed of 6 cardiometabolic risk factors (smoking, physical activity, fruit and vegetable consumption, overweight/obesity, diabetes, and hypertension; range 0-6; higher scores reflecting better CVH) was calculated for both databases. A composite measure of psychosociocultural gender was computed for each country (range 0-1, higher score identifying characteristics traditionally ascribed to women).
Results
Median CANHEART 4 (interquartile range 3-5) and CAN gender scores 0.55 (0.49-0.60) were similar to median ATHEART 4 (3-5) and AT gender scores 0.55 (0.46-0.64). Although higher gender scores (CCHS: β = −1.33, 95% confidence interval [CI] −1.44 to −1.22; AT-HIS: β = −1.08, 95% CI −1.26 to −0.89)) were associated with worse CVH, female sex (CCHS: β = 0.35, 95% CI (0.33-0.37); AT-HIS: β = 0.60, 95% CI (0.55-0.64)) was associated with better CVH in both populations. In addition, higher gender scores were associated with increased prevalence of heart disease compared with female sex. The magnitude of this risk was higher in Austrians.
Conclusions
These results demonstrate that individuals with characteristics typically ascribed to women reported poorer cardiovascular health and higher risk of heart disease, independently from biological sex and baseline CV risk factors, in both countries. Female sex exhibited better CV health and a lower prevalence of heart disease than male in both populations. However, gender factors and magnitude of gender impact varied by country.
Résumé
Contexte
L’évidence différenciant l'effet du sexe biologique des facteurs psychosocioculturels (genre) dans différentes sociétés et sa relation avec les maladies cardiovasculaires reste rare. Nous avons exploré l'association entre le sexe, le genre et la santé cardiovasculaire (SCV) parmi les populations canadienne (CAN) et autrichienne (AT).
Méthodes
L'Enquête sur la Santé dans les Collectivités Canadiennes (ESCC) (n = 63 522; 55 % de femmes) et l'Enquête autrichienne par entretien sur la santé (AT-HIS) (n = 15 771; 56 % de femmes) ont été analysées dans le cadre d'une enquête transversale. Les indices CANHEART/ATHEART représentent une mesure de la SCV idéale composée de 6 facteurs de risque cardiométabolique (tabagisme, activité physique, consommation de fruits et légumes, surpoids/obésité, diabète et hypertension; intervalle de 0 à 6; des scores plus élevés reflétant une meilleure SCV) a été calculé pour les deux bases de données. Une mesure composite du genre psycho-socio-culturel a été calculée pour chaque pays (intervalle 0-1, un score plus élevé identifiant les caractéristiques traditionnellement attribuées aux femmes).
Résultats
Les scores médians associés au CANHEART 4 (intervalle interquartile 3-5) et au genre dans la population CAN 0,55 (0,49-0,60) étaient similaires aux scores médians associés à l'ATHEART 4 (3-5) et au genre dans la population AT 0,55 (0,46-0,64). Bien que des scores liés au genre plus élevés (ESCC: β = 1,33, intervalle de confiance [IC] à 95 % -1,44 à -1,22; AT-HIS: β = 1,08, IC à 95 % -1,26 à -0,89) aient été associés à une moins bonne SCV, le sexe féminin (ESCC: β = 0,35, IC à 95 % (0,33-0,37); AT-HIS: β = 0,60, IC à 95% [0,55-0,64]) a été associé à une meilleure SCV dans les deux populations. En outre, des scores plus élevés liés au genre étaient associés à une prévalence accrue des maladies cardiaques par rapport au sexe féminin. L'ampleur de ce risque était plus élevée chez les Autrichiens.
Conclusions
Ces résultats démontrent que les personnes présentant des caractéristiques typiquement attribuées aux femmes présentaient une moins bonne santé cardiovasculaire et un risque plus élevé de maladie cardiaque, indépendamment du sexe biologique et des facteurs de risque CV de base, dans les deux pays. Les femmes présentent une meilleure santé cardiovasculaire et une plus faible prévalence de maladies cardiaques que les hommes dans les deux populations. Cependant, les facteurs liés au sexe et l'ampleur de l'impact du sexe variaient selon le pays.
Cardiovascular diseases (CVD) continue to represent the leading cause of mortality and morbidity among women and men worldwide.
While the importance of sex differences (biological characteristics in females and males) in the prevention, diagnosis, and treatment of CVD are being increasingly recognised, the impact of sociocultural gender has yet to be determined.
Sociocultural gender refers to psychosociocultural roles, behaviours and identities. It influences people's perception of themselves and their interaction with each other and contributes to the distribution of power in different societies.
Canadian Institutes of Health Research. Online training modules: integrating sex & gender in health research. Available at: https://cihr-irsc.gc.ca/e/49347.html. Accessed March 24, 2021.
Biological differences between the sexes such as anatomic and physiologic variations in coronary arteries and the autonomic nervous system alter the development and progression of CVD.
For example, smoking has been shown to have more adverse effect on females than on males, possibly owing to a difference in nicotine metabolism. Indeed, females who smoke have a 25% higher risk of ischemic heart disease than males.
Cigarette smoking as a risk factor for coronary heart disease in women compared with men: a systematic review and meta-analysis of prospective cohort studies.
Smoking as a risk factor for stroke in women compared with men: a systematic review and meta-analysis of 81 cohorts, including 3,980,359 individuals and 42,401 strokes.
Sociocultural gender also contributes to sex differences observed in cardiovascular health, including lifestyle behaviours, such as exercising, and accessibility to cardiac rehabilitation.
Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks, 1990-2015: a systematic analysis for the Global Burden of Disease Study 2015.
The rise in incidence of premature acute coronary syndrome, especially in females in recent decades, can be attributed to changes in family dynamics and social and institutional roles. Nevertheless, few studies differentiate biological sex from sociocultural gender with respect to cardiovascular risk.
Greater cardiovascular responses to laboratory mental stress are associated with poor subsequent cardiovascular risk status: a meta-analysis of prospective evidence.
As such, whether the effects of sex and gender differ based on country of residence remains to be determined.
In this study, we therefore sought to untangle the impact of sociocultural gender from biological sex in their association with cardiovascular health of Canadian and Austrian populations.
Methods
Study design
This cross-sectional survey study is part of the Gender Outcomes International Group: to Further Well-Being Development (GOING-FWD) which is a 5-country multidisciplinary consortium that was co-funded by the Canadian Institutes of Health Research, and GENDER-NET Plus (http://gender-net-plus.eu/joint-call/funded-projects/going-fwd/). The overarching aims of the consortium are to integrate sex and gender aspects in health research and to evaluate their impact on outcomes in noncommunicable diseases including CVD.
Data from 2 independent community health surveys administered in 2014 in Canada and Austria were analysed (Supplemental Appendices S1 and S2). The Canadian Community Health Survey (CCHS 2014; n = 63,522) is a cross-sectional survey that collected population-level information on social determinants of health, health status, and health care resource utilisation in the Canadian population. This survey began in 2001, and data have been collected annually since 2007. The Austria Health Interview Survey (AT-HIS 2014; n = 15,771) was conducted as part of European Health Interview Survey series to gather comparable statistical health data (ie, population health status, health determinants, health care use and access, and sociodemographic information) from various European countries.
The GOING-FWD methodology to merge data from the Canadian and Austrian surveys
The GOING-FWD systematic multistep approach for retrospective studies was used to identify gender-related variables and outcomes in both databases as well as to analyse the data. Briefly, gender-related factors were identified with the use of the Women Health Research Network's gender framework (ie, gender identity, gender roles, gender relationships, and institutionalised gender),
and finally, based on the data structure of the 2 survey databases, final analyses were performed locally and results were compared.
Gender score construction
After the identification of gender-related variables in both databases and their harmonisation, the Gender and Sex Determinants of Cardiovascular Disease: From Bench to Beyond Premature Acute Coronary Syndrome (GENESIS-PRAXY) methodology was used to generate a composite measure of gender.
The primary end points of this study were the cardiovascular health of the population using the Cardiovascular Health in Ambulatory Care Research Team (CANHEART)/ATHEART indices and prevalence of overt heart disease. To measure the cardiovascular health of the population, we used the previously published CANHEART health index.
This index is a measure of cardiovascular health, composed from the sum of the ideal metrics for 6 cardiometabolic health factors and behaviours (ie, smoking, physical activity, fruit and vegetable consumption, overweight/obesity, diabetes and hypertension), which range from 0 (worst) to 6 (best or ideal cardiovascular health). With our data, we determined the CANHEART index and used a similar method to synthesise an index to measure the cardiovascular health of the Austrian population (ATHEART) (Table 1).
Table 1Definitions of ideal cardiovascular health in Canadian and Austrian populations (CANHEART and ATHEART indices)
CANHEART: Canadian population
ATHEART: Austrian population
Smoking
Nonsmoker or former daily or occasional smoker who has quit more than 12 months
Nonsmoker or former daily or occasional smoker who has quit more than 12 months
Overweight/obesity
BMI < 25 kg/m2
BMI < 25 kg/m2
Leisure physical activity
Energy expenditure ≥ 1.5 kcal/kg/d equivalent to ≥ 30 min walking per day
Number of days doing leisure physical activity for ≥ 10 min, > 3 days per week
Fruit and vegetable consumption
≥ 5 times per day
≥ 1 time per day
Diabetes
No self-reported diabetes diagnosed by health professional
No self-reported diabetes diagnosed by health professional
Hypertension
No self-reported HTN diagnosed by health professional
No self-reported HTN diagnosed by health professional
BMI, body mass index; CANHEART, Cardiovascular Health in Ambulatory Care Research Team; HTN, hypertension.
Heart disease in the Canadian health survey was a self-reported measure of chronic heart disease diagnosed by a health care professional, whereas in the Austrian population health survey it was defined as having history of coronary heart disease or angina pectoris in the past 12 months.
Statistical analysis
Descriptive statistics were reported as mean ± SD for continuous variables and n (%) for categoric variables. To ensure statistical power for all analysis, a case analysis (pairwise deletion) approach was used for dealing with missing data.
The detailed methodology of calculating the gender score has been reported in our previous publication.
In this novel method, principal component analysis (PCA), was used to choose from a large number of relevant psychosocial variables extracted from the CCHS and AT-HIS databases. The PCA method helps reduce dimensionality and facilitate data compression to select the unique set of covariates to use in the predictive model. Details of the method are reported in Supplemental Tables S1 and S2. Ultimately, components that accounted for a cumulative variance of more than 60% of the data were selected. Factor loadings (correlation between original variables and factors) with values of 0.4 or more were used to select the best set of variables. The optimised set of gender-related variables from the selected components in the PCA (Supplemental Tables S1 and S2) were then used to create a multivariable logistic model with biological sex as the dependent variable and gender-derived components as covariate. A gender index was then calculated through the construction of a propensity score, which was derived from coefficient estimates in the final logistic regression model. The propensity score for each person was defined as the conditional probability of being a female vs a male based on gender-related variables. This score ranges from 0 to 1, with higher scores relating to characteristics traditionally ascribed to women.
Multivariable linear regression was applied to assess the association between gender score, biological sex, and cardiovascular health measured by CANHEART/ATHEART indices (including smoking, physical activity, fruit and vegetable consumption, overweight/obesity, diabetes, and hypertension) in both populations. The models were adjusted for age. The same approach was used for testing the association with overt heart disease. Multivariable logistic regression was used to assess the relationships between sex, gender, and overt heart disease. These models were adjusted for age and CANHEART/ATHEART indices. A 2-way sex–gender score interaction was assessed in all models.
Data analysis was performed with the use of R software (version 1.2.5042). P values of ≤ 0.05 were considered to be statistically significant.
Results
The CCHS 2014 included 63,522 respondents 55.3% were female (n = 35,114; 42.3% < 50 years old) and the AT-HIS 2014 included 15,771 respondents, 55.7% of whom were female (n = 8786; 53.86% < 50 years old). About 45% of the Canadians and 53% of the Austrians had normal body mass index (BMI < 25 kg/m2). Rate of diabetes was double in Canadians, whereas rate of smoking was double in Austrian population (Supplemental Tables S3-S6).
Among all gender-related variables, household size, perceived life stress, education level, sense of belonging to community, marital status, and household income were selected from the first 6 components of the CCHS based on their factor loadings. In the AT-HIS, frequency of negative emotions, education level, marital status, and household income were gender-related variables selected from retained components. The first 6 components accounted for 84% of total variance in the CCHS, and a combination of the first 3 components in the AT-HIS constituted 61% of total variance in the dataset. A gender score was calculated for all participants using propensity scores with biological sex as dependent variable (Table 2). While greater household size, perceived life stress, higher education, sense of belonging to community, being divorced or widowed, and lower household income were associated with female sex in the Canadian population, lower education, greater frequency of having negative emotion, being divorced or widowed, and having a lower household income were associated with being female in the Austrian population. Higher scores represent characteristics traditionally ascribed to women in these countries. The mean gender scores in Canadian and Austrian populations were 0.55 ± 0.09 (median 0.53, interquartile range [IQR] 0.49-0.60), and 0.55 ± 0.12 (median 0.54, IQR 0.46-0.64), respectively.
Table 2Multivariate logistic model for assessing association of gender variables with biological sex as dependent variable
CCHS
AT-HIS
Gender variable
OR (95% CI)
Gender variable
OR (95% CI)
Household size
Frequency of negative emotions
(Reference: 1 person)
–
(Reference: 1 = never)
–
2 persons
1.22 (1.15-1.30)
2 = not often
1.62 (1.49-1.75)
3 persons
1.25 (1.17-1.34)
3 = intermittently
2.57 (2.33-2.83)
4 persons
1.37 (1.28-1.47)
4 = often
2.71 (2.33-3.15)
≥ 5 persons
1.36 (1.25-1.47)
5 = always
2.03 (1.41-2.93)
Perceived life stress: stress during the day
Education
(Reference: 1 = not at all)
–
(Reference: < secondary)
–
2 = not very
1.37 (1.29-1.44)
Secondary
0.57 (0.51-0.62)
3 = a bit
1.57 (1.49-1.66)
Postsecondary
0.65 (0.58-0.69)
4 = quite a bit
1.76 (1.66-1.88)
> Postsecondary
0.51 (0.45-0.59)
5 = extremely
1.81 (1.62-2.03)
Marital status
Education
(Reference: single)
–
(Reference: < secondary)
–
Divorced/widowed
2.14 (1.92-2.38)
Secondary
1.23 (1.17-1.30)
Common-in-law/married
1.18 (1.1-1.27)
Postsecondary
1.12 (1.03-1.22)
Household income
> Postsecondary
1.20 (1.15-1.26)
(Reference: high)
–
Sense of belonging to community
Medium
1.20 (1.1-1.31)
(Reference:1 = very weak)
–
Low
1.24 (1.15-1.34)
2 = somewhat weak
1.03(0.96-1.11)
3 = somewhat strong
1.16 (1.08-1.24)
4 = very strong
1.19 (1.10-1.28)
Marital status
(Reference: single)
–
Divorced/widowed
2.62 (2.47-2.77)
Common-in-law/married
1.16 (1.11-1.22)
Household income
(Reference: high)
–
Medium
1.37 (1.32-1.43)
Low
1.81 (1.69-1.94)
Gender index was calculated through the construction of a propensity score, which was derived from coefficient estimates in the final logistic regression model with biological sex as dependent variable and gender-related variables as covariates. The propensity score for each person was defined as the conditional probability of being a female vs a male based on gender-related variables. This score ranges from 0 to 1, with higher scores relating to characteristics traditionally ascribed to women.
AT-HIS, Austria Health Interview Survey; CCHS, Canadian Community Health Survey; CI, confidence interval; OR, odds ratio.
Figure 1 represents the distribution of gender score in males and females. The blue color demonstrates gender score in females, the red color males, and the purple color shows the overlap of the score in males and females. Higher gender score shows more feminine characteristics. The distribution of the gender score in men and women did not entirely overlap with biological sex in both populations, which shows their partially independent effect (Fig. 1, I).
Figure 1Density plots: y-axis: probability density of gender; x-axis: gender score. Higher gender score demonstrates more feminine characteristics. (I) Gender score distribution in male and females in (A) Canadian and (B) Austrian populations. Red: gender score in males; blue: gender score in females; purple: overlapping of gender score in both groups. The distribution of the gender score in men and women did not entirely overlap with biological sex in both populations, which shows their partially independent effect. (II) Gender score distribution in CANHEART/ATHHEART index < 3 and ≥ 3 in (A) Canadian and (B) Austrian populations. Dark green: gender score in CANHEART/ATHHEART index < 3 (ie, worse cardiovascular health); yellow: gender score in CANHEART/ATHHEART score ≥ 3 (ie, better cardiovascular health); light green: overlapping of gender score in both groups. Higher gender score, ie, more feminine characteristics, demonstrates worst cardiovascular health in both populations. AT-HIS, Austria Health Interview Survey; CANHEART, Cardiovascular Health in Ambulatory Care Research Team; CCHS, Canadian Community Health Survey.
The mean cardiovascular health scores were 3.88 ± 1.3 (median 4, IQR 3-5) in the Canadian population, and 3.78 ± 1.23 (median 4, IQR 3-5) in the Austrian population. The cardiovascular health scores were significantly higher in females in both populations (Austria: male 3.4 vs female 4.02; Canada: male 3.74 vs female 3.99; P < 0.001).
While a higher gender score (β = −1.33; 95% confidence interval [CI] −1.44 to −1.22; P < 0.001) was associated with worse cardiovascular health, female sex (β = 0.35; 95% CI 0.32 to 0.37; P < 0.001) was associated with better cardiovascular health in the Canadian population when adjusted for age (Table 3; Fig. 1, II). A similar trend was observed in the Austrian cohort, where higher gender score (β = −1.08; 95% CI −1.26 to −0.89; P < 0.001) was associated with worse cardiovascular health, whereas female sex (β = 0.60; 95% CI 0.55 to 0.64: P < 0.001) was associated with better cardiovascular health when adjusting for age (Table 3; Fig. 1, II).
Table 3Association of cardiovascular health with biological sex and gender in Canadian and Austrians populations
Cardiovascular health in Canadians (CANHEART score)
Cardiovascular health in Austrians (ATHEART score)
Unstandardised coefficient (β)
95% CI
P value
Unstandardised coefficient (β)
95% CI
P value
Gender score
−1.33
−1.44 to −1.22
< 0.001
−1.08
−1.26 to −0.89
< 0.001
Sex (female)
0.35
0.33 to 0.37
< 0.001
0.6
0.55 to 0.64
< 0.001
Age group, y
< 20 (reference)
–
–
–
–
–
–
20-29
−0.49
−0.53 to −0.44
< 0.001
−0.5
−0.62 to −0.37
< 0.001
30-39
−0.65
−0.70 to −0.61
< 0.001
−0.83
−0.95 to −0.71
< 0.001
40-49
−0.88
−0.92 to −0.83
< 0.001
−0.86
−0.97 to −0.74
< 0.001
50-59
−1.14
−1.18 to −1.10
< 0.001
−1.1
−1.22 to−0.99
< 0.001
60-69
−1.23
−1.27 to −1.19
< 0.001
−1.2
−1.34 to −1.10
< 0.001
≥ 70
−1.24
−1.29 to −1.20
< 0.001
−1.19
−1.31 to −1.07
< 0.001
CANHEART, Cardiovascular Health in Ambulatory Care Research Team; CI, confidence interval.
The prevalence of heart disease was 8.7% (n = 2,453) and 2.14% (n = 150) in males and 6.3% (n = 2,212) and 1.59% (n = 140) in females in the Canadian and Austrian populations, respectively. Higher gender scores were associated with a higher risk of heart disease when compared to female sex in both populations (Table 4). This association was stronger in the Austrian population (Austria: odds ratio 22.14, 95% CI 7.28-68.17; Canada: odds ratio 3.87, 95% CI 2.71-5.52).
Table 4Associations between sex, gender, and heart disease in Canadian and Austrian populations
There was no significant interaction between sex and gender score in predicting cardiovascular health (CANHEART/ATHEART indices) of the Austrian and Canadian populations (P = 0.5 and P = 0.09, respectively). However, in the Canadian population there was a statistically significant interaction between sex and gender for predicting the occurrence of overt heart disease (P = 0.04).
Discussion
The results of this study conducted in population-based samples of Canadians and Austrians demonstrate that sociocultural gender, referring to personality traits and social characteristics typically ascribed to women, is associated with poorer cardiovascular health and a higher prevalence of heart disease regardless of sex. In contrast, females exhibited better cardiovascular health and a lower prevalence of heart disease than males in both populations independently from baseline cardiovascular risk factors.
In this study, we created a composite gender index in Canadian and Austrian populations. Previous literature
Combining psychosocial data to improve prediction of cardiovascular disease risk factors and events: the NHLBI-sponsored Women's Ischemia Syndrome Evaluation (WISE) study.
has highlighted the need for building a composite measure to assess the impact of psychosocial variables owing to the inherent statistical difficulties associated with addressing the large amount of variables. The present study shows that a gender score can be created with different gender-related factors depending on the study population. Although there are a number of overlapping variables such as education, marital status, and household income, factors such as perceived life stress and household size were specific to the Canadian population, and frequency of negative emotions was reported only for the Austrian database. Importantly, despite the different components that contribute to the construction of the gender score, the results of the PCA revealed a very similar distribution of the gender score in both countries.
In both populations, females experienced better cardiovascular health, and had a lower prevalence of CVD. This finding is similar to the result of the study by Maclagan et al.
that also reported better cardiovascular health in females than males and further reported that males had poorer healthy behaviours compared with females except for physical activity. Some studies have suggested that caregiver status and family commitments are barriers to physical activity in females, which may explain the observed discrepancy in this variable.
In contrast, people with characteristics ascribed to women (higher gender scores) experienced worse cardiovascular health and higher risk of heart disease in both populations. The magnitude of this risk was greater in the Austrian population compared with Canada.
The Gender Inequality Index (GII), a measure of institutionalised gender, was generated by the United Nations and measures gender inequality in 3 areas: reproductive health, empowerment, and economic status.
The GII is standardised such that 0 indicates perfect gender equality and 1 indicates perfect inequality (in favour of males). Canada (0.083) and Austria (0.073) have similar low GIIs. Therefore the difference in the impact of gender could be attributed to differences in sociocultural characteristics, health care system, or institutionalised structures (education, income) of both populations (Supplemental Table S6). For example, cultural differences in social support or mother-role expectations could lead to the slight difference between Canada and Austria.
where a higher risk of adverse cardiovascular outcomes after a premature acute coronary syndrome was evident in patients with personality traits and social roles traditionally ascribed to women, independently from biological sex. Cardiovascular health is determined by various factors, most of which are interacting with living conditions and environment of the individual. Our study explored the impact of classical risk factors such as hypertension, dyslipidemia, diabetes, smoking, and overweight/obesity, in addition to psychosocial factors such as depression, anxiety, chronic life stress, lack of social support, and socioeconomic factors such as low educational level and low income, on CVD.
Currently, one can find studies investigating the effect of some components of our gender index on cardiovascular health. The relationship between a multigenerational household and the risk of suffering a coronary artery incident has also been reported in a study by Ikeda et al.
In that study, living with a spouse and children/parents compared with a spouse alone increased the risk of developing coronary artery disease by 2-fold. Being divorced or separated was an additional factor that was considered in the gender score. While studies have demonstrated a better prognosis after myocardial infarction in married males, middle-aged married females demonstrated a higher fatality risk than unmarried females.
Living arrangements as determinants of myocardial infarction incidence and survival: a prospective register study of over 300,000 Finnish men and women.
Evidence for the role of psychosocial distress and social/environmental adversity on cardiovascular outcomes have been discussed in a variety of disciplines.
Greater cardiovascular responses to laboratory mental stress are associated with poor subsequent cardiovascular risk status: a meta-analysis of prospective evidence.
The present study reveals the importance of psychosocial and gender-related factors in cardiovascular health. Further prospective studies are warranted to assess the multidimensionality of such factors and their impact on CVD outcome. Such investigation would facilitate the development of gender-based promotion strategies with the goal of endorsing healthy behaviours to further improve the cardiovascular health within the population.
Greater cardiovascular responses to laboratory mental stress are associated with poor subsequent cardiovascular risk status: a meta-analysis of prospective evidence.
There are number of limitations with this study. The first limitation is the difference in definition of heart disease in the 2 countries. The CCHS reported heart disease as chronic heart disease diagnosed by a health care professional, whereas the AT-HIS definition was history of coronary heart disease or angina pectoris within the past 12 months. That could be the reason why we see differences in the magnitude of higher cardiovascular risk in people with characteristics ascribed to women between the 2 countries. In addition, owing to the harmonisation of both databases, some granularity of information was lost. For example, we had to use household income instead of personal income, because the AT-HIS reported only household income.
Conclusion
The results of the present study demonstrate that individuals with characteristics typically ascribed to women have poorer cardiovascular health and higher risk of heart disease, independently from biological sex and difference in baseline cardiovascular risk factors in both Canadian and Austrian populations. This is while female biological sex exhibited better cardiovascular health and a lower prevalence of heart disease than males in both populations. The study represents a practical approach to assess the complexity of the role of sociocultural gender (ie, role, identity, relation, institutionalised gender) in a country-specific manner. Current investigations revealed that the magnitude of gender impact varied by country, being greater in the Austrian than the Canadian population. This study highlights the need for the consideration and implementation of country specific gender-related factors to improve cardiovascular health.
Funding Sources
The GOING-FWD Consortium is funded by the GENDER-NET Plus European Research Area Network (ERA-NET) Initiative (project reference number GNP-78 ), the Canadian Institutes of Health Research ( GNP-161904 ), “La Caixa” Foundation (ID 100010434 with code LCF/PR/DE18/52010001), the Swedish Research Council ( 2018-00932 ), and THE Austrian Science Fund ( FWF I 4209 ). V.R. was funded by the Scientific Independence of Young Researcher Program of the Italian Ministry of University, Education, and Research ( RBSI14HNVT ).
Disclosures
The authors have no conflicts of interest to disclose.
Canadian Institutes of Health Research. Online training modules: integrating sex & gender in health research. Available at: https://cihr-irsc.gc.ca/e/49347.html. Accessed March 24, 2021.
Cigarette smoking as a risk factor for coronary heart disease in women compared with men: a systematic review and meta-analysis of prospective cohort studies.
Smoking as a risk factor for stroke in women compared with men: a systematic review and meta-analysis of 81 cohorts, including 3,980,359 individuals and 42,401 strokes.
Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks, 1990-2015: a systematic analysis for the Global Burden of Disease Study 2015.
Greater cardiovascular responses to laboratory mental stress are associated with poor subsequent cardiovascular risk status: a meta-analysis of prospective evidence.
Combining psychosocial data to improve prediction of cardiovascular disease risk factors and events: the NHLBI-sponsored Women's Ischemia Syndrome Evaluation (WISE) study.
Living arrangements as determinants of myocardial infarction incidence and survival: a prospective register study of over 300,000 Finnish men and women.
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