Can we prevent cardiovascular disease in women?

Leanne Kaufman:            

Did you know that women are seven times more likely to die of cardiovascular disease than breast cancer? And, according to data from the Heart and Stroke, early heart attack signs are missed in about 78 percent of women.

Heart disease is the number one preventable cause of death amongst Canadian women, yet heart disease remains understudied, underdiagnosed, and undertreated in women.

Hello, I’m Leanne Kaufman, and welcome to RBC Wealth Management Canada’s Matters Beyond Wealth.

With me today is Dr. Kara Nerenberg, an associate professor and clinician scientist at the University of Calgary, working in general internal medicine and obstetric medicine. I had the extreme privilege of meeting Dr. Nerenberg when she spoke at an event hosted by our colleagues at Women’s Brain Health Initiative, and I’m really excited to bring her expertise to this podcast.

Dr. Nerenberg, welcome. I’m glad we get to continue the conversation around women’s heart health and why this matters beyond wealth.

Kara Nerenberg:             

Oh, thank you very much for inviting me today.

Leanne Kaufman:            

So can you start us off by telling us about the work that you do? And in particular, the important research you’re doing in cardiovascular health?

Kara Nerenberg:             

Yes. I’m an internal medicine physician, and I’m also a researcher focused on prevention of cardiovascular diseases, and that includes both heart and brain diseases in women across their lifespan.

This interest started about 20 years ago when a landmark Canadian study came out, and it showed that women who experienced any of the high blood pressure disorders of pregnancy had, on average, a 2 to 4 times higher risk of having heart attacks and strokes, but really at a very young age, within about 8 to 10 years after delivery.

Since that landmark study, we know from other population-level data in Canada and across the world that many other reproductive events are also associated with higher risks of heart and brain disease, including the high blood pressure disorders like preeclampsia, HELLP syndrome, gestational diabetes, preterm delivery, and a long list of other less common events so, altogether, about one in five pregnancies in Canada.

But in addition to the heart and brain diseases that occur maybe 10-ish years later or after, our team’s research has shown that within the first 5 years after delivery, women start to develop many of the risk factors that lead to premature heart and brain diseases, like high blood pressure, high cholesterol, prediabetes, obesity, and others.

In addition to that, our team’s research has shown major gaps in the preventative care after pregnancy, where in Canada very few women receive any screening or treatment for these cardiovascular risk factors. And that’s important because these are largely preventable or manageable through consistent health behaviour changes, like small increases in physical activity or improvements in addition—in nutrition, sorry.

So to address these gaps in preventative care, our team’s research really focuses on novel ways that we can integrate evidence-based preventative care into day-to-day clinical practice for primary care, as well as for specialists.

And we’re also looking at better ways to support the preventative health journey of thousands of Canadian women through changes to the health system and engagement with community partners like today.

So I need to acknowledge, though, in this dual role, I’m incredibly privileged to be both a clinician and a researcher. I get to hear the stories of patients across their lifespan, and this is what drives our team’s research to address these gaps that matters most to women and the health of their families as well.

Leanne Kaufman:            

I love talking to you and researchers and clinicians like you who are not only doing the academic side of things but actually bringing it to the patients. I think it’s a great trend and such a gift.

And the preventative side, obviously, something very critical that we, on this podcast, talk a lot about, particularly when it comes to brain health.

But in any event, a lot of this started because we got introduced, like I said earlier, through our friends at the Women’s Brain Health Initiative. And this is another area where only research on men has been conducted and so that’s led to gaps in women’s healthcare, like you’ve mentioned.

So, what does your research show on how those gaps, or at least the historical gaps, have impacted lifespans?

Kara Nerenberg:             

Yeah. So I think that’s a question, and I don’t think we really know the full answer there because it’s multifaceted. There’s two major areas that this can fall into.

So, one is that conditions which predominantly affect women, like endometriosis, microvascular chest pain, just to name a couple, they’re not well studied or funded by research and this means we actually don’t understand much about the biology of some of these conditions. And this then limits our ability to diagnose and manage many of these conditions. And even if we take that further, we don’t know the impact that these conditions have on lifespan as well as quality of life.

But the second major gap is that the research that is focused on conditions that affect both men and women have largely included male participants. And this is a major challenge because the biology of females is quite different from the biology of males. It goes beyond just size and weight and body composition, but we have to start thinking about the metabolism of drugs and other hormonal changes that affect how drugs, which are studied, again, in largely male populations, actually affect the bodies and health of females.

Third, if we think about another group, we really haven’t looked at how the gender roles and responsibilities that often fall to women in our Canadian society further impact women’s health outcomes.

So if we take all that together, all these major research gaps are what’s leading to pretty big discrepancies in health outcomes for many, and probably all medical conditions if we think about it.

For example, colleagues here in Alberta did a study that showed that after a heart attack, females are prescribed much fewer evidence-based therapies than men. We also know that when we look at dementia, women get fewer treatments too, that can also improve their quality of life.

So these differences, because of the research, likely do have major impacts on the health, the quality of life, and the overall lifespan of women. Yet we don’t have data to accurately quantify these impacts.

Leanne Kaufman:            

Hmm. Well, we’re even more grateful that you’re doing the work that you’re doing.

You mentioned earlier that the impact of some of the pregnancy-related conditions and so on, which, when you’re pregnant, you’re generally younger and probably not super focused about worrying about their heart health. So why, why did you focus—you mentioned the research study but like, why do you continue to focus on pregnant women? And what have you learned from them?

Kara Nerenberg:             

Yeah. So I think that’s a great question because people aren’t really aware of what actually can go wrong in pregnancy. There’s many heart and brain conditions that occur in pregnancy, like stroke, heart failure, heart attacks, and even maternal deaths do occur in Canada.

And I focus on the area of high blood pressure disorders in pregnancy because they’re a strong contributor to all of these conditions that happen both during pregnancy and lifelong. These conditions can be fatal. And generally, when we look at a health systems level, there’s very little follow-up of blood pressure after pregnancy, which is a really common time that women might have a stroke or other adverse outcomes too.

So because of all those associations and a major gap in care, that’s why I focus on the high blood pressure disorders.

We’re working on better ways to monitor blood pressure, both during and after pregnancy, to better manage the blood pressure to prevent these catastrophic events like stroke and death. But we also then continue to follow them for months after pregnancy to make sure the blood pressure normalizes. And then—within about that first six months. And then we continue to follow these women lifelong to screen for the vascular risk factors that we talked about—so high cholesterol, prediabetes, high blood pressure—and treat them if we need to with medications.

And then we also start talking about the next pregnancies to see if we can also layer in preventative interventions in the next pregnancy to improve outcomes like baby aspirin, which has been shown to reduce high blood pressure disorders in pregnancy too.

So again, really focusing here because it’s a major gap. But we learned so much from these women about their biology, how they utilize the health systems, their health stories, and it’s really inspiring, their incredible resilience, strength, and dedication to their families.

But what we still need to work on, as you talked about, that these women aren’t super aware of their risks. It’s a really difficult conversation of, how do we talk about future health risks, which are real, not common in the first 10 years, but start to accumulate later in life? And how do we talk about this in a way that balances the information, which can be scary or overwhelming—but yet also communicates the preventative aspects of brain and heart diseases?

And then also, how do we support moving the needle on gender roles without adding to the mommy guilt of adding one more thing that they should be doing, but really in a way that we can help them prioritize their own health needs within those first few years with their family members? Because those first few years is probably where we’re going to have the greatest long-term impacts on health.

Leanne Kaufman:            

Yeah. You make a great point about the balance of the scaring enough to want someone to do something preventatively but not be paralyzed in being able to live their lives.

Kara Nerenberg:             

It’s tough because they’re in their 20s or 30s, and they think… oh, dementia, that’s later in life, but all these diseases are actually really like early, midlife and whatnot, and that’s where we get the best impact.

Leanne Kaufman:            

You’ve mentioned a couple of times sort of gender-based roles, and I do want to come back to that theme. But before we do that, back to your role as both a researcher and a clinician, we’re not all fortunate enough to have our primary caregivers be researchers at the same time. So how is the work that you’re doing being implemented or rolled out at the primary caregiver or family medicine level? And where do we hope, aspirationally, that that might go?

Kara Nerenberg:             

Yeah, that’s really the next step in our work here is that we filled in this gap of preventative care with specialty clinics across the country. We’re up to over 25 specialized postpartum prevention clinics. And really, what we’re trying to do is help integrate this a little bit more into primary care. And what we have to think about is family medicine is an incredibly demanding job many, many things to focus on. And again, prevention often gets not the same priority due to we’re always putting out fires of things that need to be addressed on a more urgent basis.

So we’re looking for ways to simplify the management of women after these reproductive events by using different technologies and approaches to support an integration of cardiovascular preventative care in family practice.

So some of this is being studied looking at using electronic medical records, co-creating resources with women that they can use on their own when they’re at home. And then also, how do we engage other health professionals who are involved in this preventative health journey and see women at multiple touch points, like pharmacists, public health, vaccination visits, et cetera? And can we do better at meeting women where they’re at?

So that’s why we’ve included a broad range of health professionals, including primary care, in our team’s research, as we really work towards the goal of integrated care.

Leanne Kaufman:            

That’s good to hear for a path forward, for sure.

You’ve talked a couple times, and I already referenced coming back to it, that some of the gender-based roles—and I know your work focuses on some of the barriers that might keep women from accessing medical care, the gender-based roles like childcare or caring for elderly parents being one of them. I think you also look at things like ethnicity, socioeconomic status.

Can you expand on some of these factors and the impact that they have in your work?

Kara Nerenberg:             

Yeah. Definitely. And I think we’re really just beginning to understand these types of barriers, and that’s important to recognize because most studies to date didn’t actually collect any of this data that we need to really fully understand the complexities of the relationship of all these intersectional determinants on women’s health, but then also using that data to identify solutions to the barriers, and then actually evaluate if the solutions work.

We don’t collect, at a national level or provincial data, information on race or ethnicity, as well as these social determinants of health. So the smaller studies are starting to do this.

And with our observational learnings from patients and these smaller studies, and particularly in the postpartum space, one of the major barriers that our patients have identified through surveys or clinical practice is the childcare responsibilities, that they’re just overwhelmed. Many of their children have been in the neonatal intensive care unit, so these childcare responsibilities are real. But then also in that sandwich generation of care of elderly parents and starting to have to worry about the health of their parents.

And what we see is that this causes a tremendous amount of psychosocial stress, which then—it makes it really hard for women to follow physical activity and nutrition plans and participate in their health behaviours. And it also really limits them to come in person to clinic visit.

So these barriers are what is driving us to look at new ways to reach women where they’re at, like with virtual care platforms, which we do know that increases attendance at visits. But there is a bit of a concern of are we getting accurate measurements of blood pressure and weight? Anyhow, we do need to look at that.

But we’re also looking at other models of, can we pair mom and baby care together, with either the well baby visits or vaccination visits, to really make it more family-centred and a one-stop shop to make things easier for women.

So we do also know that women from other equity deserving groups, whether that be from race or ethnicity or lower socioeconomic groups, they have even more barriers to preventative care. Many of our colleagues are researching this across Canada, and they’re just starting to unravel these complex relationships, and then identifying work on solutions that are tailored to the unique biology, lifestyle and cultural factors that affect many of the high-risk groups, including Indigenous communities, South Asian communities, Filipino and Black, among others.

Other groups are also looking at different policy-type interventions like financial support for healthy nutrition or activity programs and medication support to see if these policy-related interventions actually adjust these gender-related barriers to care and really move forward gender-transformative changes that get to the root of these gender-related issues.

But right now, we’re looking at short-term impacts, and we will need to follow these studies for their long-term impacts on women’s cardiovascular health.

Leanne Kaufman:            

Yeah. It’s fascinating how the holistic lens changes the whole landscape.

What about wealth? I mean, you talked about socioeconomic, but we are a wealth management firm. This is called Matters Beyond Wealth. So let’s talk about like, how does that—how do you think wealth impacts health? Or vice versa?

Kara Nerenberg:             

Yeah. I think wealth has very complex relationships with health, both heart and brain health. We know that women from lower socioeconomic groups have higher rates of the risk factors like high blood pressure, obesity, smoking, that increases the risk of heart and brain diseases like stroke and dementia.

But it also shows that women from lower socioeconomic groups, they have fewer preventative care visits compared with women from higher wealth groups. But we don’t really know how to address these discrepancies.

But what’s also really important when we’re talking about wealth is the financial impact of the development of these premature chronic conditions, because these are lifelong conditions—high blood pressure, diabetes—and they’re associated with many other cardiovascular health conditions.

And I think we’ve done a good job of looking at the impact on the health system, but not really on society, because most of these conditions are starting to affect women in their most productive work years, which has major impact on the wealth of the individual families, businesses, and even the economic growth of our country. So we really need to be thinking beyond the healthcare system about how do we support these women to stay healthy, to continue to support our businesses, our communities, our families, and that we also need to talk to women about planning ahead beyond just the medical and health issues. Like we talk about the next pregnancy, but we don’t really talk about their long-term health and whether they need to start focusing on financial planning, childcare planning, because they may have shorter periods of productivity and lifespan than other women.

Leanne Kaufman:            

Caregiving and so on.

I mentioned earlier, I first heard you speak at a Women’s Brain Health Initiative event. And of course, we in the financial services area do worry a lot about cognitive impairment, dementia, and planning for that. And you’ve mentioned heart health and brain health in the same breath a couple of times.

So, what is the connection—we’re talking about for women here, but I’m guessing maybe it’s gender-neutral in this case—between heart health and brain health?

Kara Nerenberg:             

I think this is an area of research that’s rapidly advancing here in Canada. Several centres have received funding to look at the heart-brain connections.

We know for years that there’s the vascular connection. So atherosclerosis or hardening of the arteries is a really common factor underlying both heart disease, as well as strokes and dementia.

We also know that the same preventative interventions, like nutrition, physical activity, smoking avoidance, sleep, stress management, do work to lower about 90 percent of both heart and brain diseases, because we’re looking at similar mechanisms there, as well as medications that are used for risk reduction too, whether that be cholesterol pills, blood pressure pills, et cetera.

We’ve also known a little bit about heart rhythm problems like atrial fibrillation, which is pretty common across Canada, which we know that that irregular heart rhythm can lead to clots in the atrium of the heart which can cause stroke, and that we need to treat this heart rhythm problem with blood thinners as well to lower the risk of stroke.

But what we’re really just starting to learn more about is the complex biological and hormone connections beyond the vascular treating clotting, like the role of mood, stress, and all these other factors that we’ve been talking about, on both heart and brain disease.

So we often say what’s good for your heart is also good for your brain, which is good for your kidneys and good for your bones. And it really all does go together, especially for women.

Leanne Kaufman:            

Well, back to the good old get lots of sleep, eat well, and exercise, I guess.

Okay. Beyond that, we’ve talked about how some of this can be scary information. And I think a lot of us will have had our ears perk up about some of the risk factors.

Do you have any tips for our listeners on how to advocate for themselves, or for the women in their lives, in their own healthcare journeys when it comes to these topics?

Kara Nerenberg:             

Yeah. I think that women can be real powerhouses when they’re advocating for their own health needs. And sometimes, they’re not always listened to. And again, we do need to change the system so that women are better supported for prevention and better listened to.

So until that happens, we need women who’ve had reproductive events like preeclampsia, gestational diabetes—my tip for advocating there would be to check in with your family doctor and bring up those reproductive events and talk about having your vascular risk factors screened and whether that needs to be annual or every couple of years.

For women who are experiencing different symptoms that might be relating to heart or brain health, again, that it’s important to bring those up and discuss those in a really clear way with your healthcare provider to get the investigations and management that you need to start feeling better, as you mentioned before, because there’s a real tendency to under-investigate and undertreat women compared with men.

And then for everyone, as we mentioned, all those general health behaviours, which again, they’re easier said than done. So Health Canada and Heart and Stroke do recommend these lifestyle changes because it can lower about 90 percent of the risks of all heart and brain diseases. So healthy diet, physical activity of 150 minutes per week, where we always say some is good and more is better, avoiding smoking, maintaining a healthy weight, the sleep and stress management.

So again, sometimes easier said than done, and we have to think of ways that we can actually intentionally incorporate this or make it easier on a day-to-day basis.

And then for those who need medications for their blood pressure, cholesterol, et cetera, or mood, making sure that those medications are taken as prescribed and that we’re getting the risk factors to target, so get that blood pressure to the safe range, get that cholesterol to the safe range as well.

Leanne Kaufman:            

I don’t know about you, but I find the older I get, the harder it is to maintain some of those preventative factors. But anyway, we keep trying.

Okay. If you hope listeners only remember one thing from this fabulous conversation that I’ve had the privilege of having with you today—and I know there’s a lot to choose from—but what would that one thing be?

Kara Nerenberg:             

I guess it’s kind of thinking of women’s heart and brain health as a lifelong journey that involves education and awareness, prevention, and management of the risk factors that lead to heart and brain disease. Given that—and the importance to stay on top of it because research is being developed and on an ongoing basis.

And I think the biggest message is, is that women are often very concerned about healthy families, and healthy families need her to be healthy as well; that women do need to be empowered to put their own health needs first, along with those of their families, and that they really are important.

So I hope those are messages that people walk away with, that simple changes make big differences lifelong, and that they need to put themselves first.

Leanne Kaufman:            

I think that’s a great tip to leave us with.

So, thank you so much, Dr. Nerenberg, for joining me today to help us understand the heart health risks facing women in Canada, how it connects to our brains, and why this all matters beyond wealth.

Kara Nerenberg:             

Great. Well, thank you for having me. Thank you.

Leanne Kaufman:            

You can find out more about Dr. Kara Nerenberg on LinkedIn and the University of Calgary website, and you can learn more about our friends at Women’s Brain Health Initiative, whom we have to thank for this introduction, as I’ve mentioned before, at womensbrainhealth.org.

If you enjoyed this episode and you’d like to help support the podcast, please share it with others, post about it on social media, or leave a rating and review. Until next time, I’m Leanne Kaufman. Thank you for joining us.

Outro speaker:

Whether you are planning for your own estate, the needs of your family or business, or you are an executor for a loved one’s estate, we can help guide you, simplify the complex, and support your life’s vision. Partner with RBC Royal Trust and ensure your legacy will thrive for generations to come. Leave a legacy, not a burden™. Visit rbc.com/royaltrust.

Thank you for joining us on this episode of Matters Beyond Wealth. If you would like more information about RBC Royal Trust, please visit our website at rbc.com/royaltrust.

---

Other episodes in this series