Ana Baylin, MD, DrPH, and Dongqing Wang, MPH, PhD(c), on How Lifestyle Modifications Can Lower CVD Risk in Menopause

Women’s risk of developing cardiovascular disease (CVD) is known to increase significantly after the onset of menopause

Various lifestyle factors such as smoking status, body mass index, diet, and physical activity level can all impact this risk. In fact, a new analysis of 1143 women in the Study of Women’s Health Across the Nation suggests that practicing healthy lifestyle behaviors in midlife may help lessen the acceleration of subclinical atherosclerosis during the menopausal transition.1

Consultant360 spoke about these findings and their clinical implications further with study authors Ana Baylin, MD, DrPH, FAHA, and Dongqing Wang, MPH, PhD(c), of the University of Michigan School of Public Health in Ann Arbor.

Consultant360: What should clinicians know about the relationship between the menopausal transition and CVD?

Authors: Women experience an increased risk of CVD after the menopause relative to before menopause, even after accounting for the effect of chronological aging. The complex mechanisms through which the menopausal transition affects CV risk are not yet fully deciphered.

Previous studies found that menopause is associated with several adverse changes of CV risk factors, independent of chronological aging, such as increased levels of total cholesterol, low-density lipoprotein cholesterol (LDL-C) and apolipoprotein B, which is a component of LDL-C. The menopausal transition is also associated with increases in total abdominal fat and visceral fat, which are also risk factors for CVD.

We found that women who have a healthy lifestyle—defined by abstinence from smoking, eating a healthy diet, and engaging in regular physical activity—during the midlife—defined as the life period that includes the menopausal transition—have lower levels of subclinical atherosclerosis later in their lives. This suggests that the midlife is a critical window of opportunity for CVD prevention, and that lifestyle intervention programs targeting smoking, diet, and physical activity, may be able to slow the menopause-related progression of atherosclerosis.

C360: Your study indicated that women with higher Healthy Lifestyle Scores had significantly wider arteries, less arterial thickening and buildup of fatty plaque. Could you discuss the 3 key factors that affected these scores and the impact of each?

Authors: The healthy lifestyle score was constructed using 3 behavioral CVD risk factors that are largely modifiable: smoking, diet quality, and physical activity. We found that smoking appears to be more strongly associated with subclinical atherosclerosis than unhealthy diets and lack of physical activity. Cigarette smoking is a major behavioral risk factor associated with atherosclerosis through mechanisms including thrombosis, dyslipidemia, insulin resistance, vascular inflammation, abnormal vascular growth and angiogenesis, and loss of endothelial homeostatic and regenerative functions. Actually, multiple studies have shown that prolonged smoking confers a higher CVD risk in women compared with men.

For physical activity, the very recently updated 2018 guidelines from the US Department of Health and Human Services recommend that adults pursue at least 150 minutes per week of moderate-intensity, or 75 minutes per week of vigorous-intensity, aerobic physical activity (or an equivalent combination of both) for substantial health benefits.2 In terms of diet, similar to other population groups, midlife women are recommended to consume more fruits, vegetables, legumes, nuts, fish, and whole grains, and decrease their consumption of red meat, processed meat, sweets, desserts, sugar-sweetened beverages, and refined grains.

Although the dietary and physical activity components of the healthy lifestyle score appear to have weaker effects than the smoking component on subclinical atherosclerosis, they should also be emphasized. It is possible that because smoking is measured more accurately than diet and exercise, the associations for diet and exercise are somewhat attenuated. When exposures are measured with a lot of error, which is the case for diet and exercise, the associations are typically attenuated. That still does not account for the fact that smoking is probably a stronger risk factor than diet and exercise, but it can explain why the associations between diet and exercise do not look larger.

C360: Knowing that the prevalence of certain healthy behaviors is low among midlife women, what should clinicians take away from your study? How might your findings affect clinical practice?

Authors: This work highlights the growing recognition that the midlife is a critical window for CVD prevention and strongly supports the need for lifestyle interventions aimed at promoting these modifiable health behaviors in midlife women. Practicing clinicians should emphasize to their midlife female patients the importance of improving overall lifestyle behaviors (including abstinence from smoking, eating a healthy diet, and engaging in regular physical activity), even if their patients are apparently healthy without clinically diagnosed CVD.

C360: What are the next steps in your research?

Authors: We believe more prospective studies in which midlife women are followed into their old age are needed. From this type of studies, we can further investigate how specific health behaviors during the menopausal transition could impact cardiometabolic outcomes in the future. For example, in our group, Dongqing Wang, PhD(c), has been using the same data from the Study of Women's Health Across the Nation to examine the potential effects of dietary patterns and beverage intake during the midlife on atherosclerosis later in life.

—Christina Vogt

Ana Baylin, MD, DrPH, FAHA, is associate professor of Epidemiology and Nutritional Sciences at the University of Michigan School of Public Health in Ann Arbor, MI.

Dongqing Wang, MPH, PhD(c), is a doctoral student at the University of Michigan School of Public Health in Ann Arbor, MI.


1. Wang D, Jackson EA, Karvonen-Gutierrez CA, et al. Healthy lifestyle during the midlife is prospectively associated with less subclinical carotid atherosclerosis: The Study of Women's Health Across the Nation. J Am Heart Assoc. 2018;7:e010405. doi:10.1161/JAHA.118.010405.

2. Piercy KL, Troiano RP, Ballard RM, et al. The physical activity guidelines for Americans [Published online November 12, 2018]. JAMA. doi:10.1001/jama.2018.14854.