Lifestyle Medicine for Women: The Time Is Now!

Abstract

As the founders of the American College of Lifestyle Medicine’s Women’s Health Member Interest Group, we welcome this issue focused on the important issues facing women, their providers, and researchers in this field. Women’s health extends beyond sex-specific reproductive health issues, by also encompassing the medical conditions that are more prevalent in women as well as conditions that are expressed differently in women. Inadequate representation of women in clinical research has contributed to poorer outcomes. As lifestyle medicine forms the foundation of true health, the time is now to recognize and address these issues with research, education, and advocacy.

‘For centuries, Western medicine has failed to study or understand both the sex-specific issues women and their providers face, and the fundamental importance of addressing lifestyle as the foundation of women’s health.’

In the last year, we experienced the “twindemic” of both COVID-19 (coronavirus disease 2019) and the legacy of systemic racism. Many lifestyle medicine providers experienced a “teachable moment,” questioning the past while realizing lifestyle medicine’s potential to address both disparities in health outcomes as well as foundations of true health to forge a path out of this pandemic. We hope that women’s health in lifestyle medicine can also have its “teachable moment.” For centuries, Western medicine has failed to study or understand both the sex-specific issues women and their providers face, and the fundamental importance of addressing lifestyle as the foundation of women’s health. While there are also gender factors affecting women’s health, which include behaviors, expectations, attitudes, and expressions that are socially, culturally, and personally defined and exist along a continuum, an in-depth review of these is beyond the scope of this editorial. We will focus primarily on sex-specific or biologic factors and their intersection with lifestyle.

Health Concerns With Higher Prevalence in Women

Osteoporosis

A 2015 review found that nationwide hospitalization rates and costs for US women 55 and older were higher for osteoporotic fractures than for myocardial infarction, stroke, or breast cancer. ¹ An emphasis on lifestyle measures in adolescence that support peak bone mass in their late teens and early 20s can reduce future risk and burden of osteoporosis. These measures include dietary sources of calcium such as dark leafy greens along with exercise and education about avoiding tobacco and alcohol. ² Dietary patterns and exercise throughout a woman’s lifespan can reduce risk of osteoporosis, falls, and fractures.^3-5

Breast Cancer

Breast cancer is the most commonly diagnosed cancer in women and the second highest contributor to cancer-related death in women. One in 8 women will develop invasive breast cancer in their lifetime, with an estimated 281 550 new cases of invasive breast cancer and 49 290 new cases of noninvasive breast cancer projected to be diagnosed in 2021. ⁶ Breast cancer is more common in Black women under the age of 45, and overall Black women are more likely to die of breast cancer compared with women of other ethnicities. ⁷ This difference is partially explained by disparities in socioeconomic determinants such as poverty and social injustice. Addressing obesity and chronic inflammation through exercise and a dietary pattern emphasizing fruits and vegetables, reducing refined carbohydrates and saturated fat, and reducing or eliminating alcohol supports breast cancer prevention and increases the life expectancy of breast cancer survivors.^8-10

Mood Disorders and Autoimmune Conditions

Anxiety, depression, and autoimmune conditions are more prevalent in women. While gender-related factors affect mood disorders, a potential shared biologic mechanism that connects mood disorders with autoimmune conditions is the differential modulating effects of fluctuating ovarian hormone production on women’s susceptibility to stress, brain structure and function, immune reactivity, and inflammation.^11-13 A Mediterranean dietary pattern rich in colorful fruits and vegetables, herbs, spices, and omega-3 fatty acids is associated with reduced inflammation, likely in part through beneficial effects on gut microbial diversity and intestinal permeability. Exercise, modalities such as meditation to address stress, and ensuring adequate quality and quantity of sleep may help both mood and autoimmune activation through anti-inflammatory mechanisms.^14,15

Health Concerns With Different Phenotypic Expression in Women

Cardiovascular Disease

Women have a higher prevalence of both myocardial infarction and ischemia with nonobstructive coronary artery disease. Coronary microvascular dysfunction appears to be the culprit, and in the past patients were reassured and not treated despite having higher rates of cardiovascular events. ¹⁶ In addition to addressing underlying risk factors such as hypertension and diabetes, lifestyle strategies including weight loss, smoking cessation, a high-fiber diet with an emphasis on fruits and vegetables, and exercise can improve coronary microvascular function.^17,18 Recent research has highlighted the relationship between a woman’s menstrual and reproductive history and her cardiovascular risk: hypertensive disorders of pregnancy, gestational diabetes, small for gestational age babies, and premature menopause are predictive of higher risk. ¹⁹ Proactively identifying women with this history and addressing lifestyle factors may prevent or delay development of cardiovascular disease.

Sleep Apnea and Upper Airway Resistance Syndrome

Sleep apnea has historically been viewed as a condition primarily affecting overweight men and is underdiagnosed in women. Several other factors contribute to missed diagnoses of sleep disordered breathing in women. Women are more likely to underreport or minimize snoring, ²⁰ and screening questionnaires have a lower sensitivity in women. ²¹ Women are more likely to present with morning headache, fibromyalgia, insomnia symptoms, and anxiety or depression as opposed to nocturnal gasping or choking. ²²

Upper airway resistance syndrome, or UARS (characterized by respiratory event–related arousals in the absence of significant airflow limitation or oxygen desaturation), is a more common phenotypic expression of sleep disordered breathing in women. UARS is often missed with home screening studies and does not meet insurance criteria for treatment with continuous positive airway pressure despite its effectiveness. However, women’s subjective daytime somnolence with UARS is similar to that experienced by people with more severe sleep apnea and higher apnea/hypopnea indices.^23,24 Sleep apnea and UARS are associated with polycystic ovarian syndrome, ²⁵ adverse pregnancy outcomes, ²⁶ insulin resistance, weight gain, ²⁷ and dementia. ²⁸ Identifying and referring women for assessment and treatment is an important component of lifestyle medicine.

Pregnancy and Reproductive Health

Lifestyle medicine plays an outsized role in reproductive health as the impact on women in the months to years prior to pregnancy not only affects maternal health but also the health of her children throughout their lifespan. The impact of maternal lifestyle during early pregnancy can affect the developing fetus in a variety of fundamental biological processes known as epigenetic imprinting. ²⁹ Maternal epigenetic imprinting can also affect the fetal ovarian cells and therefore the health of future grandchildren. ³⁰ Given the importance of lifestyle choices, many women are highly motivated in the preconception period and during pregnancy to improve their health. ³¹ Cultural norms and peer influence can support or hinder these changes. Women whose partners continue to smoke have higher rates of relapse after smoking cessation. ³² Pregnant women exercise at lower rates than evidence-based guidelines recommend, often because physicians are reluctant to recommend exercise to pregnant women. ³³ On a positive note, peer support can also support lifestyle change as shown by the Centering Pregnancy model where the power of supportive peers in group prenatal visits led to improved pregnancy outcomes. ³⁴

Pregnancy and the preconception period offer many opportunities for research, education, and advocacy for lifestyle medicine. While prenatal vitamins, folic acid, and supplemental iron are widely prescribed and taken by women before and during pregnancy, natural, whole food sources of these necessary nutrients are often missing. Women’s diets before and during pregnancy often reflect the baseline standard American diet, with a deficit of fiber, fresh fruits, and vegetables. ³⁵ Improved diet quality not only improves fertility but can also decrease the risk of adverse pregnancy outcomes. ³⁶ Physiologic changes of pregnancy may lead to insulin resistance and hypertension, not only increasing risk in the current pregnancy but also increasing risk for future development of hypertensive disease ³⁷ and diabetes. ³⁸ Unfortunately, poor communication between prenatal and primary care providers and inadequate postpartum care lead to lost opportunities to diagnose and provide early lifestyle change interventions. As a result, women miss an opportunity to substantially delay, or even entirely prevent future onset of these lifestyle-related conditions.

The postpartum period is also a time when pressures of childcare and cultural norms promoting sedentary behavior can lead to women not getting sufficient exercise. Studies have shown a substantial benefit to exercise in the prevention of future disease, ³⁹ again pointing to the importance of lifestyle medicine in women’s health.

One in 3 Americans does not get adequate sleep, and sleep quality and duration decreases in pregnancy and the postpartum period. ⁴⁰ Restless leg syndrome is a frequent cause of insomnia in women and rises to nearly a third of all pregnant women, ⁴¹ yet the fundamental mechanism and optimal intervention remain elusive. The syndrome is associated with low iron and folate levels, and patients should be informed that natural plant-based sources of these nutrients may decrease their symptoms and resulting insomnia. ⁴² Sleep apnea rises with the physiologic changes of pregnancy and has been associated with the onset of preeclampsia, ⁴³ yet again remains underdiagnosed and undertreated. More awareness and research is needed.

In addition to the acute financial and physical stressors women encounter in pregnancy, many women enter pregnancy with the legacy of chronic stressors. Research has shown a dose dependent relationship of one marker of chronic stress, the ACE (Adverse Childhood Experiences) score on fetal birth weight. ⁴⁴ Further research is needed on both the impact of stress on pregnancy outcomes as well as potential solutions to mitigate that stress.

Women as Caregivers

Societal pressures and cultural roles often place women in the primary roles as caregivers to not only their children but also their spouses and parents. More than 75% of caregivers are women, ⁴⁵ and caregiving demands significantly affect sleep, mood, and functionality.^46,47 Addressing the need for emotional support and improved sleep is needed to help reduce the adverse impact on caregivers’ health. COVID-19 has exacerbated this gender discrepancy, with nearly 4 times as many women leaving the workforce because of the accompanying child care and school crises with an even greater impact on mothers of color. ⁴⁸ Not only are food and housing security affected, but long-lasting effects on earnings, retirement security, and gender equity in the workplace are also expected. Understanding, advocating for, and supporting caregivers creates a ripple effect across generations.

Research in Lifestyle Medicine for Women

Both preventative lifestyle change and women’s health have historically been low priorities for research. The issues are compounded when we seek to give evidence-based advice on the benefits of preventative lifestyle change for women. Prevention is only 3% of the nearly 4 trillion-dollar annual spending on US health care, ⁴⁹ despite the fact that improving lifestyle could prevent 80% of disease. ⁵⁰ Research on nutrition had fallen as a percentage of federal research funding in recent years, ⁵¹ and the National Institutes of Health (NIH) recently proposed closing its last remaining in-house facilities for nutrition research. ⁵²

Until 1993, women of reproductive age were routinely excluded from NIH-funded clinical trials. The Health Revitalization Act mandated the inclusion of women in NIH-funded clinical trials. ⁵³ In 2016, that mandate was expanded to all NIH-funded research. ⁵⁴ However, the legacy of decades of prior exclusion continues to affect women. As women of reproductive age were excluded from drug safety trials, this may have underestimated the risks to women of new medications. One survey showed 80% of the medications pulled from the market after approval were found to have greater side effects in women than in men. ⁵⁵ The exclusion of pregnant and lactating people from COVID-19 vaccine trials is a contemporary example of uncertainty and confusion for both patients and providers arising from the ongoing lack of data. ⁵⁶

Forty percent of American women report using complementary and integrative medicine. ⁵⁷ Unfortunately, the risks and benefits of such therapies have not always been evaluated by clinical trials. Calls for greater funding to research the impact of integrative therapies on women’s health have existed for decades. ⁵⁸ It is our hope that in future years we will see greater funding for and rigorous research from the NIH’s National Center for Complementary and Integrative Health’s research initiatives specifically targeting women’s health. ⁵⁹ It is up to us to continue advocating to prioritize research, not only in fundamental lifestyle choices but also in promising integrative therapies.

Discussion

COVID-19 has shined a bright light on the urgent need (and potential) for lifestyle medicine to address health inequity. The pandemic has disproportionately traumatized women in vulnerable populations. Morbidity and mortality from COVID-19 are higher in those with underlying lifestyle-related chronic illnesses, who are economically disadvantaged, and in minority populations. This pandemic may provide a “teachable moment,” a trauma that could result in growth on a scale never before witnessed. Cancer survivorship research has shown that posttraumatic growth may be associated with positive behavior change, increased bodily care, an enhanced sense of personal strength, and perceived new possibilities. ⁶⁰ How can we as women’s health practitioners and lifestyle medicine leaders use our own health paths, our passion, our purpose, and our power to change health trajectories of others during this “teachable” moment?

Despite COVID-19, the American College of Lifestyle Medicine (ACLM) has experienced growth in membership, educational offerings, and policy work. Communities within ACLM’s Women’s Health Member Interest Group are writing a textbook, creating pregnancy focused continuing medical education, hosting webinars, and preparing an ACLM 2021 pre-conference workshop. Our subcommittees are advancing meaningful work in reproductive health, pregnancy, menopause, and breast cancer. We are inspired to collectively advance lifestyle medicine for all women and invite each of you to join us in transforming the trajectory of health for women by joining ACLM’s Women’s Health Member Interest Group. www.lifestylemedicine.org

Lifestyle medicine for women, the time is now!