Sage Journals: Discover world-class research

Abstract

Over the last several centuries, economic progress has allowed millions of women to move from rural subsistence agriculture to urban, more economically prosperous lifestyles. This trend is set to continue, even accelerate in the next century. Due to changes in diet, activity, and lifestyle, non-communicable diseases, such as cancer and heart disease, will continue to rise for women globally. At this time, we are uniquely positioned to anticipate this impact and empower women in both the developed and the developing world to learn from what has worked. Choosing the best approaches to nutrition, exercise, sleep, connectedness, substances, and stress can optimize women’s health span across the globe.

Keywords

lifestyle medicine global women’s health

What the World Needs Now: Lifestyle Medicine for All Women the potential for lifestyle medicine to address the global burden of disease faced by women as they transition into the 21st century

Introduction

The 3.8 billion women in the world today give birth to 140 million children a year,¹ provide care to billions of family members, and represent an outsized proportion of the planet’s elderly, thus the impact of global women’s health is staggering. As the planet’s population continues to transition from rural village life to a more urban environment with higher average incomes, and traditional cultural practices are replaced by western medical care, sedentary lifestyles, and western diets, the health of women will also change. In 2007, the percentage of the global population living in urban areas surpassed the rural population for the first time. This trend is expected to continue and rise to two-thirds of the global population in urban areas by 2050.²

Lifestyle medicine offers the opportunity to address the foundations of health for women and incorporates the best of both traditional practices that serve health, while using modern research to validate optimal approaches to health. While the initial applications of lifestyle medicine to human health focused on issues common to both genders (e.g., atherosclerosis and diabetes) the application of lifestyle medicine to women’s health has the potential to transform the health of the planet’s 3.8 billion women as well as the infants they give birth and those to whom they provide care.

We will examine the potential for lifestyle medicine to address the global burden of disease faced by women as they transition into the 21st century. Proceeding through the six pillars of lifestyle medicine, we will analyze the differences between women’s health in the developing and developed world and identify solutions to promote improvement of health for all women.

Nutrition

Nutritional imbalances affect most, if not all, of the conditions facing women. Women have a higher burden of malnutrition while also experiencing a greater susceptibility to obesity. Global health has traditionally focused on nutritional deficiencies in the developing world, such as iron deficiency anemia and the consequences in pregnancy. Additionally, one-third of all women of reproductive age are anemic.³ However, contemporary data suggest that there are also a wide variety of both nutritional deficiencies and excesses in the developed world. Economically prosperous developed nations often consume higher caloric foods lower in fiber while developing countries may experience inadequate levels of micronutrients. These deficiencies have a wide variety of consequences for women which are only beginning to be understood. Addressing these concerns with a comprehensive plan that emphasizes the benefits of a whole food plant–based approach, with supplementation when needed, has the potential to address many of the nutritional deficiencies that women face.

For much of the 20th century, discussions of nutrition and global women’s health focused on deficits in the developing world of overall calories, protein, and micronutrients. Recent decades have seen overall improvements globally in women’s nutritional intake.⁴ However, caloric inadequacy and food insecurity remain global health problems. Globally, 9.7% of women are underweight, increasing to 25% in India and Bangladesh.⁵ Being underweight puts women at risk for anemia, infertility, and osteoporosis. Additionally, 821 million people are suffering from food insecurity with women in developing rural areas facing the greatest burden.⁶ Furthermore, nutritional deficiencies of iron and zinc are more prevalent in women in economically developed countries than men,⁷ and less than 3% of Americans receive the recommended intake of potassium.⁸ These nutritional deficiencies can be detrimental for women, especially in the age of the pandemic, as zinc appears to be protective against respiratory infections such as COVID-19.⁹

A study of women in sub-Saharan Africa, Latin America, and South-East Asia documented inadequate intake of micronutrients, including iron, folate, and zinc¹⁰ and also supported by a review of girls and women of reproductive age in low- and middle-income countries demonstrating ongoing dietary deficiencies in iron, vitamin A, iodine, zinc, and calcium.¹¹During pregnancy, women are more susceptible to iron deficiency as 43% of women in less developed countries are affected by anemia.¹² With nearly one-third of reproductive age women globally suffering from anemia and postpartum hemorrhage, a leading cause of maternal mortality, more needs to be done.

In 2010s Global Burden of Disease Study, iron deficiency was shown to be a leading cause of lost daily adjusted life years (DALYs).⁷ Within the top 25 risk factors of declining health, 10 of them alone were dietary, including diets low in fruits, vegetables, whole grains, nuts, seeds, milk, fiber, calcium, diets high in sodium, processed meat, red meat, sugar-sweetened beverages, and trans fatty acids. Both deficiencies in nutrient-rich foods and overconsumption of less nutrient-dense foods contribute to the prevalence of non-communicable disease in the developed world. Non-communicable diseases are typically not diseases of poverty, but diseases of affluence.

As incomes rise, the traditional plant-based diets of subsistence agriculture are being replaced by lower fiber diets with more calories from processed foods and animal products. These dietary changes impact both macro and micronutrient intake. Diets focused on red meat, refined grains, refined sugars, and high-fat dairy lead to deficiencies in magnesium, iodine, calcium, and vitamin D.¹³ In addition, the greater availability of calorie-dense processed foods has led to an increase in obesity with a consequent impact on metabolic and cardiovascular disease. Currently, 15% of the world’s women meet standards for obesity with the rise being most dramatic among young females whose rates of obesity increased from 4% in 1975 to 18% today.¹⁴

Inadequate fiber intake is one of the most glaring nutritional deficiencies in women’s health. While India and many nations in sub-Saharan Africa meet current recommended fiber minimums, >90% of Americans do not get adequate fiber intake.¹⁵ Stroke and cardiovascular disease are often under-recognized as leading causes of death in women, with fiber playing an essential role in primary prevention.^16,17 In addition to a wide variety of benefits for general health, fiber has been linked to decreasing breast cancer risk.¹⁸ Increasingly, research points to the role of high fiber diets in preventing preeclampsia,¹⁹ a pregnancy complication characterized by high blood pressures. In a Norwegian study, the risk of preeclampsia was reduced by a third in mothers during pregnancy that ate a diet high in vegetables, fiber, vegetable oil, and fruits in comparison to those with a diet high in meat, salty foods, and sweetened drinks.²⁰ Additionally, an increase in dietary fiber has been shown to reduce the level of triglycerides resulting in a reduced risk in preeclampsia.²¹ However, more research needs to be conducted to fully understand the connection between fiber and preeclampsia.

Many in both developed and developing countries do not have access to nutritional foods (e.g., vegetables, fruits, and legumes) which have a detrimental impact on women’s health. Solutions to this problem of inaccessibility include food pantries, education, and personalized care. In rural Texas, food prescription programs were found to promote produce intake of healthy foods and decreased food insecurity.²² For education and support, a nutrition education intervention in Nicaragua for adolescent girls found a significant difference in height-for-age, weight-for-age, and improved nutritional knowledge after 3 years participation in the intervention.²³ Personalized care is another strategy to improve women’s health demonstrated through a study conducted on healthy pregnant women in Western countries in which the most effective dietary interventions were those that were highly tailored and provided by dietitians and nutritionists.²⁴

Exercise

Physical activity has health benefits for women across the lifespan, including improved pregnancy outcomes, decreased risk of osteoporosis, and decreased menopausal symptoms. Exercise strategies have been found to be an important component for diabetes prevention programs. The Center for Disease Control and Prevention (CDC) reports that 150 minutes of moderate weekly exercise can significantly improve outcomes pertaining to insulin sensitivity and reduce risk factors for type 2 diabetes,²⁵ but more research needs to be conducted to parse out the effects by gender. However, it has been shown that women tend to be less physically active than men due to time-consuming familial and caretaking responsibilities,²⁶ lack of motivation,²⁷ and lack of a safe place to exercise.²⁸ In pregnancy, women often do not meet minimal exercise requirements often out of concerns of the impact of exercise on pregnancy.²⁹ Additional factors that impact women include social stigma, appearance-related concerns, and cultural values²⁸ as a woman’s culture or ethnicity can impact her ability to engage in physical activity. Understanding these differences can help us address the unique challenges facing women globally.

The global transition from agriculture to urbanization has resulted in a shift to less physically demanding occupations. Prior to 1950, urbanization had mostly occurred in developed countries, but recently it has been rapid in many developing countries.³⁰ A study in China looking at the effects of rapid urbanization found an increase in sedentary occupations for women correlated with increased income and education.³¹ In addition to economic forces, cultural barriers can inhibit women from exercise. A study conducted in India found that some women engage in low levels of physical activity because they believe exercise is only for those who are obese.³² In some Muslim societies, vigorous activity is restricted during fasting periods, and traditional attire worn by women can impede physical activity.³³

Environmental conditions can also impact physical activity. India has the worst air quality in the world, which is a result of cigarette smoking, dusty winds, vehicles, garbage burning, and open landfills. In developing countries, women and young children are exposed to high levels of indoor air pollution daily.³⁴ As poor air quality is associated with cardiovascular disease, women may avoid outdoor exercise. Women may also be more sensitive to toxicologic influences of airborne pollution due to higher rates of anemia.^35,36

In addition to environmental concerns, physical inactivity can lead to many health concerns such as obesity. In the United States, over 107 million people are overweight.³⁷ However, only 23% of Americans meet the CDC recommended goal of 150 minutes of moderate intensity exercise per week.³⁸ Ethnic minority groups and low-income populations experience the highest rates of physical inactivity.³⁹ The barriers to exercise that minority women experience are instilled within culture. Additionally, these barriers differ between minority groups. For instance, some Black women feel limited when it comes to physical activity because sweating can affect one’s hair which is perceived as unprofessional for when working.²⁸ In contrast, Hispanic women are seen to have decreased activity compared to white women due to barriers relating to acculturation, language barriers, and culturally dictated gender roles.⁴⁰

Targeted programs have been studied to effectively integrate exercise and improve health. An exercise intervention study addressing cancer survivors found that more intense aerobic exercise specifically targeted for women increased quality of life.⁴¹ Additionally, a multifaceted exercise and diet intervention was effective at reducing the risk of gestational diabetes mellitus during pregnancy.⁴²

Sleep

Contrary to the belief that the primary purpose of sleep is confined to restorative effects on the central nervous system, a study conducted by Cappuccio and Miller suggests the importance of sleep on bodily functions, including metabolism, adipose tissue, and cardiovascular function.⁴³ Sleep deprivation has a wide variety of detrimental health effects, including an increased risk of dementia, cardiovascular diseases, motor vehicle accidents, and obesity. As a result of sleep deprivation, there are reciprocal changes in leptin, a hormone produced by fat cells that regulate satiety, and ghrelin, a hormone produced by the stomach that enhances hunger.⁴⁴ Additionally, women have been found to report poorer sleep quality and higher rates of insomnia.⁴⁵ Short durations of sleep seem to have greater health concerns relating to an increased risk of hypertension, type 2 diabetes, and cardiovascular diseases.⁴⁶ Women in both developed and developing nations often work irregular hours, and night shifts are known to have negative effects on sleep leading to an increased risk of insomnia and other sleep disorders. A study suggests that night shift working could affect women’s ability to function more than men’s.⁴⁷ For this reason, it is important to address factors that affect sleep as well as day-to-day activities that sleep can have an impact on in order to best advise women’s health.

Working conditions differ greatly between the developed and developing world with extreme temperature, over-crowded and noisy surroundings, malnutrition, unhygienic working and living conditions, inadequate transport, and lengthy work weeks making shift work in the developing world more strenuous.^48-50 While a study conducted on male workers in a cigarette factory in Bangladesh found that night shifts are the most disruptive of all shifts in terms of sleep deficiency,⁵¹ more research needs to be done on women. Additionally, there is a growing concern of insomnia in developing countries, such as Colombia, Ghana, Malaysia, Kenya, and Thailand.⁵² A Brazilian study found that the prevalence of insomnia was higher in women (45.3%) than in men (28.8%).⁵³ This study also suggests that elderly women are at an increased risk of falling, accidents, tiredness, and possibly increased mortality due to their insomnia.

In the United States, more than a third of adult Americans are not getting the recommended amount of 7 to 9 hours of sleep per night.⁵⁴ Sleep duration is known to differ between countries: those living in the United Kingdom tend to have shorter durations of sleep than those living in France, Portugal, or Spain.⁵⁵ Low levels of sleep are associated with greater intake of energy, fat, and carbohydrates resulting in overeating.⁵⁶ Additionally, it has been found that sleep deprivation has negative impacts on carbohydrate metabolism in men, but little is known on sleep restrictions in women.⁵⁷ One factor leading to reduced sleep in the developed world is a greater use of technology. A study conducted on the effects of television and cell phone use at bed time on adolescents demonstrated that there was elevated BMI and greater difficulty with sleep.⁵⁸ When surveying American college students, results found that women spend two more hours each day on their phone.⁴⁸ Thus, women are more at risk from technologically related health effects than men. While technology has greatly benefited the developed world, potential negative health effects exist for women.

As women’s sleep health is also impacted by racial and ethnic disparities, including these factors with tailored interventions can reduce health disparities.⁵⁹ In a sleep enhancement program for pregnant women, sleep duration increased and sleep disruption decreased when home-based interventions included audio relaxation programs and dietary recommendations.⁶⁰

Substances

Despite the commonly accepted belief among women that a glass of red wine each day is beneficial, a global health study conducted in 195 countries contends that no amount of alcohol is good for your overall health.⁶¹ In addition to alcohol, there are also serious health implications with drug abuse. In 2019, it was estimated that 35 million people worldwide suffer from drug use disorders.⁶² Substance abuse in women can result in problems with fertility, pregnancy, hormones, menstrual cycle, breastfeeding, and menopause.⁶³ Substance abuse in women can lead to a greater variety of health issues than men; these findings in women link opioids to mood and anxiety disorders, heroin to neurological deficiencies, cocaine to immune system suppression, and alcohol to domestic partner abuse.⁶⁴ Despite the clear differences in the impact of substance abuse between men and women, a limited amount of research is being conducted on the impact of substance abuse on women’s health specifically.

While more research needs to be done to understand the effects of substance abuse on women, it is known that smoking is detrimental to one’s health. Of the 1.1 billion people who smoke globally, 80% live in low- and middle-income countries.⁶⁵ This leaves the developing world with a greater burden on health outcomes and can have serious impacts on women’s health. While low-income countries currently struggle with a lower standard of living and higher rates of poverty and mortality, smoking reinforces this gap. In Bangladesh, research found that the poorest households were twice more likely to smoke than the wealthiest households, with smokers spending more on cigarettes than on clothing, housing, health and education combined.⁶⁶ The engagement with tobacco pushes people further into poverty which becomes very difficult to undo. Tobacco is also a major threat to the environment as smoking leads to the emission of 2.6 million tons of CO2 into the atmosphere.⁶⁷ Not only is the smoking of tobacco harmful to the environment but so is the cultivation of the crop, especially in low- and middle-income countries where the production of tobacco is disrupting natural ecosystems.⁶⁸ Central–Southern Africa grows 90% of all tobacco produced in the region which has resulted in loss of forests and woodlands.⁶⁹ While tobacco crops are being grown, other more beneficial food crops are not. The growth of a substance that has negative impacts on our health is also causing negative impacts on our environment. Tobacco, unlike other crops, fails to replenish the soil after its harvest which prevents other food crops from being grown.⁷⁰ Low- and middle-income countries have the burden of producing tobacco, but the environment and their ecosystems should not be put at risk.

The use of legal and illegal substances is prevalent among women in the developed world. While developed countries have more drug treatment and alcohol rehabilitation options available, incarceration for drug-related offenses is all too common for women.⁷¹ In 2018 within the United States, 26% of women in prison were convicted of a drug offense compared to 13% of men in prison, and the proportion of women imprisoned for a drug-related offense has increased by 14% since 1986.⁷² Women with substance use disorders have lower education levels, lower rates of employment, and a lower age at admission into treatment compared to men with similar issues.⁷³ While greater education may help decrease substance abuse in women, women encounter barriers in seeking treatment. In 2002, the Substance Abuse Mental Health Services Administration found that 26.3 million people had been diagnosed with substance use disorders, but only 6% of these individuals sought out treatment.⁷⁴ Work needs to be done in order to destigmatize substance use disorders to encourage those who may be suffering to seek help. Women, especially, are fearful when seeking treatment whether it be due to financial or safety concerns. In order to combat substance abuse, we need to focus on breaking down the barriers globally so that women can seek the help and guidance to improve their health.

To promote womens’ health, a study conducted on women who inject drugs suggests utilizing multifaceted interventions that address relationships, housing, and employment may be more successful in reducing risky practices compared to interventions that focus only on condom use and safe injecting practices.⁷⁵ A study conducted on veteran and civilian women with posttraumatic stress disorder (PTSD) found that a specialized yoga therapy may play a role in mitigating symptoms of PTSD, such as reducing risk of alcohol and drug use.⁷⁶ Programs that provide coordinated, comprehensive, family-centered care more effectively attract pregnant and parenting substance-abusers and provide more effective care.⁷⁷

Stress

Women have been found to report having a greater deal of stress, with married women reporting higher levels of stress than single women.⁷⁸ A study conducted to better understand the demand discrepancies between women and men pertaining to their occupational role, found that women reported their division of labor remained the same at home despite their employment status.⁷⁹ Additionally, studies have shown that low-income women are more vulnerable and have greater exposure to stress resulting in a higher prevalence of stress-related illnesses than their wealthy counterparts.⁸⁰ Stress can lead to major health concerns with some of the long-term impacts of stress being fertility issues, gastrointestinal distress, heart problems, and obesity.⁸¹ However, stress differs in the developed and developing world with differences in work and home life. Thus, it is important to address and mitigate these stressors in order to provide accurate recommendations for improving global women’s health.

In 2017, more than a third of all international migrants had moved from one developing country to another.¹ Migration often occurs as a result of civil wars, tribal conflicts, or the search for better employment opportunities. These largely impact low-income countries resulting in greater displacement of people in search of new places to live. Women, as the primary caregivers, typically move with their children in times of displacement and as such women and children have been found to be the ones most affected by migration.⁸² This can lead to increased stress as these women are responsible for ensuring their children receive the proper nutrition and resources in a time of financial uncertainty.⁸³ Additionally, there is great concern about human trafficking among refugees as 2 million individuals are trafficked every year, most being women and girls.⁸⁴ The health of these immigrants often suffers as a result of stress in terms of discrimination and settling into a new environment. Most migrants struggle to assimilate in their host country which may lead to lower levels of social support as well as poorer health during pregnancy.⁸⁵ In cases where refugees are placed in camps, the reproductive health needs of women are often overlooked and discrimination creates hostile environments for these women.⁸⁶ The stressors that lead a woman to migrate and the stressors that may come from settling in a new area can be detrimental to their health, but the effects of migration often vary between women. However, it is important to develop and implement policies that ensure the safety of women migrants to respect and protect each women’s individual health.

In America, 50% of women surveyed by the American Psychological Association reported an increase in stress over the last 5 years compared to 39% of men.⁸⁷ One cause of increased stress in women is caregiving. While families have always been the main caregivers for the mentally ill in developing countries,⁸⁸ the demand for non-familial care is on the rise in the United States and other developed nations. As the elderly population increases, families are relying on migrants, typically women, to help provide care.⁸⁹ The stress level among caregivers will increase as the senior population is projected to reach 74 million by 2030 compared to the current senior population of 49.2 million.⁹⁰ While this care is very beneficial for the ill, it can be a stressful experience for the caregiver as they often deal with emotional, physical, social, and financial burdens of their own.⁹¹ In a study conducted on middle-age Australian women, they found that caregivers displayed poorer physical health, emotional health, and lower health service use than individuals not in these roles.⁹² These women need greater access to resources to help prevent work-related stress. Caregivers of cancer patients often provide higher levels of support which in turn leads to negative health outcomes for the caregiver as they are more inclined to postpone their own healthcare needs.⁹³ The high demands of caregiving make it hard for those in this role to cope with their stress. Women, more often than not, have to modify their lifestyles to accommodate the needs of the patient; this can result in decreased leisure activity and contact with family or friends.⁹⁴ These women deserve to receive better self-care so that they can provide the best quality of care to senior citizens without the added stress.

Some effective lifestyle strategies to minimize stress in women involve support and mindfulness activities. A psychosocial intervention found supportive stress management programs are effective for reducing postpartum stress in women.⁹⁵ Likewise, a mind–body intervention focusing on mindfulness and loving-kindness meditation was found to reduce risk for health disparities related to stress and strength among African women.⁹⁶

Connectedness

Social connections are an important part of our overall health and a lack thereof can be detrimental to one’s health. This can result in a variety of health issues including cardiac and mental health problems.⁹⁷ Connections are the support and love you may receive from family, friends, and the community. In his book Aging Well, George Vaillant comments “it is the poverty in love, not the poverty in dollars that makes all the difference in old age.”⁹⁸ The keys to successful aging are self-care and love. These healthy relationships, personal connection, and a sense of belonging all help promote happiness and well-being⁹⁹ and are vital for the overall health of women. A study looking at college women found that those who lack connectedness have lower self-esteem, are less satisfied with social relationships, perceive their environments as more threatening, and are less likely to assume a social identity in social situations.¹⁰⁰ The benefits of social connectivity can also provide a sense of belonging which can have positive effects on the mental health of women. The developed and developing world experience different challenges related to connectedness, such as technology or social groups, but each group can learn from one another, recognizing and building on the strengths of each has the potential to improve global women’s health.

The developing world also has barriers related to connectedness between women. In a study investigating social connectedness among Dominican women with chronic filarial lymphedema, disruption to their social connections resulted in negative health effects and contributed to social isolation, depression, and poor health outcomes.¹⁰¹ Being a part of a team, organization, or group can help promote social interaction that enables one to have a purpose and sense of belonging and help mitigate the negative effects of lack of connectedness. Sports are a great way for girls and women to engage in the community, with each other, and foster healthy relationships. While women in the developed world have greater access to sports teams, the developing world is working to improve female participation in sports. There are deep cultural and societal norms within many of these developing nations that prevent women from participating in athletics, as many girls are expected to marry and have children early in life.¹⁰² However, studies demonstrate that adolescent girls in developing countries have narrowed social networks with few spaces to meet with peers, receive mentoring support, and acquire skills; however, sports serves as a mechanism for building social networks and bringing girls into the public sphere.¹⁰³ In addition to sports teams, support groups and other social organizations provide healthy connections and can foster a greater sense of community among women in developing nations.

Another way we form connections is through technology. In the developed world, technology is essential to everyday life as it enables us to connect with work, family, and even around the world at the touch of a button. On the positive side, technology has the potential to bridge urban and rural disparities in healthcare access by improving education, support, and connectedness between patients and providers.¹⁰⁴ But while technology connects our world, it can also divide us by reducing face-to-face interpersonal contact between individuals. Online contact can remove the personal connection and body language we use to communicate. There is increasing evidence that the Internet and social media can influence suicide-related behavior,¹⁰⁵ especially among females who spend more time on social media.¹⁰⁶ As Internet and cell phone usage increases in the developing world, informed understanding of the benefits and potential risks may help inform its use.

Technology can be used to increase connectedness, especially as physical distancing has been required in this era of COVID-19. A study using smart technologies was utilized to enhance social connectedness in older populations that live at home.¹⁰⁷ But low technology interventions also work when appropriate. A study conducted in rural Chiapas, Mexico, found that a functioning community clinic and its health interventions decrease relative social isolation and improve the connectedness of a community.¹⁰⁸

Discussion

In conclusion, the rapid changes occurring as globalization leads women from traditional rural agricultural communities to more urban lifestyles is having a tremendous impact on women’s health. Importantly, due to women’s roles in childbirth, and as caregivers, the impact of women is multiplied across their families. Given the commonalities of lifestyle treatments for a wide variety of medical conditions, some have proposed that there is one lifestyle medicine prescription, not a different lifestyle for each illness. Lifestyle modifications are an effective treatment for many related comorbidities and can offer better health outcomes for women globally.

Increases in the standard of living have led to greater caloric intake and have ameliorated some of the micronutrient deficiencies that are common in some traditional cultures; however, they have also brought greater rates of obesity and new nutritional deficiencies (e.g., fiber) which have unique consequences for women.

Sleep and physical activity are also decreasing as technology continues to impact lifestyle. A shift from traditional cultures to a Westernized urban lifestyle is accompanied by increases in consumption of tobacco, caffeine, and alcohol, as well as greater exposure to environmental chemicals all of which have consequences for women’s health. Last, transition from villages and communities is correlated with higher levels of stress and greater social isolation. Recognition of these trends and their impact on women’s health is only the first step. The benefits of improved standards of living are undeniable; however, early recognition of the full range of consequences of this transition on health gives us the opportunity to address these impacts in advance and help future generations. The World Health Organization (WHO) defines health as “physical, mental, and social well-being, not merely the absence of disease or infirmity,”¹⁰⁹ stressing how subjective health is as important as traditional objective markers of health. As living standards continue to increase in the developing world, we can learn from the challenges seen in women’s health in the developed world to guide policy in developing nations that improves women’s health.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Ethical Approval

Not applicable, because this article does not contain any studies with human or animal subjects.

ORCID iD

John McHugh

References

United Nations, Department of Economic and Social Affairs, Population Division

2019. World Population Prospects 2019. Online Edition. Rev. 1.

Ritchie

Roser

. Urbanization. 2018. https://ourworldindata.org/urbanization. Accessed February 12, 2021.

WHO . 2018 Global Nutrition Report: Shining a Light to Spur Action on Nutrition. UK: Development Initiatives.

Imamura

Micha

Khatibzadeh

, et al. Dietary quality among men and women in 187 countries in 1990 and 2010: A systematic assessment. Lancet Glob Health. 2015;3(3):e132-42. doi:10.1016/S2214-109X(14)70381-X.

(NCD-RisC) NRFC . Trends in adult body-mass index in 200 countries from 1975 to 2014: a pooled analysis of 1698 population-based measurement studies with 19·2 million participants. Lancet. 2016;387(10026):1377-1396. doi:10.1016/S0140-6736(16)30054-X.

Botreau

Cohen

. Gender inequality and food insecurity: A dozen years after the food price crisis, rural women still bear the brunt of poverty and hunger. Advances in Food Security and Sustainability. 2020;5:53-117 doi:10.1016/bs.af2s.2020.09.001.

Lim

Riddell

Nowson

Booth

Szymlek-Gay

. Iron and zinc nutrition in the economically-developed world: A review. Nutrients. 2013;5(8):3184-3211. doi:10.3390/nu5083184.

Fulgoni

Keast

Bailey

Dwyer

. Foods, fortificants, and supplements: Where do Americans get their nutrients? J Nutr. 2011;141(10):1847-1854. doi:10.3945/jn.111.142257.

Skalny

Rink

Ajsuvakova

, et al. Zinc and respiratory tract infections: Perspectives for COVID-19 (Review). Int J Mol Med. 2020;46(1):17-26. doi:10.3892/ijmm.2020.4575.

10.

Torheim

Ferguson

Penrose

Arimond

. Women in resource-poor settings are at risk of inadequate intakes of multiple micronutrients. J Nutr. 2010;140(11):2051S-2058S. doi:10.3945/jn.110.123463.

11.

Caulfield

Elliot

. Nutrition of Adolescent Girls and Women of Reproductive Age in Low-And Middle-Income Countries: Current Context and Scientific Basis for Moving Forward. USAID; 2015.

12.

Ransom

Elder

. Nutrition of women and adolescent girls: why it matters. Population Reference Bureau. https://www.prb.org/nutritionofwomenandadolescentgirlswhyitmatters/. Accessed February 12, 2021.

13.

Cordain

Eaton

Sebastian

, et al. Origins and evolution of the Western diet: Health implications for the 21st century. Am J Clin Nutr. 2005;81(2):341-354. doi:10.1093/ajcn.81.2.341.

14.

NIDDK. Obesity . U.S. Department of Health and Human Services. https://www.niddk.nih.gov/about-niddk/research-areas/obesity. Accessed February 12, 2021.

15.

Quagliani

Felt-Gunderson

. Closing America’s fiber intake gap: Communication strategies from a food and fiber summit. Am J Lifestyle Med. 2017;11(1):80-85. doi:10.1177/1559827615588079.

16.

Threapleton

Greenwood

Evans

, et al. Dietary fiber intake and risk of first stroke: A systematic review and meta-analysis. Stroke. 2013;44(5):1360-1368. doi:10.1161/STROKEAHA.111.000151.

17.

McRae

. Dietary fiber is beneficial for the prevention of cardiovascular disease: An umbrella review of meta-analyses. J Chiropr Med. 2017;16(4):289-299. doi:10.1016/j.jcm.2017.05.005.

18.

Farvid

Spence

Holmes

Barnett

. Fiber consumption and breast cancer incidence: A systematic review and meta-analysis of prospective studies. Cancer. 2020;126(13):3061-3075. doi:10.1002/cncr.32816.

19.

Allen

Rogozinska

Sivarajasingam

Khan

Thangaratinam

. Effect of diet- and lifestyle-based metabolic risk-modifying interventions on preeclampsia: a meta-analysis. Acta Obstet Gynecol Scand. 2014;93(10):973-985. doi:10.1111/aogs.12467.

20.

Brantsaeter

Haugen

Samuelsen

, et al. A dietary pattern characterized by high intake of vegetables, fruits, and vegetable oils is associated with reduced risk of preeclampsia in nulliparous pregnant Norwegian women. J Nutr. 2009;139(6):1162-1168. doi:10.3945/jn.109.104968.

21.

Qiu

Coughlin

Frederick

Sorensen

Williams

. Dietary fiber intake in early pregnancy and risk of subsequent preeclampsia. Am J Hypertens. 2008;21(8):903-909. doi:10.1038/ajh.2008.209.

22.

Aiyer

Raber

Bello

, et al. A pilot food prescription program promotes produce intake and decreases food insecurity. Transl Behav Med. 2019;9(5):922-930. doi:10.1093/tbm/ibz112.

23.

Pawloski

Moore

. Impact of a nutrition intervention program on the growth and nutritional status of Nicaraguan adolescent girls. Coll Antropol. 2007;31(2):403-411.

24.

Beulen

Super

de Vries

JHM

Koelen

Feskens

EJM

Wagemakers

. Dietary interventions for healthy pregnant women: A systematic review of tools to promote a healthy antenatal dietary intake. Nutrients. 2020;12(7)doi:10.3390/nu12071981.

25.

Dubé

Allison

Rousson

Goodpaster

Amati

. Exercise dose and insulin sensitivity: Relevance for diabetes prevention. Med Sci Sports Exerc. 2012;44(5):793-799. doi:10.1249/MSS.0b013e31823f679f.

26.

Brownson

Eyler

King

Brown

Shyu

Sallis

. Patterns and correlates of physical activity among US women 40 years and older. Am J Public Health 2000;90(2):264-270. doi:10.2105/ajph.90.2.264.

27.

Eyler

Baker

Cromer

King

Brownson

Donatelle

. Physical activity and minority women: a qualitative study. Health Educ Behav. 1998;25(5):640-652. doi:10.1177/109019819802500510.

28.

Eyler

Wilcox

Matson-Koffman

, et al. Correlates of physical activity among women from diverse racial/ethnic groups. J Womens Health Gend Based Med. 2002;11(3):239-253. doi:10.1089/152460902753668448.

29.

Ning

Williams

Dempsey

Sorensen

Frederick

Luthy

. Correlates of recreational physical activity in early pregnancy. J Matern Fetal Neonatal Med. 2003;13(6):385-393. doi:10.1080/jmf.13.6.385.393.

30.

Henderson

. Banization in developing countries. World Bank Res Obs. 2002;17(1):89-112. doi:10.1093/wbro/17.1.89.

31.

Monda

Gordon-Larsen

Stevens

Popkin

. China’s transition: The effect of rapid urbanization on adult occupational physical activity. Soc Sci Med. 2007;64(4):858-870. doi:10.1016/j.socscimed.2006.10.019.

32.

Mathews

Lakshmi

Ravindran

Pratt

Thankappan

. Perceptions of barriers and facilitators in physical activity participation among women in Thiruvananthapuram City, India. Glob Health Promot. 2016;23(4):27-36. doi:10.1177/1757975915573878.

33.

Nakamura

. Beyond the Hijab: Female Muslims and physical activity. Women Sport Phys Activ J. 2002;11(2):21-48. doi:10.1123/wspaj.11.2.21.

34.

Bruce

Perez-Padilla

Albalak

. Indoor air pollution in developing countries: A major environmental and public health challenge. Bull World Health Organ. 2000;78(9):1078-1092.

35.

Sørensen

Daneshvar

Hansen

, et al. Personal PM2.5 exposure and markers of oxidative stress in blood. Environ Health Perspect. 2003;111(2):161-166. doi:10.1289/ehp.111-1241344.

36.

Sorensen

Murray

Lemery

Balbus

. Climate change and women's health: Impacts and policy directions. PLoS Med. 2018;15(7):e1002603. doi:10.1371/journal.pmed.1002603.

37.

Flegal

Carroll

Kuczmarski

Johnson

. Overweight and obesity in the United States: prevalence and trends, 1960-1994. Int J Obes Relat Metab Disord. 1998;22(1):39-47. doi:10.1038/sj.ijo.0800541.

38.

Why walk? Why not! Physical activity: Walking. Cdc.gov. Updated September 17, 2020. https://www.cdc.gov/physicalactivity/walking/index.htm#:∼:text=ThePhysicalActivityGuidelinesfor,anequivalentcombinationeachweek. Accessed February 19.

39.

Pate

Pratt

Blair

, et al. Physical activity and public health. A recommendation from the centers for disease control and prevention and the American college of sports medicine. JAMA . 1995;273(5):402-407. doi:10.1001/jama.273.5.402.

40.

U.S. Department of Health and Human Services . Physical Activity and Health: A Report of the Surgeon General. 1996. https://www.cdc.gov/nccdphp/sgr/pdf/sgrfull.pdf. Accessed February 19, 2021.

41.

Ferrer

Huedo-Medina

Johnson

Ryan

Pescatello

. Exercise interventions for cancer survivors: A meta-analysis of quality of life outcomes. Ann Behav Med. 2011;41(1):32-47. doi:10.1007/s12160-010-9225-1.

42.

Shepherd

Gomersall

Tieu

Han

Crowther

Middleton

. Combined diet and exercise interventions for preventing gestational diabetes mellitus. Cochrane Database Syst Rev. 2017;11:CD010443. doi:10.1002/14651858.CD010443.pub3.

43.

Cappuccio

Miller

. Sleep and cardio-metabolic disease. Curr Cardiol Rep. 2017;19(11):110. doi:10.1007/s11886-017-0916-0.

44.

Spiegel

Tasali

Penev

Van Cauter

. Brief communication: Sleep curtailment in healthy young men is associated with decreased leptin levels, elevated ghrelin levels, and increased hunger and appetite. Ann Intern Med. 2004;141(11):846-850. doi:10.7326/0003-4819-141-11-200412070-00008.

45.

Lindberg

Janson

Gislason

Björnsson

Hetta

Boman

. Sleep disturbances in a young adult population: can gender differences be explained by differences in psychological status? Sleep. 1997;20(6):381-387. doi:10.1093/sleep/20.6.381.

46.

St-Onge

Grandner

Brown

, et al. Sleep duration and quality: Impact on lifestyle behaviors and cardiometabolic health: A scientific statement from the American heart association. Circulation. 2016;134(18):e367-e386. doi:10.1161/CIR.0000000000000444.

47.

Santhi

Lazar

McCabe

Groeger

Dijk

. Sex differences in the circadian regulation of sleep and waking cognition in humans. Proc Natl Acad Sci U S A. 2016;113(19):E2730-E2739. doi:10.1073/pnas.1521637113.

48.

Walker

. Social problems of shiftwork. In: Monk

SFTH

, ed. Hours of Work: Temporal Factors in Work Scheduling. Wiley; 1985:211-226.

49.

Knutsson

. Shift work and coronary heart disease. Scand J Soc Med Suppl. 1989;44:1-36.

50.

Ogińska

Pokorski

Ogiński

. Gender, ageing, and shiftwork intolerance. Ergonomics. 1993;36(1-3):161-168. doi:10.1080/00140139308967868.

51.

Khaleque

. Sleep deficiency and quality of life of shift workers. Soc Indicat Res. 1999;46:181-189. doi:.

52.

WHO . Fact Sheet No. 135: Population aging-A public health challenge. World Health Organization Press Office. 2021. http://www.nzdl.org/cgi-bin/library?e=d-00000-00---off-0cdl--00-0----0-10-0---0---0direct-10---4-------0-0l--11-en-50---20-about---00-0-1-00-0--4----0-0-11-10-0utfZz-8-00&a=d&c=cdl&cl=CL1.242&d=HASHf1d1ff7392e6b9482edd6e.2. Accessed February 19, 2021.

53.

Rocha

Uchoa

Guerra

Firmo

Vidigal

Lima-Costa

. Prevalence of sleep complaints and associated factors in community-dwelling older people in Brazil: The Bambuí Health and Ageing Study (BHAS). Sleep Med. 2002;3(3):231-238. doi:10.1016/s1389-9457(01)00156-3.

54.

Gradisar

Wolfson

Harvey

Hale

Rosenberg

Czeisler

. The sleep and technology use of Americans: findings from the National Sleep Foundation’s 2011 sleep in America poll. J Clin Sleep Med. 2013;9(12):1291-1299. doi:10.5664/jcsm.3272.

55.

Ohayon

. Interactions between sleep normative data and sociocultural characteristics in the elderly. J Psychosom Res. 2004;56(5):479-486. doi:10.1016/j.psychores.2004.04.365.

56.

Shechter

Grandner

St-Onge

. The role of sleep in the control of food intake. Am J Lifestyle Med. 2014;8(6):371-374. doi:10.1177/1559827614545315.

57.

VanHelder

Symons

Radomski

. Effects of sleep deprivation and exercise on glucose tolerance. Aviat Space Environ Med. 1993;64(6):487-492.

58.

Fuller

Lehman

Hicks

Novick

. Bedtime use of technology and associated sleep problems in children. Glob Pediatr Health. 2017;4:2333794X17736972. doi:10.1177/2333794X17736972.

59.

Jackson

Powell-Wiley

Gaston

Andrews

Tamura

Ramos

. Racial/ethnic disparities in sleep health and potential interventions among women in the United States. J Womens Health (Larchmt). 2020;29(3):435-442. doi:10.1089/jwh.2020.8329.

60.

Lee

Gay

Alsten

. Sleep enhancement training for pregnant women. Obstet Gynecol. 2016;128(5):964-971. doi:10.1097/AOG.0000000000001654.

61.

Collaborators

. Alcohol use and burden for 195 countries and territories, 1990-2016: A systematic analysis for the global burden of disease study 2016. Lancet. 2018;392(10152):1015-1035. doi:10.1016/S0140-6736(18)31310-2.

62.

United Nations Office on Drugs and Crime (UNODC) . World drug report 2019: 35 million people worldwide suffer from drug use disorders while only 1 in 7 people receive treatment. Accessed February 12, 2021.

63.

Substance Use in Women DrugFacts: Sex and Gender Differences in Substance Use. National Institute on Drug Abuse. https://www.drugabuse.gov/publications/drugfacts/substance-use-in-women. Updated January 2020. Accessed February 12, 2021.

64.

Kay

Taylor

Barthwell

Wichelecki

Leopold

. Substance use and women’s health. J Addict Dis. 2010;29(2):139-163. doi:10.1080/10550881003684640.

65.

ASH Fact Sheet: Tobacco and the Developing World 2019. https://ash.org.uk/wp-content/uploads/2019/10/Tobacco-Developing-World.pdf. Accessed February 12, 2021.

66.

Efroymson

Ahmed

Townsend

, et al. Hungry for tobacco: An analysis of the economic impact of tobacco consumption on the poor in Bangladesh. Tob Control. 2001;10(3):212-217. doi:10.1136/tc.10.3.212.

67.

Mathers

Loncar

. Projections of global mortality and burden of disease from 2002 to 2030. PLoS Med. 2006;3(11):e442. doi:10.1371/journal.pmed.0030442.

68.

Kulik

Bialous

Munthali

Max

. Tobacco growing and the sustainable development goals, Malawi. Bull World Health Organ. 2017;95(5):362-367. doi:10.2471/BLT.16.175596.

69.

Mayes

Mustard

. Forest cover change in Miombo Woodlands: Modeling land cover of African dry tropical forests with linear spectral mixture analysis. Rem Sens Environ. 2015;165:203-215.

70.

Akhter

Mazhar

Sobhan

, et al. From tobacco to food production: Assessing constraints and transition strategies in Bangladesh. International Development Research Centre. 2008.

71.

American Addiction Centers Editorial Staff . Drug use and addiction in developed countries. Recovery First. https://recoveryfirst.org/blog/drug-use-and-addiction-in-developed-countries/. Updated July 23, 2019. Accessed February 21, 2021.

72.

Fact Sheet: Incarcerated Women and Girls. The Sentencing Project. https://www.sentencingproject.org/publications/incarcerated-women-and-girls/. Accessed February 16, 2021.

73.

Wong

Badger

Sigmon

Higgins

. Examining possible gender differences among cocaine-dependent outpatients. Exp Clin Psychopharmacol. 2002;10(3):316-323. doi:10.1037//1064-1297.10.3.316.

74.

Coombs

. Addiction Counseling Review: Preparing for Comprehensive, Certification and Licensing Examinations. New York, NY: Routledge; 2005:668.

75.

Pinkham

Stoicescu

Myers

. Developing effective health interventions for women who inject drugs: Key areas and recommendations for program development and policy. Adv Prev Med. 2012;2012:269123. doi:10.1155/2012/269123.

76.

Reddy

Dick

Gerber

Mitchell

. The effect of a yoga intervention on alcohol and drug abuse risk in veteran and civilian women with posttraumatic stress disorder. J Alternative Compl Med. 2014;20(10):750-756. doi:10.1089/acm.2014.0014.

77.

Finkelstein

. Treatment issues for alcohol- and drug-dependent pregnant and parenting women. Health Soc Work. 1994;19(1):7-15. doi:10.1093/hsw/19.1.7.

78.

APA . Gender and stress. https://www.apa.org/news/press/releases/stress/2010/gender-stress. Accessed February 16, 2021.

79.

Frankenhaeuser

Lundberg

Chesney

. Women, Work, and Health: Stress and Opportunities. New York, NY: Plenum Press; 2012.

80.

Williams

Lawler

. Stress and illness in low-income women: the roles of hardiness, John Henryism, and race. Women Health. 2001;32(4):61-75. doi:10.1300/J013v32n04_04.

81.

AdventHealth . Stress and women’s health: Side effects and coping. 2020. https://www.adventhealth.com/hospital/adventhealth-orlando/blog/stress-and-womens-health-side-effects-and-coping. Accessed February 21, 2021.

82.

Al Gasseer

Dresden

Keeney

Warren

. Status of women and infants in complex humanitarian emergencies. J Midwifery Wom Health. 2004;49(4 suppl 1):7-13. doi:10.1016/j.jmwh.2004.05.001.

83.

Adanu

Johnson

. Migration and women's health. Int J Gynaecol Obstet. 2009;106(2):179-181. doi:10.1016/j.ijgo.2009.03.036.

84.

Llácer

Zunzunegui

del Amo

Mazarrasa

Bolumar

. The contribution of a gender perspective to the understanding of migrants’ health. J Epidemiol Community Health. 2007;61 (suppl 2):ii4-ii10. doi:10.1136/jech.2007.061770.

85.

Landale

Gorman

Oropesa

. Selective migration and infant mortality among Puerto Ricans. Matern Child Health J. 2006;10(4):351-360. doi:10.1007/s10995-006-0072-4.

86.

Carballo

Grocutt

Hadzihasanovic

. Women and migration: A public health issue. World Health Stat Q. 1996;49(2):158-164.

87.

The American Psychological Association . Stress in America: Paying with our health. 2015. http://www.apa.org/news/press/releases/stress/2014/financial-stress. Accessed February 23, 2020.

88.

Shankar

Rao

. From burden to empowerment: The journey of family caregivers in India. In: Sartorius

Leff

Lopez-Ibor

Okasha

, eds. Families and Mental Disorders. John Wiley & Sons, Ltd; 2005:259-290.

89.

Michel

. Global Care Tilt: Migrant Caregivers Flock to Wealthy Countries to Meet Rising Demand. NewSecurityBeat blog. 2019. https://www.newsecuritybeat.org/2019/04/global-care-tilt-migrant-caregivers-flock-wealthy-countries-meet-rising-demand/. Accessed February 21, 2021.

90.

Knickman

Snell

. The 2030 problem: Caring for aging baby boomers. Health Serv Res. 2002;37(4):849-884. doi:10.1034/j.1600-0560.2002.56.x.

91.

Hollingsworth

. Falling through the cracks: Care of the chronically mentally ill in the United States, Germany, and the United Kingdom. J Health Polit Policy Law. 1992;17(4):899-928. doi:10.1215/03616878-17-4-899.

92.

Lee

Gramotney

. Transitions into and out of caregiving: Health and social characteristics of mid-age Australian women. Psychol Health. 2007;22(2):193-209. doi:10.1080/14756360600682202.

93.

Kim

Schulz

. Family caregivers’ strains: comparative analysis of cancer caregiving with dementia, diabetes, and frail elderly caregiving. J Aging Health. 2008;20(5):483-503. doi:10.1177/0898264308317533.

. Review of the literature on the effects of caring for a patient with cancer. Psycho Oncol. 2010;19(10):1013-1025. doi:10.1002/pon.1670.

. A systematic review of psychosocial interventions for women with postpartum stress. J Obstet Gynecol Neonatal Nurs. 2015;44(2):183-192. doi:10.1111/1552-6909.12541.

96.

Woods-Giscombé

Black

. Mind-body interventions to reduce risk for health disparities related to stress and strength among African American women: The potential of mindfulness-based stress reduction, loving-kindness, and the NTU therapeutic framework. Complement Health Pract Rev. 2010;15(3):115-131. doi:10.1177/1533210110386776.

97.

Hailes

. Women’s health: Social connectedness, confidence and wellbeing. Rural Women’s Network blog. 2018. https://nswruralwomensnetwork.wordpress.com/2018/03/14/womens-health-social-connectedness-confidence-and-wellbeing/. Accessed February 21, 2021.

98.

Vaillant

. Aging Well: Surprising Guideposts to a Happier Life from the Landmark Harvard Study of Adult Development. New York, NY: Little, Brown Spark; 2003.

99.

Sannidhi

. Translation of lifestyle into clinical practice: Making the case, providing the cure. Am J Lifestyle Med. 2019;13(5):440-442. doi:10.1177/1559827619851033.

100.

Lee

Robbins

. Understanding social connectedness in college women and men. J Counsel Dev. 2000;78(4):484-491. doi:.

. Disrupted social connectedness among Dominican women with chronic filarial lymphedema. Patient Educ Couns. 2007;68(3):279-286. doi:10.1016/j.pec.2007.06.015.

102.

Global Sports . Hidden gender: Women’s sports in developing nations. https://intelligence.globalsportsjobs.com/hidden-gender-women-s-sport-in-developing-nations. Accessed February 20, 2021.

103.

Brady

. Creating safe spaces and building social assets for young women in the developing world: A new role for sports. Wom Stud Q. 2005;33(1/2):35-49.

104.

Farrell

McKinnon

. Technology and rural mental health. Arch Psychiatr Nurs. 2003;17(1):20-26. doi:10.1053/apnu.2003.4.

105.

Luxton

June

Fairall

. Social media and suicide: a public health perspective. Am J Public Health. 2012;102 (suppl 2):S195-S200. doi:10.2105/AJPH.2011.300608.

106.

Twenge

Joiner

Rogers

Martin

. Increases in depressive symptoms, suicide-related outcomes, and suicide rates among US adolescents after 2010 and links to increased new media screen time. Clinical and Psychological Science. 2018;6(1):3-17.

107.

Morris

Adair

Ozanne

, et al. Smart technologies to enhance social connectedness in older people who live at home. Australas J Ageing. 2014;33(3):142-152. doi:10.1111/ajag.12154.

108.

Deitz

Hellerstein

St George

Palazuelos

Schimek

. A qualitative study of social connectedness and its relationship to community health programs in rural Chiapas, Mexico. BMC Publ Health. 2020;20(1):852. doi:10.1186/s12889-020-09008-6.

109.

World Health Organization . Preamble to the constitution of the world health organization as adopted. Paper presented at: International Health Conference; 19-22 June, 1946; New York, NY; signed on 22 July 1946 by the representatives of 61 States (Official Records of the World Health Organization, no. 2, p. 100) and entered into force on 7 April 1948. https://www.who.int/governance/eb/who_constitution_en.pdf.