The Art and Science of Fitness | Men and women die differently

Cardiovascular diseases kill 1 in 5 women, as compared to 1 in 40 with breast cancer, yet most today would think that the top killer for women is breast cancer, even though clearly it is not. There is simply more awareness of breast cancer and preventative screenings. Heart disease in women continues to fly under the radar. In the US, it was in 1984 that women had caught up with men, in terms of deaths because of heart disease. As a matter of fact, a lot of them were already dying because of it even earlier but weren’t diagnosed because investigations were focused on heart diseases in men, not women.

Why was that so? Sometimes to find the factual answer, we need to look at fiction. It was in 1983 that a Hollywood film titled ‘Yentl’ was released. It was based on Isaac Bashevis Singer’s short story, Yentl the Yeshiva Boy, set in Poland in 1904, in which the protagonist, Barbara Streisand, had to disguise herself as a man so that she could receive education and study the Talmud, the Hebrew Bible, which otherwise was forbidden for women.

In the editorial of the July 1991 edition of the New England Journal of Medicine, Bernadine Healey mentioned that being ‘just like a man’ has historically been a price women have to pay for equality. She went on to say that being different from men has meant being second-class and less than equal for most of the recorded time and throughout most of the world.

For decades, all the volunteers in heart disease studies were men. This led to the development of therapeutic strategies to address heart diseases in men, and women with heart conditions not being diagnosed or misdiagnosed, and not treated or mistreated, leading to more and more women dying because of their heart as compared to men. Healey coined the term ‘Yentl Syndrome’ for women with cardiac diseases because they were being treated based on whatever was known about the disease in men, not women.

Even today women make up less than a quarter of participants in all heart-related research studies even though they make up more than half of heart patients. This leads to women with heart diseases being misdiagnosed seven times more than men. More than 40% of women don’t experience chest pain. For these reasons, women end up waiting longer than men to go to a hospital. As if this wasn’t bad enough, women’s heart attacks are twice as likely to be fatal as men’s. If they were to survive the heart attack but had pre-existing Diabetes, it would double their risk of a second heart attack, as compared to men.

Merz pointed out a fundamental difference between men and women. “The fatty plaque in a man is lumpy-bumpy, like a beer belly in his coronary arteries. Whereas in a woman, they are very smooth, as if she has just laid it down nice and tidy until it finally completely shuts off the artery. The fatty build-up of plaque in a coronary artery (the main blood supply going into the heart muscle) causing a heart attack will usually rupture or ‘explode’ in men. But in women, it will often be a much smaller, more subtle event, caused by ‘erosion’, not explosion. Often their symptoms may throw doctors off track to the wrong diagnosis, and in many cases, women won’t even know they have had a heart attack until it’s too late.” The problem with this is that these findings can easily be missed in women.

“So, I’ll describe the male-pattern heart attack first. Hollywood heart attack. Ughhhh. Horrible chest pain. EKG goes pbbrrhh, so the doctors can see this hugely abnormal EKG. There’s a big clot in the middle of the artery. And they go up to the cath lab and boom, boom, boom get rid of the clot. That’s a male heart attack. Some women have those heart attacks, but more women have a different kind of heart attack, where it erodes, doesn’t completely fill with clot, symptoms are subtle, and EKG findings are different — female-pattern. So, what do you think happens to these gals? They’re often not recognised and sent home. I’m not sure what it was. Might have been gas.”

“When we watch people become obese, where do men get fat? Right here, it’s just a focal — right there (pointing to tummy). Where do women get fat? All over. Cellulite here, cellulite here. So, we said, “Look, women look like they’re pretty good about putting kind of the garbage away, smoothly putting it away. Men just have to dump it in a single area.”

Has the heart disease story for women been any different in India? According to the WHO’s 2014 India report, based on death certificates, males had 349 deaths per 1,00,000 people because of cardiovascular disease as compared to 265 in women. This begs the question raised by Merz, were fewer cardiovascular diseases reported in women because we simply didn’t know what to look for? Most probably yes.

The “Cause of death” section in Death Certificates in India is such an afterthought that it’s doubtful if the correct cause is usually mentioned, more so because it’s rare that heart disease is associated with deaths in women. Even if we assume this not to be the case, those are staggering numbers. When it comes to the US, men have a mortality rate due to heart disease of 170 per 1,00,000 and women have 108.

Besides continuously improving investigations and treatment protocols, there is more good news for women and even men. They can do something, as a matter of fact, a lot, for themselves. We’ve known for decades now that heart conditions are lifestyle diseases. When we lead a better lifestyle, like improving our eating, sleeping, physical activity, and mental health and stopping smoking, that will reduce the chances of having heart diseases and even reverse them in those who already do.

In the February 2024 edition of the Journal of the American College of Cardiology a paper titled ‘Sex difference in association of physical activity with all-cause and cardiovascular mortality’ concluded that as compared to men, women have greater gains in cardiovascular mortality risk reduction from equivalent doses of leisure time physical activity. To put it differently, this study found that women only need to exercise about two and a half hours per week to obtain the same survival benefits that men achieve with five hours of exercise per week. It is important to note that the benefits are similar in men and women for exercises done for 15 minutes a day, i.e. 90 minutes a week, but then start to emerge gender differences.

It makes one wonder why this would happen. Yes, we are different, but what is it that is making this happen? Are men really from Mars and women from Venus, or are there actual anatomical and physiological differences?

One potential explanation is that men, across all ages, have measurably greater exercise capacity than women. This in part could be attributed to average proportionately larger hearts and blood vessels (arteries and veins), wider lung airways, greater lung diffusion capacity (capacity to transfer oxygen from each breath into the bloodstream) and larger muscle fibres in men. Men have a third more lean body mass as compared to women, so they basically need to do more to gain the same benefits as women.

Women, on the other hand, need to do less to improve their muscle strength. It might hit men’s ego even more that women have a higher density of capillaries per unit of skeletal muscles (muscles used for movement, posture, breathing, swallowing, joint stabilization etc) when compared with men. Effectively, an average woman might have lower strength at baseline, but when they undergo strength training, they become stronger than men with lesser time and frequency spent doing it, even though they might not look like it, because they don’t put on as much muscle mass as men do. These sex differences were most pronounced between 40-59 years of age, so rather than coming up with, ‘Oh, I am too old’, this is the time when women can not only catch up with men but can leave them in the dust.

Some would get discouraged thinking that they need to do a lot for these benefits, which is not the case, but Martha Gulati, a co-author of the study adds, “The public health message should be that everyone benefits from exercise and a small amount goes far in terms of a reduction in mortality. For women, finally, we have some good news: You benefit a little more for every minute of exercise compared with men!”

Gulati makes a point about what could be another reason for women needing lesser physical activity for as many benefits as men. “Women at every age group report less physical activity than men, but it may be that they are being active and just not calling it “exercise.” It is really hard to know how much non-leisure activity may confound the results. Women do tend to take on more household responsibilities and caregiving duties for children and older parents, which may add up to a lot of unmeasured physical work.”

As much as doing half the physical activity to get as many benefits as men with heart conditions is good news, it is still a massive challenge for women in India to get moving. They have been discouraged from being active from the time they are born. Most of those who are active as school children, tend to stop when they hit puberty because of physiological changes leading to anatomical changes. At each stage when they attempt to get moving again, there is some or the other barrier that comes along. The magic lies in doing little but consistently, rather than complicated stuff done for a few days only.

Ultimately, we will all die. The good news is that we can extend our healthy, active years by being mindful of symptoms of disease, which might look very different in men and women. But healthy, physically active lifestyles improve everyone’s quality and quantity of life, no matter the gender, no matter the age.

Dr Rajat Chauhan (drrajatchauhan.com) Sports Medicine & Musculoskeletal Medicine Physician, Author and Student of Running & Pain

Eva Bacon (evabacon.com) Runner, Roller Blader, Rock Climber, Urban Hiker, Translator and IT Program Manager

Eva and Rajat write a weekly column, exclusively for HT Premium readers, that breaks down the art and science of movement and exercise.

The views expressed are personal.