Professor Nicole Freene is a clinical physiotherapist based at the University of Canberra. For more than two decades she has worked as a physiotherapist and over the last decade her research has focused on the primary and secondary prevention of chronic disease and increasing the populations’ physical activity levels.
Her latest research looks at women over 40 and the under-recognition of cardiovascular issues, and the importance of tailored physical activity guidelines to improve health outcomes.
How long have you been looking at the issue of heart disease in women over 40?
I have been working as a clinical physiotherapist for over 25 years. Most of that time in rehabilitation and particularly cardiac rehabilitation. Ten years ago, I completed my PhD looking at increasing physical activity in middle-aged adults for primary prevention of heart disease and other chronic diseases.
So, I have been interested in heart disease for a long time and trying to prevent initial or recurrent cardiac events by increasing physical activity levels
Why does this issue matter so much to you?
Heart disease in women is currently under-recognised, under-diagnosed and under-researched. When we think of someone with heart disease, we typically think of an overweight/obese middle-aged to older male.
On average, this is who we see in cardiac rehabilitation programs, but women also suffer from heart disease. In Australia, approximately 20 women per day die every day from coronary heart disease. This is more than twice as many who die from breast cancer.
What specific barriers do women face in accessing treatment for coronary heart disease compared to men? How can these be addressed?
To start with, most health care professionals and patients tend to underestimate cardiovascular risk in women.
There are psychological, social, economic and cultural risk factors that disproportionately affect women such as depression, intimate partner violence and sociocultural roles. (Editor’s note: sociocultural means “relating to or involving a combination of social and cultural factors”.)
There are also conditions specific to women that can increase cardiovascular disease risk such as premature menopause, gestational hypertension and diabetes. And there are also sex-specific differences in how women present clinically with heart disease, being less likely to present with chest pain and more likely to have pain in the jaw, neck, shoulder or fatigue and nausea.
What factors contribute to the longer delays women experience in seeking hospital treatment during heart attacks?
A number of factors contribute to timely presentation and appropriate treatment for women during and after a heart attack. It could be that women have low awareness of personal risk, they misinterpret their symptoms, fear, embarrassment and accessing care.
Diagnosis can take longer with cardiovascular risk often underestimated in women and even once diagnosed, they are less likely to receive appropriate treatment compared to men. All of these factors may contribute to women with heart disease more likely to die in hospital than men.
Can you explain how your findings on physical activity thresholds differ between men and women, and what implications this has for public health recommendations?
We used data from the 45 and Up study conducted in NSW that includes approximately 270,000 people 45 years and older who were surveyed from 2006-2020.
We identified approximately 40,000 individuals with coronary heart disease from this cohort, approximately 15,000 women and 25,000 men, and looked at the relationship between physical activity levels and all-causes of death.
We found women with heart disease needed to complete less physical activity than men with heart disease to get the same health benefits.
That is, women only needed to complete 89 minutes per week of moderate-to-vigorous physical activity, while men needed to complete 139 minutes per week to reduce their risk of all-causes of death by approximately 35%. This research will be published soon.
Other research from this project also found that women had greater associated reductions in cardiac death for the same level of moderate physical activity and walking.
These results can be used to inform heart disease-specific physical activity guidelines and may be particularly useful to engage females in physical activity as they commonly report less physical activity than males, with and without heart disease. These are important findings illustrating a sex-specific difference in physical activity thresholds and this needs to be investigated further.
Professor Nicole Freene. Picture: Supplied
How does the under-recognition and under-diagnosis of heart disease in women impact their health outcomes, and what steps can be taken to raise awareness?
As mentioned above, the under-recognition and under-diagnosis of heart disease in women can result in poorer health outcomes. Education is needed for both women and health care professionals to raise awareness of heart disease in women.
This could include government initiated public education campaigns and encouraging a range of health professionals to routinely screen women with diseases that increase cardiovascular risk
What role does socioeconomic status play in the physical activity levels of women with coronary heart disease, and how might this differ from men’s experiences?
We did not investigate this but differences in physical activity are reported in men and women with low socio-economic status without heart disease.
Considering that women are less likely to complete cardiac rehabilitation programs, what strategies could be implemented to improve attendance and completion rates?
Women are less likely to be referred to, attend and complete cardiac rehabilitation.
Women report issues with transport, family responsibilities, multiple medical issues and finding exercise tiring. Female-only cardiac rehabilitation programs could be a solution.
Hybrid or home-based cardiac rehabilitation could also overcome many of the barriers.
- Please note: Image at stock is a photo
Ginger Gorman is a fearless and multi award-winning social justice journalist and feminist. Ginger’s bestselling book, Troll Hunting,came out in 2019. Since then, she’s been in demand both nationally and globally as an expert on cyberhate and the real-life harm predator trolling can do. She's also the editor of BroadAgenda and gender editor at HerCanberra. Ginger hosts the popular "Seriously Social" podcast for the Academy of the Social Sciences in Australia. Follow her on Twitter.
