Men Versus Women

Every day we read about prominent men dying of a "heart attack" in the prime of life; such news items about women are not at all common. Why? Well, of course men are more in the news than women anyway but the fact is that over most of the life-span coronary heart disease is much less of a threat to women than to men. This is clear from the vital statistics given in Table 1, though these data may exaggerate the true disparity between the sexes in susceptibility to the disease.

Until recently the idea that women are relatively immune was so firmly entrenched that some doctors were reluctant to make the diagnosis of a "man's disease" in a woman. But better diagnostic methods and the accumulation of autopsy data are changing the picture. In the first place, as Table 2 shows, the disparity between the sexes in reported coronary mortality is much less in some countries (Italy, Japan) than in others (U.S.A., England and Wales), and this disparity steadily diminishes as age progresses.

Deaths ascribed to coronary heart disease in 1955. Death rates ofrates (male death rate divided by female death rate).

60-64 70-74 80-84

Country U.S.A.			50-54 45	112	239	538
	Sex Ratio	6.2	4.7	2.8	1.8	1.3
England & Wales	Male Rate	6	25	76	203	569
	Sex Ratio	5.6	4.5	2.9	1.7	1.3
Italy	Male Rate	3	14	42	117	351
	Sex Ratio	1.9	2.3	1.7	1.1	1.0
Japan	Male Rate	3	7	19	48	86
	Sex Ratio	1.0	1.3	1.3	1.2	1.2

But mortality is not all of the story and we must consider morbidity as well, that is the number of men and women who are ill with coronary heart disease. Women tend to die less suddenly and to survive longer with this disease. Not long ago we organized surveys of the medical patients in general hospitals. In six hospitals in Minneapolis and St. Paul, Minnesota, we found that 104 out of a total of 564 patients were in the hospital because of coronary heart disease. Thirty-one per cent of the men patients had coronary heart disease; 21 per cent of the women patients were so diagnosed. The main diference between men and women in this regard is that, on the average, women in the U.S.A., and in other high coronary prevalence countries, tend to show clinical signs of the disease some 8 or 10 years later than the men. And, from an inspection of Tables 1 and 2, it appears that the real problem is not so much why women are less affected but why there is such an excessive and early incidence of the disease among men in some countries.

The difference between men and women in this respect is puzzling when we observe that the serum cholesterol levels in men and women do not differ much until the fifties and beyond and then women actually tend to have higher levels than do men. But when the serum cholesterol is separated into the alpha and beta lipoprotein there is a difference. Women have more of their blood cholesterol in the alpha fraction and less in the beta lipoprotein and it is the latter that worries us.

The sex hormones are involved in this different distribution of the serum cholesterol as well as in the sex difference in susceptibility to coronary heart disease. Women who have had their ovaries removed surgically seem to be much more susceptible to the disease than ordinary women, while castrated men are reported to be relatively protected. This is one more reason why doctors are increasingly anxious to avoid castrating women or, if they must, they urge continuing replacement therapy with female sex hormones.

The converse, castrating men to protect them from coronary heart disease, is not attractive but many attempts have been made to confer the protection of the female by giving female sex hormones to men. Such treatment does change the blood chemical pattern towards the more favourable female type - higher alpha and lower beta lipoprotein cholesterol - and perhaps this does give some protection, though at grave cost. In order to produce such change in the blood the dosage of female sex hormones must be so high as to be really feminizing; breasts enlarge and become tender, libido and virility is lost and other distressing physical and emotional side effects intervene.

If we pursue the idea of the ill effects of saturated fats in the diet, we conclude that young women dispose of them more safely than do men. Certainly men and women differ in regard to fat in general. The female child has a much greater fat content in the body than does the male child and this difference persists throughout most of life. And, though women tend to deposit adipose tissue more than do men, the deposition of cholesterol and other lipids in the arteries is less marked.

Bile and the Excretion of Cholesterol The amount of cholesterol in the blood (and in the body as a whole) represents a net balance between income and outgo, that is the cholesterol made in the body (plus any dietary intake) minus the cholesterol eliminated. So we must ask, what happens to cholesterol once it is in the body? How do we get rid of an excess? Theoretically, cholesterol could pile up by failure to eliminate it just as well as by excessive synthesis of it in the liver. Interference with the excretion of cholesterol, as in some forms of liver and gall bladder disease, is known to raise the blood cholesterol level.

And it now appears that a major effect of the fats in the diet is exercised somehow by their influence on the elimination of cholesterol. The body does not destroy cholesterol by "burning" it; the resistance of cholesterol to such destruction is a main reason why it creates problems. But the body can and normally does get rid of much cholesterol by way of the bile and so out in the stools.

Bile is made by the liver and flows into the upper part of the intestine from the gall bladder. It contains cholesterol and bile salts, or bile acids, which are made from cholesterol by only slight changes in the molecule. So the more bile is produced, the more cholesterol is taken away from the liver, either as such or after conversion to bile salts. But this is not the whole story because some of the cholesterol and bile salts in the bile are reabsorbed further down in the intestine and only a part is finally excreted.

In any case, eating saturated fats reduces the net loss, via the stools, of cholesterol and the related compounds made from it. If we switch over to poly-unsaturated fats, such as in most vegetable oils, the balance changes and the amount of cholesterol and bile salts in the stools is much increased. In the meantime the liver, confronted with this rapid withdrawal of cholesterol from it, speeds up the manufacture of cholesterol but it does not catch up. The result is a net loss, less cholesterol on hand to go into the blood, and the blood cholesterol level falls.

These new findings from experiments on human beings seem to explain much of the effect of diet fats but why the bile loss responds in this way is unknown. Perhaps the main diet fat action is on the reabsorption of cholesterol and related compounds in the lower intestine. We are reminded of the fact that, in general, people whose lower intestines do a poor job of absorbing tend to have particularly low blood cholesterol levels. This is the picture in patients who have had a substantial part of the intestine removed by surgery or who suffer from protracted dysentery from almost any cause. Surgeons could probably keep your serum cholesterol low by removing a considerable part of your intestine. We think a wise diet is easier and a lot safer!

Tension, Emotion, and Heart Disease Many people including not a few doctors, have a ready explanation for the fact that coronary heart disease is now a veritable plague among the world's most prosperous peoples. They say it is all the result of modern "tension" which presses most heavily on just those peoples (meaning us) who prove to be so susceptible to the disease. Men of substance and responsibility are said to be especially vulnerable, and attention is called to the newspaper accounts of the business and political leaders who are stricken in apparent good physical health.

Such men are viewed as sacrificing their hearts in their dedication to the affairs of state and the rigours of the business world, victims on the altar of the executive desk. Promotion to high authority is the signal for family and friends to advise, "Take it easy." The devoted wife presents her husband with a new armchair, more like a bed or a cradle, to indicate her concern. Where men of responsibility gather there are apt to be discussions about the relative merits of sedatives, tranquillizers, and sea voyages, all in the belief that in modern life to be a leader (or merely ambitious to be one) means "tension" and tension is the road to the heart attack.

This facile explanation of the origin of atherosclerosis and coronary thrombosis is, we think, positively harmful, as well as being unsupported by scientific fact. We say "harmful" not only because it leads to sage nonsense about taking life "easy"; it promotes smug self-pity and a distorted sense of values and, above all, it diverts attention from more reasonable consideration in physiological terms of a great health problem that menaces all members of our modern civilization, not only the captains and would-be captains of enterprise. Not long ago, when electrocardiographs and skilled cardiologists were less available to the general public, the diagnosis of coronary heart disease was socially stratified; rich men of affairs seemed to be more susceptible - or more able to afford the disease and its diagnosis. More critical inquiry today reveals the fallacies in the conclusions drawn from older vital statistics. In any case, the development of a National Health Service makes all of us prosperous enough today to acquire coronary heart disease.

It is true that in many areas of the world there are great differences between economic classes in the amount of coronary disease, and this is not merely a reflection of varying diagnosis. We have personally checked this point in Spain, Italy, Greece, and South Africa. On the other hand, in the United States, Norway, and Finland, where this question has been examined lately, such differences are much smaller or even non-existent. Business owners, professional men, clerks in routine jobs, and mechanics in Oslo show no appreciable differences in the frequency of heart attacks; the coronary mortality rate at given ages in Chicago is reported to be the same, or higher, among labourers as it is among executives; coronary heart disease among poor Finnish farmers is not noticeably less, and may be more, than among the white-collar class living under the stresses of Helsinki. We cannot believe that "tension" applies to all classes in the United States, in Oslo, and in Finland but only to the economically privileged in Madrid and Naples and Athens.

Aside from the fact that no evidence is forthcoming for these supposed emotional differences, a simple and very different explanation is at hand when the diets are considered. In Oslo and in Finland all classes have much the same diet, but in Spain, Italy, and Greece the diets of the rich and poor differ greatly. And in this country the level of prosperity is such that the dietary differences between the rich and the relatively poor are now in items of embellishment rather than in how often we eat meat or butter. And, it may be added, if exercise is important one can avoid it just as successfully in a baby Morris as in a Rolls-Royce.

The proponents of the theory that tension promotes heart disease are not silenced by failure of the study of economic strata to give them support. They answer that tension is not measured by the size of the cheques a person signs or by the external importance of the job held; the important point, we are told, is the emotional "strain". But how, then, can the tension theory explain the great differences between populations?

Worry, Anxiety, Fear, and Tension Worry, anxiety, fear, the drive of competition, the pressures of society are and always have been part and parcel of human nature in all communities. Perhaps the tension-producing elements are greater in big cities and are augmented by noise, traffic hazards, and the like. This idea could be offered to explain why coronary heart disease is often more frequent in cities than in rural areas in many countries. But why, then, do we find so many heart attacks in rural Finland, so few in the big cities of Japan where life is fiercely competitive, noisy, and beset, seemingly beyond endurance, with all possible assaults on the sense of security - where life, in short, is ultra-tense?

As a last refuge the defenders of the theory that tension produces heart disease are forced to assume that, in contrast with those populations exhibiting an excessive incidence of heart disease, people in other areas are blessed with a philosophy that allows them to keep relaxed and placid even though they are equally subject to stressful situations. No one who has actually lived and worked in communities all over the world is likely to agree. Do we fly into rages and get excited? If so, what about the southern Italian? Does the Briton with his stiff upper lip boil inwardly while concealing his true emotions? In this respect we do not hold a candle to the Japanese and Finns who, incidentally, represent opposite extremes in the tendency to develop coronary heart disease.

The real difficulty with this theory and the questions it is concerned with is the complete absence of any scientific measure of tension; there is not even an objective definition of it. It is not surprising that arguments about the effects of this unmeasured, undefined tension take on the character of mediaeval debates on fine points of theology - there is no end and no result.

There is some real basis for the popular tradition, so long expressed in literature, that the heart is the seat or at least the receptacle of emotions. We do sometimes have sensations, ascribed to the general region of the heart, associated with intense feelings of love or sorrow, of joy and hate and, above all, of fear. But the subjective recognition of the anatomical origin of internal feelings in man is notoriously imprecise and the human heart is suspiciously close to the stomach anatomically (the stomach is not low down in the belly). However, sudden, violent emotions of fear or rage can produce changes in the rate and force of the heart's action, and extreme excitement, usually associated with violent responses of the muscles, may even affect blood clotting. These are brief and temporary responses to unusually powerful stimuli that bear little or no relation to chronic anxiety or tension. Besides, though extreme emotional excitement may be harmful to a heart already seriously diseased, there is no evidence that it has a lasting and injurious effect on an otherwise normal heart. In other words, while we are unimpressed by the tension theory as a cause of heart disease, we may allow a possible role of strong emotion in influencing the course of established heart disease.