The Heart of the Matter: The Real Facts on Women and Heart Disease

Donna Zfat-Zwas, MD, MPH, is a cardiologist and the Director, Linda Joy Pullin Cardiovascular Wellness Center for Women, in the Division of Cardiology at the Hadassah University Medical Center of the Hadassah Medical Organization in Jerusalem, Israel.


Melanie Cole (Host): Did you know that heart disease is the number one killer of women and is more deadly than all forms of cancer combined? The more a woman knows about heart disease, the better her chances of beating it. We are chatting today with Dr. Donna Zwas of this episode of Hadassah On Call.

Melanie Cole (Host): Lately, there has been progress in preventing and treating heart disease, but women are still more affected by this disease than men. My guest today is Dr. Donna Zwas. She is a cardiologist and the director of the Linda Joy Pullin Cardiovascular Wellness Center for Women in the division of Cardiology at the Hadassah University Medical Center of the Hadassah Medical Organization in Jerusalem Israel. Welcome to the show Dr. Zwas. So, tell us how prevalent is cardiovascular disease in women and are you seeing a difference in Israel and in the US as far as incidence and even awareness?

Dr. Donna Zfat-Zwas, MD, MPH (Guest): We are seeing increased awareness in women very, very slowly. And we are seeing a decrease in mortality from heart disease both in the United States and in Israel.

Melanie: So, the studies have always been focused on men for years. Do you see this changing at what do you think prompted the change?

Dr. Zwas: I am not convinced that it is changing. One of our big challenges in recruiting women into these studies, is the fact that they tend to be somewhat older when they have heart disease and their caregiver status. Meaning if the husband wants to participate in the study, the wife tags along, but if the wife wants to participate in the study, there's a lot of resistance or the patient is the grandmother caring for the grandchildren or she has other caregiver demands which adversely affect her ability to participate in research.

Melanie: Well and I can see why it would. Women, we are the caregivers of society and they say put your own mask on before you put the mask of your loved ones on, but women don't always do that, do they? We sort of brush off symptoms or we are too busy to deal with things within our own bodies.

Dr. Zwas: That's really the crucial part of the awareness campaign. Because when a man has chest pain or discomfort in his chest or shortness of breath; immediately everyone thinks, oh my God, this could be a heart attack and they immediately call for help. When a woman feels these symptoms, a thousand things come up in her head, but the last one on the list is that it could be her heart. She thinks I lifted something, I did too much, I ate something, and it just doesn't even occur to her that this really could be a heart attack. And then even if it occurs to her that it could be a heart attack; even then she says well, maybe if I go to the hospital they will think I'm hysterical. I don't want to bother people. I don't want my relatives to have to take me anywhere. I don't want to be a burden to anyone and even if she does think it's a heart attack she doesn't call for help. So, the key in the awareness campaign is understanding what are the triggers that will actually help a woman call for help.

One of the things that we have been using, is a survey that we did, a pattern on a survey that they did in the United States. They asked women what would you do if the person next to you had the signs and symptoms of a heart attack? And between 75-80 percent of them said they would call for help. And then they asked well what would you do if you had signs of a heart attack? And only 50% of them said they would call for help. So, one of the focal points of the campaign that we are organizing is if you call for someone else, call for yourself. We really want to empower women to make the decision to call for help.

Melanie: That's really a great idea. So, tell us about your work for heart disease besides this awareness campaign, and how it can be a model for other countries. What can we learn from your studies?

Dr. Zwas: Well, we've developed a very comprehensive center where we work on addressing the individual, the community and the digital world. So, we have a clinic, a multidisciplinary clinic that focuses on women who either have heart disease or three of more risk factors for heart disease and we work with them to develop a plan that works for them to make the changes that they need to make to prevent heart disease. Very often a woman goes to the doctor and the doctor says oh go lose weight. Go do more exercise. It is very hard to translate that into the stressful reality of day to day life. So, we work with the woman, we work with her to overcome her old emotional barriers to making change and we work with her to create specific doable goals that she can really do, and we thereby build her health self-efficacy, her ability to know that she can really take care of herself and we are seeing real change.

We are also working on the community level because people just don't like going to the hospital and they don't like to be medicalized, so we are going out to the community and working with all sorts of different infrastructures within the community to build intervention programs that improve nutrition, physical activity, and stress reduction. So, we work in partnership with the city of Jerusalem and women's support groups. We work at schools. We work in community centers. We work in the Arab community, the ultraorthodox community, the general community and we are building programs in the community where women get together and support each other to make the kind of changes that will make our communities healthier communities.

We are also working in the digital world and that's with using digital media to get really to everyone in this country, Arab, Jew, it is a little harder to get to our ultraorthodox because they don't admit to using any media, but we are trying to use specific campaigns to really work on the awareness of heart disease in respect to what we were talking about before, when and how to make the call.

Melanie: And tell us about your work in underserved populations in Israel.

Dr. Zwas: Well I have to say it has been a tremendous educational experience for me to really understand the social challenges the different populations in Israel face. In order to reach the women in the Arab community, we have been going to schools because it is socially unacceptable for a woman to leave her house to do something for herself. So, if she is doing something that's related to the education of her children then that's okay. So, we go into the schools. We take programs for the kids and then we include the mothers and then we train them in nutrition and the importance of physical activity and then we can really reach out to them once we have gotten them in. So, the other challenge that we faced in the Arab community which we are working very hard on addressing is second hand smoke; because more than 50% of Arab men smoke and it is socially very challenging for them to - for the women to get them to not smoke in the house. And that is something that we are working very hard on developing a program and campaign, a comprehensive approach in order to get the houses smoke free.

In terms of the ultraorthodox communities the challenges are different. The challenges tend to come from just the extreme stress that these women are under in terms of the logistics of their lives. They have seven kids, ten kids, they are working, they are dealing with poverty and it's almost impossible for these women to find the time to do anything for themselves. So, we are really working with them on incorporating exercise into daily life. We have actually developed a very interesting program where they exercise in each other's houses. They don't want to go to health clubs. They don't want to go to the health plan because there are people outside the community there, so we have developed a program where they each pay a small amount of money to an exercise instructor and they meet in each other's living rooms. We have a coordinator who runs this program and it has been amazingly successful in increasing the exercise in that community.

Melanie: Are you seeing a decline in heart disease deaths in Israel and if you are, do you think that diet is playing a factor? Tell us the role that diet plays within the heart disease community.

Dr. Zwas: So, there are two separate questions that you are asking. We are seeing a decrease in mortality after heart attack, but I don't think it is related to diet. I think it is related to increased awareness in physicians. I think the doctors are now realizing that women have heart disease. The doctors are treating the women faster. The doctors are treating the women better and that's why I think that our mortality is going down. In terms of diet, I am concerned about the opposite. For many years, the diet in Israel was the Mediterranean diet and is very healthy. But in Israel as well as in America, we are suffering from the sheer overwhelming abound of high carbohydrate, high fat, low nutritional value food which is just assaulting you from every venue. If you go into a local store; it's almost impossible to find something healthy to eat in there. If you go to a supermarket; out of the ten rows, maybe one and a half of them have healthy food and I think that the increased economic status in Israel is adversely affecting the diet here.

Melanie: So, what do you want women to know about preventing cardiovascular disease? Give us a little kind of summary wrap up about exercise, lifestyle factors, diet, people have heard a lot Dr. Zwas, in the media, but you put it into us such a nice easy way for us to understand. So, kind of summarize it all for us, what you tell people every day.

Dr. Zwas: What I think people need to know in terms of preventing heart disease is that diet and exercise are the key. So, in terms of exercise; you need to do 150 minutes a week of moderate exercise, approximately 30 minutes five times a week and just doing that, will protect you to a significant degree. There are studies that show that people who are fat and fit, meaning you are overweight, but you are in shape, those people have a better prognosis than people who are skinny and out of shape. So, it is not your weight that matters, it's your exercise level and it is also what you eat. The new data about the Mediterranean diet and really the American Dash diet or the American version of the Mediterranean diet, they are both the same. If you eat a lot of fruits and vegetables, whole grains, legumes, nuts, fish, and low-fat dairy and really decrease the high fat, high animal fat parts of your diet, just eating those foods is protective. And the other stuff you eat is less important. So, if you manage to get a very diverse diet that in and of itself is protective.

Melanie: What a great message. And tell us about the Linda Joy Pullin Cardiovascular Wellness Center for Women.

Dr. Zwas: So, the Pullin Center was founded by Mrs. Irene Pullin of Washington DC, in order to promote cardiovascular wellness. She and we have tried to adopt her global vision of wellness as our goal. So, rather than trying to think about disease, we try to understand what it is that we can do to make women healthier longer and keep their hearts healthy. So, that's why we work on the individual level, the group level, the community level and we try to get our message out to as many people as possible. And I just want to add, that even exercising one time per week can make a significant difference in a woman's heart health and her prognosis. It can keep those heart attacks away. All women need to take the time to take care of themselves, to put in that extra bit so that we can be here to take care of those we love.

Melanie: Thank you so Dr. Zwas for being on with us today and thank you so much for all the great work that you do. This is Hadassah On Call, New Frontiers in Medicine, brought to you by Hadassah the Women's Zionist Organization of America. The largest Jewish women's organization in America, Hadassah enhances the health of people worldwide through medical education, care and research innovations at the Hadassah Medical Organization. For more information on the latest advances in medicine please visit Hadassah.org, and to hear more episodes in this podcast series, please visit Hadassah.org/podcasts, that's Haddasah.org/podcasts. This is Melanie Cole. Thanks so much for listening.

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