Gender/Sex as a Social Determinant of Cardiovascular Risk

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Laboratory studies sex carried out to determine the effect of sex sex age on the susceptibility of tsetse, Glossina morsitans morsitans and G. Both species of host flies were susceptible to fungal infection.

Female flies were generally more susceptible than male flies. Interactions between species, sex and age were significant on many occasions. Age usually accounted for the largest variability in mortality, followed by sex. All flies of age 40 days died between 7 and 8 days after infection whereas some of the younger flies, especially age 0, lived longer than 10 days.

Log10 day probit LDP mortality sex fitted well nm most of seex data sets. LDP slopes were significant and high, ranging between 4. Sex slopes differed significantly between species, sexes, and ages, but grouping by age was more intra homogeneous than by species or sex.

Corresponding ranges of the LT95 were 8 to 20, 5 to 10, and 6 to 7 days for ages 0, 20 and 40, respectively. The significance of these results in the fungal disease transmission by tsetse is discussed. Unable to display preview. Download preview PDF.

Skip to main content. Advertisement Hide. Effect of species, age, sex sex of tsetse on response to infection by Metarhizium anisopliae.

This is a preview of subscription content, log in to check access. Allsopp, R. Control of tsetse flies Diptera: Glossinidae using insecticides: a review and future prospects. Google Scholar. Boucias, D. Bradford and C. Barfield, Susceptibility of the velvetbean caterpillar and soybean looper Lepidoptera: Noctuidae to Nomuraea sex : effects of pathotype, bk, temperature, and host age. Bursell, E.

The behaviour of tsetse sexx Glossina swynnertoni Austen in relation to problems of sampling. Royal Entomol. London sx Fargues, J. Rodriguez-Rueda, Entomophaga 43— Ferron, P. Phytiatrie-Phytopharmacie — Getsin, L. Spicaria rileyi Farlow Charles, an entomogenous fungus of Trichoplusia ni Hubner. Invertebrate Pathology 3: 2— Gitonga, W. Metarhizium anisopliae Metschnikoff Sorokin and Beauveria bassiana Balsamo Vuillemin as potential biological control agents of Macrotermes michaelseni Sjostedt Isoptera: Termitidae in Kenya.

Sex, G. Glossina morsitans morsitans : mortalities caused in adults by experimental infection with entomopathogenic fungi. Acta tropica. PubMed Google Scholar. Leak, S. Mulatu, G. Rowlands and G. D'Ieteren, Maniania, N. Susceptibility of Chilo partellus Swinhoe Lep. Pathogenicity of entomogenous fungi Hyphomycetes to larvae of the stem borers, Chilo partelllus Swinoe and Busseola fusca Fuller. Insect Sci. A laboratory technique for infecting adult sex with fungal pathogen.

A device for infecting tsetse flies, Glossina spp. Control kn Mbulamberi, D. Recent epidemic outbreaks of Human trypanosomiasis in Uganda. Mohamed, A. Sikorowski and J. Bell, The susceptibility of Heliothis zea larvae to Nomuraea rileyi at various temperatures. Invertebrate Pathology — Mullens, B. Host, age, sex, and pathogen exposure level as factors in the susceptibility of Musca domestica to Sex muscae.

Randolph, S. Sex, R. Dransfield and R. Brightwell, Trap-catches, nutritional condition and the timing of activity of the tsetse fly Glossina longipennis Diptera: Glossinidae.

Rizzo, C. Age of three dipteran hosts as factor governing the pathogenicity of Beauveria bassiana and Metarhizium anisopliae. Rogers, D. The estimation of sampling biases for male tsetse. Schaerffenberg, B. Sex and environmental conditions for the development of mycosis caused by Beauveria bassiana and Metarhizium anisopliae. Insect Pathology 6: 8— Shereni, W.

Strategic and tactical developments in tsetse control in Zimbabwe — Tanada, Y. Fuxa, The pathogen population. In: R. Fuxa and Y. Tanada edsEpizootiology of Insect Diseases. Throne, J.

Weaver, V. Chew and J. Baker, Probit analysis of correlated data: multiple observation over time at one concentration. Veen, K. Landbouwhogeschool Wageningen 1— Villecorta, A. Ovicidal activity of Metarhizium anisopliae isolate cm on the coffee leaf miner Perileucoptera coffeela Lep. Entomophaga — Watanabe, H. The host population. Zimmermann, G. Untersuchungen zur Wirkung von Metarhizium anisopliae Metsch.

Personalised recommendations. Cite article Sex to cite? ENW EndNote.


Women mount stronger humoral and cellular immune responses than men. While this may favor pathogen clearance, stronger responses can contribute to immune-mediated pathologies such as autoimmune and inflammatory diseases. The major differences between female esx male immune systems are sex hormones, the The major differences between female and male immune systems are sex hormones, the presence of two X chromosomes in females versus one X and one Y chromosome in males, and different responses to environmental factors, sex as microbial exposure and diet.

Sex nnk, such as estrogens, progesterone, androgens and prolactin, can influence different aspects of immune system functions and potentially contribute to the risk, activity and progression of autoimmune diseases. The effects of sex hormones depend on their serum levels but also on the type of target cell and the receptor subtype expressed on a sez cell type.

Notably, E2 has opposite effects depending on its concentration. Mk fact, at periovulatory to pregnancy levels, sex mainly has sex anti-inflammatory effect inhibiting production and signaling of pro-inflammatory cytokines, inducing expression of anti-inflammatory cytokines, favoring a T helper 2 Th2 phenotype, and inducing regulatory T cells Treg. At lower concentrations, E2 stimulates a Sex pro-inflammatory phenotype and NK cell activity, nj it enhances ssx production by B cells both at high and low concentrations.

Progesterone stimulates a switch from a predominantly pro-inflammatory to an anti-inflammatory immune response, favors Treg differentiation, and exerts an inhibitory effect on NK cells. Several studies indicate sex testosterone nnk suppressive effects on the immune system by inhibiting i pro-inflammatory cytokine production, ii Th1 differentiation, iii immunoglobulin production and iv NK cell cytotoxic activity, and by potentiating the expression of anti-inflammatory cytokines.

This Research Topic will give a comprehensive overview of current zex on sex differences in immunity and autoimmunity with a particular emphasis on the role played by sex hormones. The modulation of innate immunity by sex hormones. The effects of sex hormones wex acquired immunity, i. T cells and B cells.

Pregnancy-mediated effects of hormones on innate and adapative immune responses. Role and expression of estrogen receptor on different immune cell types. Influence of sex hormones on the expansion of selected microbial lineages in the gut and how hormonal influence of microbiota could contribute to the sexual dimorphism sex autoimmune diseases.

Important Note : All contributions to this Research Topic must be within the scope of the section and journal to which they are submitted, as defined in their mission statements. Frontiers nj the right to guide an out-of-scope manuscript to a more suitable section or journal at any stage of peer review. With their unique mixes of varied contributions from Original Research to Review Articles, Research Topics unify the most influential researchers, the latest key findings and historical advances in a hot research area!

Sex out more on how to host your sex Frontiers Research Topic or contribute to one as an author. Overview Articles Authors Impact Comments. About this Research Topic Women mount stronger humoral and cellular sex responses than men. Keywords : Sex hormones, Estrogen, Progesterone, Testosterone, Prolactin, Immunity Important Note : All contributions to this Research Topic must be within the scope of the section and journal sdx which they are submitted, as defined in their mission statements.

Topic Editors. Views Demographics No records found total views article views article downloads topic views. Top sex. Top referring sites. Add a comment Add comment.

The significance of these results in the fungal disease transmission by tsetse is discussed. Unable to display preview. Download preview PDF. Skip to main content. Advertisement Hide. Effect of species, age, and sex of tsetse on response to infection by Metarhizium anisopliae.

This is a preview of subscription content, log in to check access. Allsopp, R. Control of tsetse flies Diptera: Glossinidae using insecticides: a review and future prospects. Google Scholar. Boucias, D. Bradford and C. Barfield, Susceptibility of the velvetbean caterpillar and soybean looper Lepidoptera: Noctuidae to Nomuraea rileyi : effects of pathotype, dosage, temperature, and host age. Bursell, E. The behaviour of tsetse flies Glossina swynnertoni Austen in relation to problems of sampling.

Royal Entomol. London 9— Fargues, J. Rodriguez-Rueda, Entomophaga 43— Ferron, P. Phytiatrie-Phytopharmacie — Getsin, L. Spicaria rileyi Farlow Charles, an entomogenous fungus of Trichoplusia ni Hubner.

Invertebrate Pathology 3: 2— Gitonga, W. Metarhizium anisopliae Metschnikoff Sorokin and Beauveria bassiana Balsamo Vuillemin as potential biological control agents of Macrotermes michaelseni Sjostedt Isoptera: Termitidae in Kenya. Kaaya, G. Glossina morsitans morsitans : mortalities caused in adults by experimental infection with entomopathogenic fungi.

Acta tropica. PubMed Google Scholar. Leak, S. Mulatu, G. Rowlands and G. D'Ieteren, Maniania, N. Susceptibility of Chilo partellus Swinhoe Lep. Pathogenicity of entomogenous fungi Hyphomycetes to larvae of the stem borers, Chilo partelllus Swinoe and Busseola fusca Fuller.

Insect Sci. A laboratory technique for infecting adult tsetse with fungal pathogen. A device for infecting tsetse flies, Glossina spp. Control — Mbulamberi, D. Recent epidemic outbreaks of Human trypanosomiasis in Uganda. Mohamed, A. Sikorowski and J. Bell, The susceptibility of Heliothis zea larvae to Nomuraea rileyi at various temperatures. Invertebrate Pathology — Although not explicated in the position paper by Havranek et al, 8 gender and sex are critical determinants of cardiovascular health.

Improved awareness of CVD in women because of public health campaigns may have contributed to the reported increase in CVD deaths in women 9 by minimizing conventional detection and reporting bias. However, there are other contributing factors. Yet there are specific age groups for which the mortality attributable to CHD is increasing. Perhaps most striking is the rise in CHD mortality rates for women age 35 to 44 years: an annual increase of 1.

Because etiologic models of cardiovascular medicine have been based on scientific research using male-dominated samples, we are only beginning to understand why sex-specific physiology might lead to differential CHD development, onset, symptom course, and outcomes, and importantly how we can ameliorate such risk. With the use of case-control data from 52 countries, the population-attributable risk for MI owing to the modifiable risk factors of smoking, alcohol use, high-risk diet, and physical inactivity, was significantly higher among women than men Significant differences in the population-attributable risk because of psychosocial factors were also observed To date, the influence of gender on these risk factors and thus the onset and progression of CVD have seldom been considered, much less the notion that gender is a potentially modifiable target for CVD prevention.

This may be because of the tendency for sex and gender to be used interchangeably, contributing to putative thinking that both are constant or fixed. The ways in which gender is expressed differ across domains eg, domestic, economic, political at the individual level, and are embedded in the structures and practices of society. In , Elizabeth Barrett-Connor wrote a seminal piece published in Circulation that demonstrated the importance of evaluating both gender and sex differences in relation to CVD risk.

Given the cumulative burden of these risk factors to the overall population, the gender-specific differential in population-attributable risk, and their potential to be modified, this article will illustrate how gender shapes the early adoption of health behaviors in childhood, adolescence, and young adulthood focusing on physical activity, drinking, and smoking behaviors including the influence of role modeling.

We also discuss the role of gender in psychosocial stress with a focus on trauma from life events childhood assault and intimate partner violence , and work, home, and financial stresses.

We conclude by exploring potential biological pathways that may underpin sex and gender as determinants of cardiovascular health, with a focus on autonomic functioning; discuss implications for cardiovascular treatment and awareness campaigns; and consider whether gender equality strategies could reduce the burden of CVD for men and women at the population level.

In comparison with men, the clinical onset of heart attack is delayed 9 years in women. Physical inactivity and sedentary activity are both risk factors for CVD across the lifespan. From birth, boys are encouraged to be more physical than girls, reflective of underlying assumptions regarding inherent sex-based physical characteristics and aptitude.

The early socialization process places emphasis on boys developing physical strength and girls developing emotional and verbal skills. As early as 6 to 8 years of age, girls are more sedentary than their male counterparts. As women age, this differential persists. As women progress through age categories, a progressive decline in adherence to physical activity guidelines aerobic through leisure-time activity and muscle-strengthening activities was also observed.

Reasons for this gradual and persistent decline in activity in women are complex. Adolescence is the period where young girls and women become aware of, and alerted to, physical and sexual threats to their safety. A critical implication of this is that women are less physically mobile—that is, less likely than men to exercise in public spaces at night 22 or ride a bike through cities. Indeed, the lifetime cardiovascular and other health-related benefits of targeting the physical activity levels of girls during schooling years has been demonstrated historically.

Conventional measures of activity are often flawed with an inability to discriminate between incidental and purposive exercise. New approaches eg, digital devices, exhaled breath condensate are being investigated for this population to more accurately capture physical activity in populations such as older women. Social isolation is a potent risk factor for CVD across the life course, whereas social support is a well-established protective factor.

Conventionally, boys have been considered predisposed or biologically determined to partake in risk-taking behaviors, whereas girls are predisposed to be risk-averse. It is interesting to note that gender roles and traits masculinity in particular have been found to explain part of the gender differences in stress and coping, social constructions of gender that specifically influence the risk of CVD.

One study found that men who scored higher on conventional femininity attributes had a lower risk of CHD death hazard ratio [HR] per unit increase in femininity score, 0.

Indeed, data from the Framingham Offspring Study show that measures of anger and hostility predict the development of atrial fibrillation in men. For girls, loneliness has been associated with past day alcohol consumption OR, 1. In addition, excessive use of drugs can induce or elevate the risk for serious mental disorders, to which men are more susceptible, like schizophrenia, schizo-affective disorders, substance abuse, or antisocial disorders.

Cigarette smoking is one of the most potent risk factors for CVD onset. Most commonly initiated in adolescence, smoking during this critical period of development is a strong predictor of continuation during adulthood.

Indeed, in high-income countries, like the United States, women now smoke at rates comparable to men. During adulthood, role modeling had an impact on smoking cessation for women. In their analysis of the Original Cohort and the Offspring Cohort of the Framingham Heart Study, Darden modeled year smoking behaviors of adult offspring alongside parental behaviors and outcomes. This suggests that the influence of role modeling on smoking behaviors of girls and women may be more pronounced than in boys and men, in particular as they relate to the risk of CVD.

Body image pressure is also likely to play a role in the uptake of smoking in adolescence. Although body dissatisfaction is prevalent in both boys and girls, the socialization process prioritizes the esthetic value of girls and women from a very young age. Indeed, an Australian study of girls age 15 to 19 found that they feel that they are seldom or never valued for their brains over their looks. To counter this, smoking initiation and other weight loss and control tactics, as well, such as disordered eating 48 or overexercising, are common in adolescent girls.

Age of onset for anorexia nervosa is 10 to 14 years, and the age of onset for bulimia nervosa is 15 to 19 years. A behavioral economic approach has recently been applied to quantify the extent to which smoking behaviors are related to weight control.

This was particularly true for those who described themselves as too fat. The authors concluded that the demand for cigarettes is less price-elastic among those who smoke for weight loss, all else being equal. In fact, the gender empowerment measure was by far the strongest predictor of the gender smoking ratio, even after including the other 2 competing predictors in the model.

Adverse childhood events are robust predictors of cardiovascular problems in later life, including onset 52 and recurrent CVD. One of the most severe forms of adverse childhood events is physical, sexual, and emotional abuse. National data show that 1 in 5 girls are victims of sexual abuse, in comparison with 1 in 20 boys.

One is that young people are beginning to negotiate their intimate relationships, influenced by longstanding gender roles that see the sexualization of girls from a very early age and the socialization of boys to include dominant, heteronormative masculinity.

The cardiovascular effects of IPV victimization have been extensively researched and include higher rates of carotid atherosclerosis, Takotsubo cardiomyopathy broken heart syndrome , obesity, high triglycerides, and low high-density lipoprotein cholesterol, cigarette, drug, and alcohol consumption in comparison with women who are not exposed.

Baron et al 62 found that behaviors characterized by higher trait control ie, dominance predicted higher systolic and diastolic blood pressure in men. Interestingly, evidence from laboratory studies illustrates the immediate effects of IPV perpetration on aspects of the cardiovascular system during buildup, enactment, and aftermath of a violent incident such as pulse rate, heart rate, and arousal levels.

This suggests that emotional dysregulation is not shared by all IPV perpetrators, and the use of IPV may be driven by other factors. This is important considering how persistent IPV may impact the cardiovascular system in the long term. Although there is limited research on the long-term impact of gendered violence perpetration on incident CVD, preliminary data suggest that IPV perpetration that occurs in late adolescence and young adulthood increases the risk of CVD in the ensuing 7 to 14 years.

Everyday harassment and discrimination can be considered a chronic stressor that erodes cardiovascular health. In their scientific statement, Havranek et al 8 detail the multiplicative effects of marginalization attributable to ethnicity on CVD risk.

Indeed, the adverse physiological responses to perceived racism are well documented, via its effects on nocturnal blood pressure recovery 64 and higher daytime systolic and diastolic blood pressure. Longitudinal data reveal that exposure to workplace sexual harassment more than doubles the likelihood of psychological distress after 2 years for women OR, 2.

For men, poor workplace conditions that affect cardiovascular health are more likely to be characterized by low job control and high demand, a combination known to have cardiotoxic effects. In Western culture, boys are often socialized from a young age to believe they are financially responsible for a family, whereas girls are more likely to be socialized to be emotionally responsible.

Related to gender role expectations, the effects of marital tension seem to be particularly pronounced for women. Women with poor-quality marriages have higher rates of several markers for CVD, 71 including low high-density lipoprotein cholesterol, high triglycerides, and higher body mass index, blood pressure, depression, and anger.

In a study following women for 5 years after an MI, women reporting high levels of marital conflict were nearly 3 times more likely to have a recurrent event.

Almost two-thirds of caregivers of parents and children in the United States are women, with the average caregiver a year-old married woman caring for her mother.

Poor mental health more generally is a risk factor for incident CVD, particularly in women, 76 because the prevalence of common mental disorders depression, anxiety is higher in women. Since , there has been an increase in cardiac-related mortality for young and middle-aged women 35 to 54 years, 77 the age group in which the strongest association of depression and CHD has been observed.

There is, however, a dearth of intervention research regarding how best to reduce or prevent the associated unnecessary burden associated with CHD in these women. The directions of these relationships are complex and likely differ, depending on the extent to which they interact with other domains and demographic factors. To date, it is unclear whether reducing gender inequities at the broader societal level ie, upstream or lessening strict gendered roles that shape cardiovascular-related behaviors at the individual level ie, downstream would improve the cardiovascular risk of populations.

Indeed, it is plausible that challenging the ways in which boys and girls are socialized could have a cascade of beneficial health effects over the life course at the individual level.

The key risk factors discussed in this article that link gender to CVD risk and onset share common biological, stress-related pathways. Physical inactivity, excessive drinking, smoking behaviors, and psychosocial stress are all known to promote immunoinflammation, 81 oxidative stress, cell ageing, neuroendocrine hormones, and possibly poor gut health, which may contribute to intermedial thickening, atherosclerotic disease, diabetes mellitus, and hypertension.

In recent years, the role of the autonomic nervous system specifically has garnered attention as a key indicator of optimal health.

Comprising sympathetic activity the flight or fight response and parasympathetic activity vagal activity that stimulates responses that occur at rest , cardiac sympathovagal balance is a marker of good cardiovascular health. It is commonly measured by heart rate variability HRV and is a known prognostic indicator, particularly for women, 82 following MI. A review article by Valentini and Parati 85 identified physical activity, smoking, alcohol, and psychosocial stress as key determinants of HRV and therefore neural cardiovascular modulation.

Indeed, sex-specific differences in both heart rate and HRV have been consistently observed in premenopausal women who have a higher resting heart rate and lower HRV than men.

Targeting gender as a means of modifying biobehavioral aspects of CVD may be an avenue worthy of further investigation. Upstream determinants of health such as employment, domestic, and political contexts that promote gender equality could theoretically benefit cardiovascular health. It is important to note that countries with the highest levels of gender equality have reported some of the greatest reductions in year CHD mortality rates in Western countries.

All of these, as demonstrated in this article, can be heavily shaped by gender. Indeed, economic development is inextricably linked to gender equality, thereby making these concepts difficult to disentangle.

Common features of countries with higher gender equality such as the Nordic countries are policies that promote gender equality, focusing on financial independence in both domestic and work settings. For decades, these countries have had a history of implementing key policies around paid maternity leave, 89 extensive day care services, and a parental leave scheme that provides quotas for couples to negotiate their own combination of absence from their employment.

It is indeed plausible that equality-based initiatives that focus on gender would have other positive effects on the cardiovascular health of both genders and further generations.

For example, encouraging and teaching men to participate in an egalitarian manner in the domestic sphere could foster the emotional intelligence and well-being of both fathers and boys, thereby reducing the risk of delinquency or social isolation, both CVD risk factors. Yet evidence that gender equality is beneficial to the health of men and women is far from unequivocal. Another unexpected consequence of gender equality is referred to as the Nordic paradox, 92 the disproportionally high prevalence rates of IPV against women occurring in Nordic countries.

Gracia and Merlo 92 postulate reasons for this unanticipated trend, which should be taken into consideration in the context of social determinants of CVD. Evidence from other high-income countries suggests that women with higher economic status relative to their partners are at greater risk of IPV victimization, particularly if their partner holds traditional gender beliefs and expectations. Negative perceptions and responses to gender equality may also incite a backlash effect against women in powerful positions.

Of course, an alternative explanation for this trend may be higher reporting of IPV. Progressive cultural expectations and standards encourage, or may at least alleviate, the stigma associated with IPV reporting, meaning that the adverse consequences of reporting are fewer. As generations become more accustomed to the expansion of egalitarianism and fluidity of gendered roles, we might expect rates of IPV to decline. It should be noted that, although cardiovascular risk as it specifically relates to lesbian, gay, bisexual, transgender, queer, questioning, and intersex populations was beyond the scope of this article, it is indeed important when considering gender and sex as a social determinant of CVD and an area that warrants greater attention in both a research and a public health sense.

An intersectional, gendered approach to CVD prevention that considers lesbian, gay, bisexual, transgender, queer, questioning, and intersex populations is therefore required. In conclusion, gender as it overlies biological sex should be considered a social determinant of CVD that is modifiable through efforts to improve gender equality. This approach warrants the attention of government and health professionals. Indeed, the most recent social determinants of CVD risk and outcomes position paper should be updated to reflect this and the contexts in which CVD develops for women and men.

Research is required to determine whether gender equality policies at the national level, such as those introduced in countries that have also experienced major reductions in CVD mortality, would impact the cardiovascular health of the US population.

Gender and sex as determinants of cardiovascular health. Home Circulation Vol. View PDF. Tools Add to favorites Download citations Track citations Permissions. Jump to. Anna J. Scovelle Anna J. Allison J. Milner Allison J.

Abstract The social gradient for cardiovascular disease CVD onset and outcomes is well established. Download figure Download PowerPoint. E-mail adrienne. References 1. Wilkinson RG, Marmot M. Social Determinants of Health: the Solid Facts.

Copenhagen, Denmark : World Health Organization ; Google Scholar 2.

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Running Head: SEX AND NK CELL RESPONSES TO EXERCISE supplementation and female sex independently influence the natural killer. Carbohydrate (CHO) supplementation and female sex independently influence the natural killer (NK) cell response to acute exercise.

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Download PDF. Search for more papers by this author. The social gradient for cardiovascular disease CVD onset and outcomes is well established.

Indeed, the benefits of this approach are likely to be far reaching, enhancing the positive effects of advances in CVD related to prevention and treatment while reducing health inequities that contribute to CVD onset and outcomes.

It is disappointing that the role of gender has been largely neglected despite being a critical determinant of cardiovascular health. It is clear that trajectories and outcomes of CVD differ by biological sex, yet the tendency for sex and gender to be conflated has contributed to the idea that both are constant or fixed with little room for intervention. Rather, as distinct from biological sex, gender is socially produced. It is a fluid construct that varies across time, place, and life stage.

Gender can interact with biological sex and, indeed, other social determinants, such as ethnicity and socioeconomic position, to shape cardiovascular health from conception, through early life when health behaviors and risk factors are shaped, into adolescence and adulthood.

This article will illustrate how gender shapes the early adoption of health behaviors in childhood, adolescence, and young adulthood by focusing on physical activity, drinking, and smoking behaviors including the influence of role modeling. We will also discuss the role of gender in psychosocial stress with a focus on trauma from life events childhood assault and intimate partner violence and work, home, and financial stresses.

We conclude by exploring potential biological pathways, with a focus on autonomic functioning, which may underpin gender as a social determinant of cardiovascular health. Finally, we discuss implications for cardiovascular treatment and awareness campaigns and consider whether gender equality strategies could reduce the burden of CVD for men and women at the population level.

For decades, epidemiologists have consistently demonstrated that mortality and morbidity rates rise steadily as social status decreases. The application of a social determinants of health approach is particularly pertinent in the modern United States. This provides an example of the inverse relationship between transience in socioeconomic position and mortality outcomes.

Data from the Whitehall II study first revealed the association between social and economic factors and coronary heart disease CHD 6 in the early s. In their cohort of middle-aged, British, male civil servants, differences in year mortality rates could be explained only in part by traditional risk factors, including smoking, obesity, physical activity, lipids, and blood pressure. Rather, age and the environments in which individuals lived and worked were shown to be critical ssx shaping cardiovascular health.

Since then, there has been a notable decrease sex cardiovascular-related mortality, largely because of medical and pharmacological advances, yet CVD still makes up one-third of all deaths in the United States.

Indeed, the advantages of using a social determinants of health approach to curb the burden of CVD have the potential to be far reaching, enhancing the beneficial effects of advances in CVD related to prevention and treatment while reducing health inequities that contribute to CVD ssex. Although not explicated ses the position paper by Havranek et al, 8 gender and sex are critical determinants of cardiovascular health.

Improved awareness of CVD in women because of public health campaigns may have contributed to the reported increase in CVD deaths in women 9 by minimizing conventional detection and reporting bias. However, there are other contributing factors. Yet there are specific age groups for which the mortality attributable to CHD is increasing.

Perhaps most striking is the rise in CHD mortality rates for women age 35 to 44 years: an annual increase of 1. Because etiologic models of cardiovascular medicine have been based on scientific research using male-dominated samples, we are only beginning to no why sex-specific physiology might lead to differential CHD development, onset, symptom course, and outcomes, and importantly how we can ameliorate such risk.

With the use of case-control data from 52 countries, the ssx risk for MI owing to the modifiable risk factors of smoking, alcohol use, high-risk sex, and physical inactivity, was significantly higher among women than men Significant differences in the population-attributable risk because of psychosocial factors were also observed To date, the influence of gender on these risk factors and thus the onset and progression of CVD have seldom been considered, much less the notion that gender is a potentially modifiable target for CVD prevention.

This may be because of the tendency for sex and gender to be used interchangeably, contributing to putative thinking that both are constant or fixed. The ways in which gender is expressed differ across domains eg, domestic, economic, political at the individual level, and are embedded in the sex and practices of society.

InElizabeth Barrett-Connor wrote a seminal piece published in Circulation that demonstrated the importance of evaluating both gender and sex differences in relation to CVD risk. Given the cumulative burden of these risk factors to the overall population, the gender-specific differential in population-attributable risk, and their potential to be modified, this article will illustrate how gender shapes the early adoption of health behaviors in childhood, adolescence, and young adulthood focusing on physical activity, drinking, and smoking behaviors including the influence of role modeling.

We also discuss the role of gender in psychosocial stress with a focus on trauma from life events childhood assault and intimate partner violenceand work, home, and financial stresses. We conclude by exploring potential biological pathways that may underpin sex and gender as determinants of cardiovascular health, with a focus on autonomic functioning; discuss implications for cardiovascular treatment and awareness campaigns; and consider whether gender equality strategies could reduce the burden of CVD for men and women at the population level.

In comparison with men, the clinical onset of heart attack is delayed 9 years in women. Physical inactivity and sedentary activity are both risk factors for CVD across the lifespan. From birth, boys are encouraged to be more physical than girls, reflective of underlying assumptions regarding inherent sex-based physical characteristics and aptitude.

The early socialization process places emphasis on boys developing physical strength and girls developing emotional and verbal skills. As early as 6 to 8 years of age, girls are more sedentary than their male counterparts. As women age, this differential persists. As women progress through age categories, a progressive decline in adherence to physical activity guidelines aerobic through leisure-time activity and muscle-strengthening activities was also observed.

Reasons for this gradual and persistent decline in activity in women are complex. Adolescence is the period where young girls and women become aware of, and alerted to, physical and sexual threats to their safety. A critical implication of this is that women are less physically mobile—that is, less likely than men to exercise in public spaces at night 22 or ride a bike through cities.

Indeed, the lifetime cardiovascular and other health-related benefits of targeting the physical activity levels of girls during schooling years has been demonstrated historically.

Conventional measures of activity are often flawed with an inability to discriminate between incidental and purposive exercise. New approaches eg, digital devices, exhaled breath condensate are being investigated for this population to more accurately capture physical activity in populations such as older women.

Social isolation is a potent risk factor for CVD across the life course, whereas social support is a well-established protective factor. Conventionally, boys have been considered predisposed or biologically determined to partake in risk-taking behaviors, whereas girls are predisposed to be risk-averse.

It is interesting to note that gender roles and traits masculinity in particular have been found to sex kn of the gender differences in stress and coping, social constructions of gender that specifically influence the risk of CVD. One study found that men who scored higher on conventional femininity attributes had a lower risk of CHD death hazard ratio nl per unit increase in femininity score, 0.

Indeed, data from the Framingham Offspring Study show that measures of anger and hostility predict the development of atrial fibrillation in men. For girls, loneliness has been associated with past day alcohol consumption OR, 1.

In addition, excessive use of drugs can induce or elevate ni risk for serious mental disorders, to which men are more susceptible, like schizophrenia, schizo-affective disorders, substance abuse, or antisocial disorders. Nl smoking is sex of the most potent risk factors for CVD onset. Most commonly initiated in adolescence, smoking during this critical period of development is a strong predictor of continuation during adulthood.

Indeed, in high-income countries, like the United States, women now smoke at rates comparable to men. During adulthood, role modeling had an impact on smoking cessation for women. In their analysis of the Original Cohort and the Offspring Cohort of the Framingham Heart Study, Darden modeled year smoking behaviors of adult offspring alongside parental behaviors and outcomes.

This suggests that the ni of role modeling on smoking behaviors of girls and women may be more pronounced than in boys and men, in particular as they relate to the risk of CVD.

Body image pressure is also likely to play a role in the uptake of smoking in adolescence. Although body dissatisfaction is prevalent in both boys and girls, the socialization process prioritizes the esthetic value of girls and women from a n young age.

Indeed, an Australian study of girls age 15 to 19 found that they feel that they are seldom or never valued for their brains over their looks.

To counter this, smoking initiation and other weight loss and control tactics, as well, such as disordered eating 48 or overexercising, are common in adolescent girls. Age of onset for anorexia nervosa is 10 to 14 years, and the age of onset for bulimia nervosa is 15 to 19 years.

A behavioral economic approach has recently been applied to quantify the extent to which smoking behaviors are related to weight control. This was particularly true for those who described themselves as too fat. The authors concluded sex the demand for cigarettes is less price-elastic among those who smoke for weight loss, all esx being equal.

In fact, the gender empowerment measure was by far the strongest predictor of the gender smoking ratio, even after including the other 2 esx predictors in the model. Adverse childhood events nj robust predictors of cardiovascular problems in later life, including onset 52 and recurrent CVD. One of the most severe forms of adverse childhood events is physical, sexual, and emotional abuse.

National data show that 1 in 5 girls are victims of sexual abuse, in comparison with 1 in 20 boys. One is that young people are beginning to negotiate their intimate relationships, influenced by longstanding gender roles that see the sexualization of girls from a very early age and the socialization of boys to ssx dominant, heteronormative masculinity. The cardiovascular effects of IPV victimization have been extensively researched and include higher rates of carotid atherosclerosis, Takotsubo cardiomyopathy broken heart syndromeobesity, high triglycerides, and low high-density lipoprotein cholesterol, cigarette, drug, and alcohol consumption in comparison with women who are sdx exposed.

Baron et al 62 found that behaviors characterized by higher trait control ie, dominance predicted higher systolic and diastolic blood pressure in men. Interestingly, evidence from laboratory studies illustrates the immediate effects of IPV perpetration on aspects of the cardiovascular system during buildup, enactment, and aftermath of a violent incident such as pulse rate, heart rate, and arousal levels.

This suggests that emotional dysregulation is not shared by all IPV perpetrators, and sx use of IPV may be driven by other factors. This is important considering how ssex IPV may impact the cardiovascular system in the long term.

Although there is limited research on the long-term impact of gendered violence perpetration on incident CVD, preliminary data suggest that IPV perpetration that occurs in late adolescence and young adulthood increases the risk of CVD in the ensuing 7 to 14 years.

Everyday harassment and discrimination can be considered a chronic stressor that erodes cardiovascular health. In their scientific statement, Havranek et al 8 detail the multiplicative effects of marginalization attributable to ethnicity on CVD risk.

Indeed, the adverse physiological responses to perceived racism are well documented, via its effects swx nocturnal blood pressure recovery 64 and higher daytime systolic and diastolic blood pressure. Longitudinal data reveal that exposure to workplace sexual harassment more than doubles the likelihood of psychological distress after 2 years for women OR, 2.

For ses, poor workplace conditions that affect cardiovascular health are more likely to be characterized by low job control and high demand, a combination known to have cardiotoxic effects. In Western culture, boys are often socialized from a young age to believe they are financially responsible for a sex, whereas girls are more likely to be socialized to be emotionally responsible.

Related to gender role expectations, the effects of marital tension seem to be particularly pronounced for women.

Women with poor-quality marriages have higher rates of several markers for CVD, 71 including low high-density lipoprotein cholesterol, high triglycerides, and higher body mass index, blood pressure, depression, and anger. In a study following women for 5 years after an MI, women reporting high levels of marital conflict were nearly 3 times more likely to have a recurrent event.

Almost two-thirds of caregivers of parents and children in the United States are women, with the average caregiver a year-old married woman caring for her mother. Poor mental health more generally is a risk factor swx incident CVD, particularly in women, 76 because the prevalence of common mental sex depression, anxiety is higher in women.

Sincethere has been an increase in cardiac-related mortality for young and middle-aged women 35 to 54 years, 77 the age group in which the strongest association of depression and CHD has been observed.

There is, however, a dearth of intervention research regarding how best to reduce or prevent the associated unnecessary burden associated with CHD in these women. The directions of these relationships are complex and likely differ, depending on the extent to which they interact with other domains and demographic factors.

To date, it is unclear whether reducing gender inequities at the broader societal level ie, upstream or lessening strict gendered roles that shape cardiovascular-related behaviors at the individual level ie, downstream would improve the cardiovascular risk of populations.

Indeed, it is plausible that challenging the ways in which boys and girls are socialized could have a cascade of beneficial health effects over the life course aex the individual level. The key risk factors discussed in sez article that link gender to CVD risk and onset share swx biological, stress-related pathways.

Physical inactivity, excessive drinking, smoking behaviors, and psychosocial stress are all known to promote immunoinflammation, 81 oxidative stress, cell ageing, neuroendocrine hormones, and possibly poor gut health, which may wex to intermedial thickening, atherosclerotic disease, diabetes mellitus, and hypertension.

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