Season 3, Episode 6: The complexities of chronic disease in women
A woman’s risk of being diagnosed with one or more chronic conditions, such as heart disease, can be influenced by her lifestyle and family history. In this episode, we’re joined by Dr. Crystal Clark, chief medical officer for Community HealthChoices and senior advisor for the Center for Social Impact at UPMC Health Plan; and cardiologist Dr. Amber Johnson, to discuss chronic diseases that affect women. We also discuss how social determinants such as education, community, and career can impact health.
Love your heart. Heart disease is the leading cause of death of women in the United States. More than 40% of women are living with the disease, the Centers for Disease Control & Prevention reports.
Develop new healthy habits from the American Heart Association’s Life’s Essential Eight.
Know the danger signs. Women sometimes miss symptoms of a heart attack, or mistake what they’re feeling for another, less severe condition. Nausea, vomiting, and a pain in the neck are among the symptoms women might experience. Learn from the CDC.
Get informed. Read more about surveys conducted by the Heart Association since 1997, to try to gauge awareness of coronary heart disease among women. Read more..
Where you live, and what your lifestyle habits are, both affect your health more than your access to quality health care. The National Academy of Medicine breaks it down, using county health rankings.
UPMC members can get further resources by checking out the Magee-Womens Heart Program, or by calling 1-855-876-2484..
Learn more about the UPMC Health Plan Center for Social Impact, which offers resources related to social determinants of health.
Dr. Ellen Beckjord: In this episode. Dr. Crystal Clark, chief medical officer for Community HealthChoices and senior advisor for the Center for Social Impact at UPMC Health Plan, joins us to discuss chronic diseases that affect women, as well as the influence of social determinants of health. Dr. Clark, welcome to Good Health, Better World.
Dr. Crystal Clark: Thank you for having me.
Dr. Ellen Beckjord: Also joining us today is Dr. Amber Johnson, recently now at the University of Chicago. But at the time of this conversation, still cardiologist and assistant professor at the University of Pittsburgh School of Medicine who will provide insight and information to help raise awareness of these topics that are critical to improving women’s health. Dr. Johnson, thank you for joining us today.
Dr. Amber Johnson: Thank you so much for having me.
Dr. Ellen Beckjord: If I can start with you, Dr. Johnson. So, heart disease is the number one cause of death for women in the United States. This is something that I knew before we were preparing for this episode, yet it felt surprising as I was reminded of it. And we know that heart disease for women is often not diagnosed until there’s a catastrophic event like a heart attack. Could you tell us a little bit about heart disease and the impact it has on women in particular, as well as share some ideas about what women should be thinking about as they seek to prevent heart disease?
Dr. Amber Johnson: Yeah, certainly. And you’re absolutely right that we know that heart disease is the number one killer for both men and women. However, oftentimes women don’t think about heart disease. Women may think of other things like cancer, breast cancer.
Recently, there was a survey study that was published by the American Heart Association where they looked at the perception of risk among women. And they did this survey back in 2009. And then they repeated the survey again in 2019. And they found that over the course of those 10 years, women’s understanding of their risk for heart disease had decreased and, most notably, decreased among younger women and among minority women, racial minority women. So, Latinas and Black women. And that is particularly important because we know, as we’ll get into later, the social determinants of health can increase one’s risk of developing chronic diseases like heart disease. So, it’s really important for all of us to understand what our risk factors are.
You asked about why it is that women are less cognizant of these risks. And I think that when we tend to portray heart disease in the media or on TV, it’s usually a social demographic of older men who are having heart attacks. But it’s important to realize that heart disease includes a lot of things, not just heart attacks. It can include things like high blood pressure, which is incredibly common. It can also include heart arrhythmias — so, one of the most common heart arrhythmias is called atrial fibrillation — and a number of other heart diseases. Another really important point that a lot of women don’t realize is that pregnancy can increase the risk of developing heart disease. There are diseases like hypertensive disorders of pregnancy where your blood pressure is higher; preeclampsia, which some people may have developed themselves or may know someone who had preeclampsia that can affect both mom and baby; as well as peripartum cardiomyopathy, where your heart becomes weak as a result of being pregnant. And those types of heart diseases are actually on the rise, and they increase your risk of developing chronic heart disease as you get older. So very important points.
Dr. Ellen Beckjord: Would you comment a little bit on the importance of leading a healthy lifestyle, which I think is related to the American Heart Association’s Essential Eight? What are the Essential Eight?
Dr. Amber Johnson: Yeah. So, there are several things that can help mitigate the risk of heart disease. A few years ago, the American Heart Association came up with Life’s Simple Seven, and then they updated it and added an eighth thing, so now it’s called Life’s Essential Eight. And that includes things like leading a heart-healthy lifestyle. So, having your blood pressure be under control. If you have hypertension, if you have diabetes, make sure your blood sugars are under control, your cholesterol is under control, getting a good amount of physical activity and exercise, eating a heart-healthy diet. If you smoke, quit. And just making sure that you get enough sleep at night. So those eight things, while they seem relatively straightforward, sometimes they can be hard to achieve. So, you know, while these things are super important, I think so long as we’re striving toward them, it’s OK if we don’t get it perfect.
Dr. Ellen Beckjord: But the important thing is to be trying to the degree that you can architect your life around being able to achieve those goals, which, as you mentioned, is not easy, I think, for most people, and certainly not easy for more vulnerable populations.
Dr. Amber Johnson: Certainly.
Dr. Ellen Beckjord: And then last, if I could ask you to comment on, you were part of a team that in November of 2020 published a scientific statement on cardiovascular disease for women during the menopausal transition. And I thought that this was such an important scientific statement. It was certainly eye-opening for me. Would you just give listeners a few of the high points of that scientific statement?
Dr. Amber Johnson: Yes, definitely. There are different phases throughout a woman’s life, you know, throughout anyone’s life where your risk factors may change. And as women get older and go through the menopause transition, it can change your risk for developing heart disease, particularly coronary artery disease. And, so, some of the things that we talked about in that scientific statement were with regard to understanding risk factors for developing heart disease. The section that I helped to write was about getting your cholesterol under control. So, what are ways that we can manage your cholesterol, your lipids, to decrease the risk of developing coronary artery disease or having a heart attack or stroke? And these things differ for women versus men. Throughout the menopause transition, the levels of estrogen and progesterone will change. The level of testosterone will change. And once a woman has completed menopause, their risk is pretty much the same as that of a man’s, which a lot of women don’t realize. So sometimes men will have a higher risk of developing heart disease. But around that menopause transition, it becomes pretty much the same between men and women.
Another really important point for women to realize is that the age at which you undergo menopause is important because if you undergo menopause earlier, that means that your risk increases to that of a man’s at an earlier age. And, so, you have a longer duration at that higher risk of heart disease. In addition, if you’ve ever been on hormone replacement therapy, that can change your risk as well. We know that if you have been on hormone replacement therapy during menopause for an extended period of time, so 10 years plus, then that is what increases your risk of developing heart problems. .
Dr. Ellen Beckjord: Dr. Clark, if I could turn to you to talk about chronic disease more broadly: What knowledge gaps exist around chronic disease management and, in particular, what is UPMC Health Plan doing to help educate communities and the members we serve about chronic disease?
Dr. Crystal Clark: Well, you know, Dr. Johnson’s comments really set us up very well for this part of the discussion. And thank you so much for your comments. When we talk about chronic disease, let’s just talk quickly about the definition. And I like to use the one from the Department of Health and Human Services, which are conditions that last a year or more and require ongoing medical attention and/or limit activities of daily living. I’d also like to just point out that the Centers for Medicare and Medicaid go one step further and identify 21 conditions that they consider chronic diseases: Alzheimer’s disease and related dementia is one. Arthritis, asthma, atrial fibrillation, autism, four cancers in particular — breast, lung, colorectal, and prostate — depression, diabetes, heart failure, Hepatitis B and C, HIV AIDS, high cholesterol, hypertension, ischemic heart disease, osteoporosis, schizophrenia, and stroke.
And I just take the time to highlight those because in the 21 conditions I listed, six of them in particular, women have higher rates: Alzheimer’s is one. Arthritis is another. Breast, of course. Depression, osteoporosis, and hypertension. So right now we know that there’s increased rates of certain chronic conditions that are experienced by women. But where is the gap? A huge gap, huge gap, was identified actually in 2021, and we think it was in the midst of the pandemic when Congress said, where are we with women’s health and representation of women in research? And we found that there is equal representation of male and female subjects in research, which was required by law. But we find that a lot of the research does not get down into the sex and gender specifics so that the conclusions are not as clear. And as Dr. Johnson said so clearly, women experience health differently. So there’s biological reasons that your disease may function and your outcome may be different. But there are socioeconomic factors that a woman experiences different from a man: physical environment, safety, stress.
So, we need to really understand what the impact is by gender and by sex, in addition to studying the chronic disease outcome overall. So, we know chronic disease rates are increasing. We know most chronic disease research has not looked specifically at sex and gender impact. Women’s health has traditionally focused on reproductive health, but it’s become clearer and clearer that there are significant differences in how women and men experience chronic diseases.
As Dr. Johnson said, chronic disease risk in women accumulates with age and as they move into menopause. And, also, this was the one that was really fascinating to me — women experienced something called multimorbidity more than men. So, having one chronic disease is having one chronic disease. But imagine having three chronic diseases at the same time. Four at the same time. It’s not just a recipe for adding additional medications. You’ve got to balance all of that.
When you talk about women’s health, most of us immediately go to reproductive health. We really need to spend time on understanding the impact of chronic disease on women. UPMC does amazing things as far as education and trying to close these knowledge gaps for our members and for our staff.
We have apps and websites with education that’s easy to understand, easily accessible and again, able to use this in your own home. We have remote counseling and consultative services like [UPMC] AnywhereCare. We have RxWell, which is an app where you can actually download and work through stress and ask questions that help you discern where you are with your health. So, we’ve done a lot, I believe, to try and close knowledge gaps with what we do know about chronic diseases in women’s health at this point with UPMC.
Dr. Ellen Beckjord: I want to say I really appreciate that you shared that list of 21 conditions considered to be chronic conditions, because there were some on that list that I probably wouldn’t have guessed. Your comment about multimorbidity and how multimorbidity is really more of an exponential complicator than an additive complicator was also an excellent point.
Dr. Johnson, let’s talk a little bit more about social determinants of health and how they relate to chronic disease or heart disease in particular.
Dr. Amber Johnson: Sure. So, there are social and structural determinants or predictors of health. And the reason why I sort of broaden the statement a bit is social determinants are rather limited in what we would include. But if you sort of think about it more from a broad perspective of structural predictors of health, you can include a lot more things.
And, so, what do I mean by that? Social determinants are what makes a person who they are. So, rurality versus living in an urban environment. Geography — where someone lives in the country, what state they live in. Income — how much money someone makes, or how much of an education someone has or doesn’t have. All of those things are related to health outcomes, and a lot of those things are related to policies and structures that exist within our social hierarchies.
So, for example, when we think about one’s ethnicity or race, then things like structural barriers and racism can play a part in one’s ability to obtain health.
I really liked the comment that Dr. Clark made with regard to women. So sexual orientation, gender identity. These things are part of one’s social determinants of health as well. And the comment that she made about safety, it reminded me of a statistic that I heard while listening to the radio one day — that all things being equal, if a woman felt safe, what would she do more? She would go outside and walk. She would go outside and exercise. Like, how powerful is that? That one’s identity and how you move through the world can determine the things that you are able to do or you feel safe to do to better your health. And so that’s what we’re talking about when we say social determinants of health.
Dr. Ellen Beckjord: I’m so glad that you that you made that point as one of sort of many examples we could think of, but a great demonstration of how social determinants of health can directly affect what’s available to people as far as participating in different behaviors aligned with, for example, the prevention of chronic disease, but recognizing that those choices are not equitable. And there are all kinds of factors that make those health-promoting choices within better reach of some people versus others.
I really appreciate the addition of structural determinants of health to what we typically refer to as social determinants of health. And one structural determinant in particular that I’d love to hear your thoughts on is access to the internet, could you talk about internet access as a structural determinant of health and maybe even other structural or social determinants of health, and how they can really change the trajectory that a woman might be on when it comes to getting diagnosed with a chronic condition or getting diagnosed with a new chronic condition that may then lead to being in that multimorbidity state that Dr. Clark talked about where this is just now an additional chronic condition on top of others?
Dr. Amber Johnson: Certainly. It gets complicated, right? So, all of these different aspects that we’re talking about can make accessing health care insurmountable for certain populations, for certain individuals.
There are many people, probably the majority of the people who live in this country, who don’t have access to things like Wi-Fi, or if they do, they’ve got to go to their local fast food restaurant to get it. And we saw this during the pandemic where there were children who were unable to access the internet at home. And so they had to do their homework, you know, their remote work at their local fast-food restaurants.
So we have found throughout the course of the pandemic that [the] internet is absolutely a structural determinant of health. Our country is moving towards trying to make internet more ubiquitous. There’s the broadband act that was passed just in 2021. It’s a bipartisan act where we’re trying to ensure that every household is able to access the internet, be it a rural household or an urban one, because we know that there are vulnerable populations in each of those communities, rural and urban. So, increasing internet [access] is one thing. By increasing internet, we can do more things online, educational things, health-related things, but then also making sure that the populations who need those services know what to do with them, that they trust them, that they have safe places to access the internet.
Dr. Ellen Beckjord: One thing implicit to what you’re saying, and I know I’ve said this like a million times, you’re probably sick of it. I don’t know though, Dr. Clark maybe it’s the first time you’re hearing it, so I’ll use that as the excuse.
But the way that Dr. Johnson and I first met is I’d written a report about some activity happening at UPMC related to health disparities. And you gave me wonderful feedback on that report. And one of the pieces of feedback you gave me was, you know, effectively you keep writing about how white and non-white groups access care differently and you need to talk about how they receive care differently. And that was so powerful for me. And it relates to what you just said for me, because I think implicit to what you’re saying is that access is necessary but not sufficient to receiving. It’s important that we address access. But for people to really receive care, they have to trust the care that’s behind that access. The care behind that access has to be culturally competent. The care behind that access has to be accommodating of whatever their needs might be. And so while access is important, again, it’s really just kind of an entry into actual receipt of care and then a whole host of other structural and social factors come into play to close the gap between access and receipt.
Dr. Amber Johnson: Thank you. I’m so glad that that stuck with you.
Dr. Ellen Beckjord: Dr. Clark, could you talk about how partnerships like those between UPMC Health Plan, particularly in our Center for Social Impact and community organizations, can help meet social needs by addressing some of those social determinants of health, like improving job opportunities, advancing access to affordable housing, and working to decrease other disparities in communities?
Dr. Crystal Clark: Well, I think the data that usually turns heads, no matter the audience, you know, physicians, politicians, laypeople, is some of the data that came from University of Wisconsin using county health rankings. So almost every county in the United States has health rankings that they run, and they can stratify these factors into buckets. And those buckets are around the access to high quality health care. And then the social factors where they live, where they work, what their income is, what their social supports, all the things that Dr. Johnson outlined for us. Where you get people’s attention is where this research was able to tell you what impact on overall health and wellness each of those buckets provides. So, if I just asked a person how, what percentage of your overall health do you think depends on your access to high-quality health care? Most people would say, wow, probably 99 percent. And they found out that 20 percent, only 20 percent of your overall health and wellness is determined by your access to quality health care. Bricks-and-mortar health care, 20 percent.
So, where’s the other 80 percent? Ten percent is physical environment, as Dr. Johnson pointed out how important that is; 30 percent is your own personal behavior, so, diet, exercise, tobacco use, risky behaviors, personal decisions; and then 40 percent, the remaining 40 percent, is your social factors: where you live, your educational level, your income, your social support, all those things.
So, if we just focus on what we’ve done as an organization extraordinarily well, I mean, our tagline is “Life Changing Medicine.” And it is indeed that. But we realized some time ago, if we just focus on life-changing medicine — great hospitals, great doctors, great nurses, great pharmacists — we’re only really only addressing 20 percent of what determines our members’ overall health and wellness. And we have to address the other 80 percent. And more importantly, you cannot address that other 80 percent alone. A health insurance company cannot address all the other determinants that make up 80 percent of your overall health and wellness. And, so, what do you do? You partner. You unite actors across sectors. That’s how you can move that needle and help people get on a trajectory of overall health and wellness. And so for us at UPMC in 2019 we launched the UPMC Center for Social Impact, and it was an entity that we specifically designed to try and address the social determinants. So, things like housing and income, which is completely driven by what kind of jobs you can get, social supports and social networking. We designed an entity called the Center for Social Impact that uses our stature, our legacy, our reach with organizations that work on housing, that help people prepare for employment.
Because you don’t just help a person get a job, you help them become successful and you actually teach them how to get another job. UPMC is one of the biggest employers in the state. Oh, we have vacancies every day. So, you know, lead by example. So, we’ve created Pathways to Work, which we cultivate for our members to come into our workforce with different supports and structures. But if they don’t want to work at UPMC, we have to sit down with chambers of commerce and employment entities across the state to say we have a pipeline that we can help you identify individuals that we think would be a great addition to what you’re doing. And not only that, but we have worked with these folks to set them up for success so that they have an opportunity to try and pick employment that speaks to them, that will help with sustainability. And it’s a win-win all around. I mean, it helps everyone.
The last thing I will say about working as well, there’s always controversy, controversy around folks who have challenged economics, tying insurance coverage or different types of support to employment. We don’t do that. But we also know — and this is international data, it’s just not national — that a person’s ability to work, if they so choose, improves their overall mental health as well as their social integration. It decreases social isolation and it becomes a role model that can transform an entire family. So, we advocate for employment if the situation is appropriate. So, we don’t shy away from that. We think that employment does so many things other than just bring in income, and we have worked to try and further the skills and behaviors of transforming neighborhoods and communities.
We opened something called the Neighborhood Center in 2022 in East Liberty and it is a huge installation that essentially becomes a one-stop shop. A person can come in and we tell them the things that we have to offer, whether it be support with housing, whether it be to see if they qualify for assistance with utilities, whether it’s food. And this is important because then it’s not just for our members, it’s for the entire community.
We found that when you help one member, but you make that experience such that they leave there with something valuable and they actually leave there with hope, you’re developing transparency and trust, not just with that member, but with the people in their household and maybe in their community.
So, the last thing I’ll say, too, and it’s the compounding nature, not just of multimorbidity, but also social determinants of health.
If you think about where you live, how much money you make, the education that you’ve had, the social support you have, the physical environment that you’re in, all of that is impacted by your ZIP code. All of that is impacted by one thing. And so, while we try to think about these things — and we do need to list them because we need to track if we’re making any kind of progress in improving each and every one of them — we also have to step back and be humble, that one thing can impact so much of overall health and wellness for an individual.
Dr. Ellen Beckjord: This has been a wonderful conversation and I can’t tell you how much I appreciate you both being on this episode. I think you both know, I mean, I’m fortunate enough to call you a colleague at the Health Plan, Dr. Clark. And Dr. Johnson, you and I met several years ago, and I just deeply respect and admire both of you so much. And I’m really grateful that you took time to talk with us today on Good Health, Better World. So, Dr. Johnson, thank you for being here.
Dr. Amber Johnson: Thank you.
Dr. Ellen Beckjord: Dr. Clark, thank you for being here.
Dr. Crystal Clark: It’s been my pleasure.
Dr. Ellen Beckjord: There’s a lot to unpack about the relationship between social and environmental factors and health, and how that relationship affects health disparities and equity — particularly in the context of chronic condition management and the burden of chronic disease in women. Learn more about social determinants of health by listening to the first season of Good Health Better World wherever you get your podcasts and visit postindustrial.com/goodhealth for show notes and additional information.
Dr. Ellen Beckjord, MPH, is host of the Good Health, Better World podcast.
Ellen is a behavioral scientist, epidemiologist, and licensed clinical psychologist working at the intersection of population and digital health. A long-time member of the Society of Behavioral Medicine, Ellen currently serves on the board of directors as president-elect.
Her work focuses on promoting health, wellness, and health behavior change. She is vice president of population health and clinical optimization for UPMC Health Plan based in Pittsburgh.
Ellen trained at the University of Vermont, where she worked with cancer survivors and their families, at Vanderbilt University, and at the Johns Hopkins Bloomberg School of Public Health.
She completed post-doctoral research at the National Cancer Institute in the Health Communication and Informatics Research Branch within the Division of Cancer Control and Population Sciences. She spent nearly five years in academic medicine at the University of Pittsburgh and Hillman Cancer Center.
Ellen also is the co-author of “Porchtraits” in which she interviewed people in Pittsburgh during the early months of the COVID-19 pandemic about what they were learning, missing, enjoying, what surprised them, and what they felt hopeful about.
Ellen’s guiding principle: “Lead with love.”
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