Healthy Lifestyle During the Midlife Is Prospectively Associated With Less Subclinical Carotid Atherosclerosis: The Study of Women's Health Across the Nation

Abstract

Background Measures of subclinical atherosclerosis are predictors of future cardiovascular outcomes as well as of physical and cognitive functioning. The menopausal transition is associated with accelerated progression of atherosclerosis in women. The prospective association between a healthy lifestyle during the midlife and subclinical atherosclerosis is unclear. Methods and Results Self-reported data on smoking, diet, and physical activity from 1143 women in the Study of Women's Health Across the Nation were used to construct a 10-year average Healthy Lifestyle Score ( HLS ) during the midlife. Markers of subclinical atherosclerosis were measured 14 years after baseline and included common carotid artery intima-media thickness ( CCA - IMT ), adventitial diameter ( CCA - AD ), and carotid plaque. The associations of average HLS with CCA - IMT and CCA - AD were estimated using linear models; the association of average HLS with carotid plaque was estimated using cumulative logit models. Average HLS was associated with smaller CCA - IMT and CCA - AD in the fully adjusted models ( P=0.0031 and <0.001, respectively). Compared with participants in the lowest HLS level, those in the highest level had 0.024 mm smaller CCA - IMT (95% confidence interval: -0.048, 0.000), which equals 17% of the SD of CCA - IMT , and 0.16 mm smaller CCA - AD (95% confidence interval: -0.27, -0.04), which equals 24% of the SD of CCA - AD . Among the 3 components of the HLS , abstinence from smoking had the strongest association with subclinical atherosclerosis. Conclusions Healthy lifestyle during the menopausal transition is associated with less subclinical atherosclerosis, highlighting the growing recognition that the midlife is a critical window for cardiovascular prevention in women.

Keywords: atherosclerosis; cardiovascular disease; lifestyle; risk factors; women.

Figure 1

Exclusion criteria of the participants in the Study of Women's Health Across the Nation. CVD indicates cardiovascular disease; FFQ, food frequency questionnaire; HLS, Healthy Lifestyle Score; SWAN, Study of Women's Health Across the Nation.

Figure 2

Average HLS and measures of subclinical carotid atherosclerosis among 1143 SWAN participants. Values are least squares means (95% CIs) for CCA‐IMT/CCA‐AD from linear models and odds ratios (95% CIs) for carotid plaque (high vs moderate vs none) from cumulative logit models. P values were computed by using the HLS as a continuous variable. Models were adjusted for age at the carotid scan (continuous), race/ethnicity (black, Hispanic, Chinese, or non‐Hispanic white), education (≤ high school, some college, or college degree/postcollege), financial strain (somewhat/very hard paying for basics, or not hard paying for basics), marital status (single/never married, married/living as if married, or separated/widowed/divorced), self‐rated overall health (excellent/very good, good, or fair/poor), Center for Epidemiological Studies Depression scale (≥16 or <16), total energy intake (continuous), menopausal status (premenopausal or early perimenopausal), use of hormone therapy during the follow‐up (ever or never), hot flash at Visit 12 (binary), number of missing visits for HLS (0, 1, or 2), body mass index (continuous), high blood pressure (binary), impaired fasting glucose (binary), serum triglycerides (continuous), total cholesterol (continuous), HDL cholesterol (continuous), LDL cholesterol (continuous), use of antilipidemic medications (binary; Visit 12), and use of antihypertensive medications (binary; Visit 12). The baseline covariates were used unless otherwise specified. AD indicates adventitial diameter; CCA, common carotid artery; CI; confidence interval; HDL, high‐density lipoprotein; HLS, Healthy Lifestyle Score; IMT, intima‐media thickness; LDL, low‐density lipoprotein; OR, odds ratio; SWAN, Study of Women's Health Across the Nation.