Will Teens Go Red? Low Cardiovascular Disease Awareness Among Young Women.

Background The American Heart Association Go Red for Women campaign has improved awareness of cardiovascular disease ( CVD ) among adult women aged 25 years and older. Little is known about awareness among younger women. Methods and Results We assessed awareness of CVD and prevention efforts among 331 young women aged 15 to 24 years using the American Heart Association National Women's Health Study survey. We compared responses from this cohort to the 2012 American Heart Association online survey of 1227 women aged 25 years and older. Only 33 (10.0%) young women correctly identified CVD as the leading cause of death in women. This was significantly lower than awareness among all adult women in 2012 (785 [64.0%]) and among women aged 25 to 34 years (90 of 168 [53.6%]) ( P<0.01 for both). Many young women in the current study (144 [43.5%]) said they were not at all informed about CVD ; most worried little (130 [39.2%]) or not at all (126 [38%]) about CVD . Young women did report engaging in behaviors known to reduce risk of CVD , although not considering oneself at risk was cited as the number one barrier to engaging in prevention behaviors. Conclusions Young women are largely unaware of CVD as the leading cause of death for women. Given that most young women are not worried about CVD and their 10-year risk for CVD events is low, campaigns to promote heart-healthy behaviors among younger women should underscore the benefits of these preventive behaviors to current health in addition to reductions in lifetime risk of CVD .

Clinical Perspective

What Is New?

Women aged 15 to 24 years have low short‐term but high lifetime risk for cardiovascular disease, including heart disease and stroke.

Only 10% of women surveyed in this age group recognized that heart disease is the number one killer of women.

Young women preferred to learn about heart disease from their doctor, but few had spoken to a doctor about heart disease prevention.

What Are the Clinical Implications?

Physicians should educate young women on their lifetime risk for cardiovascular disease using a developmentally appropriate approach that emphasizes issues that matter to them, including emotional health in addition to physical health.

Cardiovascular disease (CVD) remains the number one cause of death for American women.1 Since 1997, the American Heart Association (AHA) has surveyed adult women aged 25 years and older triennially about heart disease prevalence, risk factors, and preventive behaviors.2 Awareness of CVD has improved over the past 15 years among women, due in part to the AHA's Go Red for Women media communications campaign. However, awareness among younger women has consistently lagged behind that of older women. Forty‐one percent of women aged 25 to 34 were unaware that CVD is the number one cause of mortality in women at the last published assessment in 2012.2 Younger women were also the most likely age group to report that their doctor had never discussed CVD prevention with them (94%) and to report that they did not think they were at risk for CVD (14%).2

There is clear evidence that traditional CVD risk factors, including elevated blood pressure, blood cholesterol, and blood glucose, have their origins in childhood and adolescence.3, 4, 5 In 2010 the AHA set the goal of improving the cardiovascular health of all Americans by 20% by 20206 and recognized the importance of improving the cardiovascular health of youth to this goal.7 Cardiovascular health is defined as the simultaneous presence of 4 ideal cardiovascular behaviors (nonsmoking, normal body mass index, healthy diet, and adequate physical activity) and 3 ideal cardiovascular factors (normal blood pressure, blood cholesterol, and blood glucose without the use of medications). While 41% of adolescent girls have at least 5 cardiovascular health metrics, only 20% of adult women do,1 demonstrating that the transition to young adulthood is a key time for the loss of cardiovascular health. Furthermore, while almost all young adults have a low 10‐year risk of CVD, up to 50% have a high lifetime risk of CVD due to obesity, tobacco use, and nonideal diet and exercise patterns along with borderline levels of the traditional CVD risk factors.8, 9 Experts agree that the most efficacious way to improve the cardiovascular health of Americans and reduce the lifetime risk of CVD is to focus on the primordial prevention of CVD risk factors before they ever occur, thus increasing the number of children and adolescents who retain their cardiovascular health into adulthood.10, 11 However, little is understood about how best to inform young women about their lifetime risk for CVD or to motivate them to adopt and maintain cardiovascular health–promoting behaviors. We aimed to assess awareness of CVD, CVD risk factors, and preventive behaviors proven to improve cardiovascular health among young women aged 15 to 24 years and compare their responses to women aged 25 years and older.

Methods

The data that support the findings of this study are available from the corresponding author upon reasonable request. All English‐ and Spanish‐speaking patients aged 15 to 24 years who self‐identified as female in the electronic medical record, and were visiting an urban academic medical center or a community health center between September 2017 and January 2018 were eligible to enroll in the study. Research assistants approached patients to complete the anonymous survey on an iPad with the goal to reach the estimated sample size of 220 (based on the power to detect a difference in heart disease awareness and preventive actions to reduce the risk of heart disease from the published adult data2). Ultimately, 331 patients provided informed consent to participate and were included in the study; 7 participants elected to complete the survey in Spanish. The institutional Office of Research Investigation approved this study.

We used the previously published AHA Women's Health Study survey with permission from Karen Robb (see acknowledgments). Pilot testing with youth from the hospital's teen advisory board led to the slight modification of a few questions and addition of questions related to young women's health (Data S1). Effort was made to maintain as much as possible the same survey questions to allow us to appropriately compare adolescent/young adult (AYA) responses to those of the adult cohort. We calculated participants’ body mass index (BMI) from self‐reported height and weight as kg/m2; we classified individuals as overweight if the BMI was ≥85th% and <95th% for age (if under 20 years) or if the BMI was ≥25 and <30 kg/m2 (if 20 years of age and older), and as obese if the BMI was ≥95th% for age (if under 20 years) or if the BMI was ≥30 kg/m2 (if aged 20 years and older). Participants were asked to select a racial category; based on the race data distribution, we then classified participants as black, white, or other (which included participants who self‐identified as from another race or as more than 1 race). Participants were also asked whether they self‐identified as Hispanic regardless of other racial categories chosen.

We obtained original data with permission from the AHA for 1227 women aged 25 years and older who were surveyed by Harris Poll Online between August 28 and October 5, 2012; see Mosca et al2 for details regarding participant recruitment and survey administration. Our study focused mainly on comparisons with the entire AHA cohort; we also include additional comparisons to the subcohort of those aged 25 to 34 years (n=168). We primarily report statistical comparisons between groups without adjustment for confounders using the nonparametric Wilcoxon rank sum test. We developed multivariate (and, when appropriate, multinomial) logistic regression models to assess the associations between participant responses in the AYA cohort and various independent variables that could potentially confound these associations, including race, ethnicity, age, family income, and education level. A contrast matrix was constructed to model race, using white as the reference category (white versus black and white versus other). Ethnicity was modeled as a binary variable. We assumed a statistical significance level of 0.05 for all analyses and conducted analyses using the software package Matlab (Mathworks, Inc). Reported frequencies in the text and figures are based on the entire AYA and AHA cohorts. Missing data for individual questions are reported in the figures and tables.

Results

Demographic and selected clinical characteristics of young AYA women participating in the survey are listed in Table. A greater proportion of the AYA sample identified as Hispanic, black, or other race/ethnicity (248, 74.9%), compared with the adult (AHA) sample where the majority identified as non‐Hispanic white (672, 54.8%). AYA participants were more likely to have health insurance and less likely to have a personal medical history of common heart disease risk factors compared with the adult sample. Median BMI for the AYA sample was 25.0 (interquartile range, 10.8); 48 (14.5%) were overweight and 72 (21.8%) were obese. Weight status of the AYA sample overall was statistically similar to that seen in women aged 25 to 34 years in the AHA cohort (P=0.11), where the median was BMI 24.0 (interquartile range, 10.2), and 26 (15.5%) were overweight and 45 (26.8%) obese. However, the BMI for black women aged 25 to 34 years in the AHA cohort was significantly higher (median BMI, 31.0; interquartile range, 14.8) than for black participants in the AYA cohort (median BMI, 25.3; interquartile range, 10.9; P=0.03).

Table 1

Demographic Characteristics of Current AYA Study Participants and 2012 AHA Participants

	2017 AYA Participants (N=331) N (%)	2012 AHA Participants (N=1227) N (%)
Age, y
15–17	91 (27.5)	···
18–21	140 (42.3)	···
22–24	69 (20.8)	···
25–34	···	168 (13.7)
35–44	···	192 (15.6)
45–54	···	257 (21.0)
55–64	···	330 (26.9)
>65	···	280 (22.8)
Missing	31 (9.4)	23 (0.9)
Race/Ethnicity
Black	68 (42.0)	202 (16.5)
White	57 (35.2)	672 (54.8)
Other	37 (22.8)	153 (12.5)
Hispanic	123 (37.2)	200 (16.3)
Missing	46 (13.9)	0
Household income
$<35 000	105 (31.7)	417 (34.0)
$35 000 to <50 000	14 (4.2)	190 (15.5)
$50 000 to <75 000	17 (5.1)	236 (19.2)
$≥75 000	38 (11.5)	318 (25.9)
Don't know/missing	157 (47.5)	66 (5.4)
Health insurance status
Yes	301 (90.9)	1060 (86.4)
No	1 (0.3)	167 (13.6)
Missing	29 (8.8)	0
Personal medical history
Overweight/obesity	85 (25.7)	71 (42.3)
Depression	107 (32.3)	249 (20.3)
Smoking	23 (7.0)	159 (13.0)
Family history of heart disease	62 (18.7)	405 (33.0)
High blood pressure	23 (9.0)	407 (33.2)
High cholesterol	17 (5.1)	391 (31.9)
Diabetes mellitus/ pre–diabetes mellitus	17 (5.1)/22 (6.7)	152 (12.4)
Missing	52 (15.7)	185 (15.1)

All personal medical history variables were self‐reported. Classification of overweight/obesity in the Adolescent/Young Adult (AYA) sample was based on pediatric (if aged <20 years) and adult (if aged ≥20 years) Centers for Disease Control and Prevention body mass index thresholds using self‐reported height and weight for the AYA sample. Classification of overweight/obesity in the American Heart Association (AHA) sample was based on self‐report of being ≥20 lb over one's ideal weight for height. Personal history of heart disease was considered present if the participant noted any history of a heart attack or stroke.

Awareness of Heart Disease and Competing Health Priorities

Only 33 (10.0%) AYA participants identified heart disease as a leading cause of death for women of all ages, compared with 62 (18.7%) who identified breast cancer and 73 (22.1%) who identified cancer in general. This was significantly lower than the proportion of women in the full AHA cohort who identified heart disease as the leading cause of death (785 [64.0%]; P<0.01), and lower than the next age group of women aged 25 to 34 years in the AHA cohort (90 [53.6%]; P<0.01). The distribution of identified causes of death is summarized in Figure 1A for the AYA cohort and Figure 1B for the AHA cohort of women aged 25 years and older. In multivariate models adjusting for age, education level, and family income, AYA women of other/mixed race were less likely than white women to identify heart disease as the leading cause of death (adjusted odds ratio, 0.51; CI, 0.28–0.94). No other racial, ethnic, family income, or education differences in identifying heart disease as the leading cause of death were found in the AYA sample (P≥0.12).

Figure 1

Leading causes of death for women of all ages as reported by adolescent/young women (AYA) aged 15 to 24 years (A) and women aged 25 years and older in the American Heart Association (AHA) cohort (B). Seventy‐nine (23.9%) women in the AYA cohort and 32 (2.6%) women in the AHA cohort did not provide a response to this question.

Only 16 participants in the AYA cohort (4.8%) identified heart disease as a major health problem facing women of all ages, and only 3 (0.9%) identified it as such for women aged 15 to 24. Breast cancer, cancer in general, sexual health, and mood disorders were identified as major health problems for women of all ages by 69 (20.9%), 32 (9.7%), 66 (19.9%), and 66 (19%) of AYA women, respectively. In contrast, a significantly higher number of women in the full AHA cohort (280 [22.8%]; P<0.01), as well as a significantly higher number of women aged 25 to 34 in the AHA cohort (30 [17.9%]; P<0.01) identified heart disease as a major health problem. The complete distribution of major health problems for women is summarized in Figure 2A for the AYA cohort and Figure 2B for the AHA cohort of women aged 25 years and older. In multivariate models adjusting for race, ethnicity, family income, or education differences, no significant demographic differences were found in identification of major health problems in the AYA sample (P≥0.33).

Figure 2

Leading health problem for women of all ages as reported by adolescent/young women (AYA) aged 15 to 24 years (A) and women aged 25 years and older in the American Heart Association (AHA) cohort (B). Two (0.6%) women in the AYA cohort and 469 (38.2%) women in the AHA cohort did not provide a response to this question. STIs indicates sexually transmitted infections.

The top 4 causes of death for women aged 15 to 24 years identified by the AYA participants were suicide (91 [27.5%]), drug addiction (77 [23.3%]), accidental death (27 [8.2%]), and violent crime (24 [7.3%]).

Mood disorders were the number one health problem identified for women aged 15 to 24 years, with 59 (17.8%) participants choosing this option; an additional 27 (8.2%) identified eating disorders and 19 (5.7%) identified drugs/alcoholism as major public health issues facing this young age group. The full distribution of identified causes of death and major health problems for women aged 15 to 24 are summarized in Figure 3A and 3B for the AYA cohort. No significant race, ethnicity, family income, or education differences were found in multivariate models (P≥0.48). These questions were not asked of the women aged 25 years and older in the AHA cohort.

Figure 3

Leading cause of death for women aged 15 to 24 years (A) and leading health problem for women aged 15 to 24 years (B) as reported by adolescent/young (AYA) women aged 15 to 24 years. Fifty (15.1%) AYA women did not provide a response for leading cause of death in their age group, and 133 (40.2%) did not provide a response for leading health problem in their age group. STIs indicates sexually transmitted infections.

Awareness of Heart Disease Risk Factors and Sources of Heart Health Information

Despite 272 (82.2%) AYA women reporting having seen a healthcare professional on a regular basis, only 64 (19.3%) had discussed heart disease with their provider in the past 6 months. Participants identified 3 major reasons for not speaking to health professionals about heart disease, including the healthcare professional not bringing it up (111 [33.5%]), participants not feeling the need to discuss it (99 [29.9%]), and not feeling they are at higher risk for heart disease than others (70 [21.1%]). Relatively few young women identified being overweight (n=38 [11.5%]) or smoking (28 [8.5%]) as very common reasons for avoiding or delaying going to their doctor.

When asked specifically about causes of heart disease, the majority of AYA participants identified family history as a major cause (252 [76.1%]), followed by high blood pressure (240 [72.5%]), obesity (235 [71.0%]), high cholesterol (218 [65.9%]), stress (180 [54.4%]), and diabetes mellitus (157 [47.4%]). This suggests that young women have adequate awareness of heart disease risk factors. However, only 35 (10.6%) of AYA women felt that they were well informed about heart disease, compared with 35 (20.8%) women aged 25 to 34 years and 345 (28.1%) women overall in the AHA cohort. A substantial number of AYA participants (141 [42.6%]) said that they would like to be informed about heart disease by their physician.

Preventive Health Behaviors, Barriers, and Facilitators

Almost 85% of the of AYA participants (280 [84.6%]) reported at least one preventive heart health behavior, such as getting physical exercise, getting adequate sleep, and reducing sugar intake (see Figure 4 for the full distribution of reported behaviors). The most common reasons for such actions were to improve their health (237 [71.6%]), live longer (207 [62.5%]), feel better (205 [61.9%]), and avoid taking medications (130 [39.3%]). Similarly, >90% of the AHA participants (1108 [90.3%]) reported preventive actions, and the adult women reported the same top 4 reasons as the young women for doing so. Over one third of young women were encouraged to take action by their healthcare provider (113 [34.1%]) and almost half of them were encouraged to by a family member (151 [45.6%]). There was no statistically significant association in the AYA cohort between identifying heart disease as a major cause of death for all women or a major health problem and any preventive action (P≥0.2 and P≥0.74, respectively).

Figure 4

Preventive actions taken in the past year by adolescent and young adult (AYA) women aged 15 to 24 years.

The most common personal barrier cited by AYA women for not taking preventive action was that they did not perceive themselves at risk for heart disease (130 [39.3%]), followed by stress (108 [32.6%]), lack of knowledge of what to do (67 [20.2%]), and lack of confidence (65 [19.6%]). Compared with older women, AYA women were more likely to report lack of risk for heart disease, stress, lack of confidence, fear of change, depression, and confusion (including not knowing what to do) as major factors in not taking any action compared with older women (P≤0.01) but less likely to report lack of money/insurance coverage as a major barrier. More than 70% of AYA participants (241 [72.8%]) felt that access to healthier foods (including better fruits and vegetables) would facilitate a heart‐healthy lifestyle. Slightly more than half of young women surveyed felt that greater access to public recreational facilities and policies requiring restaurants to post nutrition information for menu items would lead to healthier lifestyles (191 [57.7%] and 177 [53.5%], respectively).

Discussion

In this study of adolescent and young adult women presenting for clinical care in the northeastern United States, we found very low awareness of heart disease risk. Only 1 in 10 young women in our sample cited heart disease as the leading cause of death in women, and <5% believed that heart disease was the leading health problem for women. This was substantially lower than rates of awareness seen in adult women even just 1 decade older in the national adult sample. Adolescent and young adult women were much more likely to cite breast cancer or cancer in general as the leading causes of death in women, and to cite mood disorders, eating disorders, and sexually transmitted infections as the leading health problems for both women of all ages and women in their specific age group.

That adolescent and young adult women cite mood disorders, eating disorders, and sexually transmitted infections as leading health problems is not surprising, as each of these conditions has a peak onset in adolescent and young adulthood.12 Furthermore, the percentage of total deaths attributed to unintentional injuries, suicide, and homicide for women aged 15 to 19 years and 20 to 24 years were 40.1% and 44.1%, 16.7% and 11.6%, and 8.8% and 7.7%, respectively, in 2016,13 demonstrating that young women in our study have excellent awareness of the health issues facing their age group in the short term. However, as noted in the introduction, the lifetime risk of CVD is high in many young women even though their short‐term risk for CVD is very low.9 Adolescents have been shown in some research studies to have difficulty projecting out far into the future,14 which may partially explain why subjects in our sample endorsed the prevalent adolescent conditions of mood disorders and sexual health concerns as the most common health problems for women of all ages. Importantly, young women in our study were still much more likely to cite cancer over heart disease as a leading health problem for all women and women their age, despite the low rates of cancer in young people15 and the rising incidence of myocardial infarction in women under age 55.16 The recent increase in stroke incidence among young adults17 is also cause for alarm and presents evidence of the need for immediate improvement of both heart disease awareness and preventive health behaviors among young women.

Heart disease affects 1 of every 3 women in the United States,1 and breast cancer affects 1 of every 9.15 Despite this disparity in incidence, women may be less apt to talk openly about heart disease and stroke with younger members of their families or communities because the effects of heart disease treatments relative to cancer therapies may be less visible. In addition, cancer awareness campaigns may have been more successful at reaching teens through professional sports and cosmetics advertising18 or antitobacco campaigns19 targeted at adolescents. Textual analyses of media representation of women's breast cancer and heart disease confirm that not only is breast cancer more frequently reported on, but breast cancer reporting also contains more personal testimonies,20 which may skew young women's perceptions of the 2 diseases.

Notably, not viewing oneself as being at risk for heart disease was a top barrier to engaging in preventive health behaviors for both the AYA women in our sample and women in the adult sample. Healthcare providers were identified as an important source of information by both cohorts, but few of the AYA women and few of the women aged <35 years in the AHA cohort had spoken to a physician about their heart disease risk. This lack of communication about heart health may be attributable to low perceived short‐term risk for CVD by both patients and providers. It may also be the result of competing priorities such as unintentional injuries, mental health concerns, and sexual health issues in this age group. Other common barriers to preventive actions, including not knowing what to do and lack of confidence in one's ability to change behavior, could also be addressed in the physician's office. Efforts to improve heart disease awareness and screening for heart disease risk factors in younger women must include targeted education and quality improvement efforts with healthcare providers most likely to treat this age group,21 including obstetricians and gynecologists, family physicians, nurse practitioners, college health providers, and pediatricians.

The young women in our sample also identified stress as a common barrier to engaging in preventive action. This, coupled with the finding that mood disorders are the number one health concern among young women, indicates that future campaigns aiming to increase heart‐healthy behaviors among adolescents may benefit from highlighting the ameliorating effects of healthy diet, exercise, and tobacco cessation on mood. Furthermore, many AYA women in our sample cited a desire to feel better, improve their health, and live longer as internal motivations to engaging in preventive behaviors, so messages targeted toward these motivations should be incorporated in future heart disease prevention campaigns.

Our study has several important limitations. First, although sufficiently large for the purposes of our study, our sample size is relatively small. Future nationally representative samples with more participants may be conducted to validate our findings. Given the anonymous nature of our survey, we are unable to report data on the physician‐verified healthcare problems, family history, or frequency of healthcare visits for our participants and unable to calculate individual lifetime risk for CVD; 10‐year risk estimation is not recommended for participant under age 40 years.22 Additional limitations to our study include the difference in sampling time (2012 versus 2017), strategy, and scope from the AHA sample. Our participants were more racially and ethnically diverse than the AHA sample, and one of the clinical sites for recruitment held subspecialty clinics for treating eating disorders and obesity, although participants being seen in these specific clinics were not eligible for recruitment. Participants in both samples completed the survey online; in the adult sample, participants gave a free response to the questions about leading cause of death and leading health problem; in the current study, participants were presented a list from which to choose the answer for these questions. The AHA sample is nationally representative, and our participants were drawn from 2 clinical sites in the northeastern United States in a state with high rates of health insurance coverage and healthcare utilization. Our sample, therefore, likely represents a healthier population than the nationally representative adult sample, if anything, making the low rates of heart disease awareness in the AYA sample even more concerning. In addition, survey weights were applied to account for the chance of inclusion in the sample in the original AHA analysis, and as we did not apply survey weights to the adult data in this analysis, our findings differ slightly from those published by Mosca and colleagues in 2013.

Conclusion

Adolescence and early young adulthood are an important time in the life course for the prevention of heart disease. Although women in this age group have a low short‐term risk for CVD, they often have a high lifetime risk of CVD, and CVD remains the number one cause of mortality for American women. CVD risk factors begin to accumulate early in life, and promotion of cardiovascular health and heart disease awareness among young people is essential to reducing the burden of CVD worldwide. Future studies should explore effective strategies for linking heart health promotion with issues that matter to young women—especially emotional health—as well as health communication channels most likely to reach women in this age group. A multifaceted approach that partners with young people to improve health curricula in schools, train physicians who provide care for this age group, and engage youth in the community and online will be necessary to tackle the low awareness in young women of the importance heart disease as a lifelong health concern.

Sources of Funding

This project was funded by a National Heart, Lung, and Blood Institute (NHLBI) K23 grant awarded to Dr Holly Gooding (K23 HL122361).

Disclosures

None.

Data S1. FUTURE survey adapted from the American Heart Association Women & Heart Disease Women's Health Study.

Click here for additional data file.