Listen to the Clinical Chemistry Podcast
Haider J. Warraich and Robert M. Califf. Differences in Health Outcomes between Men and Women: Biological, Behavioral, and Societal Factors. Clin Chem 2019;65:19-23.
Dr. Robert Califf is Vice Chancellor for Health Data Science and Professor of Cardiology in the Duke University School of Medicine and a former Commissioner of Food and Drugs at the USFDA. Dr. Haider Warraich is a physician, writer, and clinical researcher with the Division of Cardiology at Duke.
This is a podcast from Clinical Chemistry, sponsored by the Department of Laboratory Medicine at Boston Children’s Hospital. I am Bob Barrett.
In almost all high-income countries, the U.S. included, women live longer than men. As we enter a new era in which biomedical data are increasingly ubiquitous, current and future research may help us understand the fundamental issues that drive differences in longevity and other health outcomes between men and women. Our ability to measure the entire spectrum of information about the human biological, environmental, and behavioral condition will become both routine and relatively inexpensive from genes to genomics. From clinical data to the electronic health record in insurance claims. From digital information about behavior and social interaction to geospatial referencing.
The January 2019 issue of Clinical Chemistry is devoted to topics of men’s health and in that issue, an article examined differences in health outcomes between men and women and underlying biological, behavioral, and societal factors. We are pleased to have both authors of that article as our guests in this podcast.
Dr. Robert Califf is Vice Chancellor for Health Data Science and Director of Duke Forge, the Center for Actionable Health Data Science at Duke Health and Professor of Cardiology in the Duke University School of Medicine. From 2016–17, he served as Commissioner for Food and Drugs at the U.S. Food and Drug Administration.
Dr. Haider Warraich is a physician, writer and clinical researcher with the Division of Cardiology, Department of Medicine, Duke University School of Medicine in Durham, North Carolina. And we will start with you, Dr. Warraich. What explains the difference in mortality between men and women, is it biology or behavior or just something else?
I think for a long time it was perhaps believed, especially over the first half of the century, that biology might explain the differences in lifespan between men and women, but I
think one of the things that we are seeing increasingly as we
can widen the lens and start to think of other factors that
affect human health, that it’s probably a combination of not
only biology but also behavior and societal factors.
Certainly, if you look at trends in the United States, trends
that have led to relative widening of the gap in mortality
between men and women, I think it is our belief that at this
point at least, the reason for that is more behavior rather
I would just add that behavior has some base in biology and
some base in—obviously in culture and socialization and
the way it happens, but I think it’s almost irrefutable now
that men take more risk earlier in life in ways that are
detrimental to longevity than women do.
Does this mean if a man has made it past 65, are they
about equal after that?
The difference is they do even out once people get older but
there’s so many differences earlier. I think almost everyone
now has a relative who has been in the nursing home, and if
you look at the nursing population, it’s vastly majority
women because of the men are dead by that time.
If you look at centenarians and super centenarians, people
who are even older than a hundred, the ratio between men
and women becomes even more stark just to add to Dr.
Califf’s great point.
So how can modern digital technology help bridge the gap,
if it all?
So, I would say some of this could be helped by digital
technology if it gave, sort of, promoted better health habits
and less unnecessary risk-taking and one could argue that
actually digital technologies have been reinforcing risky
health behaviors up until now because of the way
advertising works and the way certain things are glamorized
that men tend to be attracted by, extreme skiing being one
example I think about with my two sons. But you can
imagine that the same kind of technology since it reaches
almost everyone could be used to inform people better
about risk and what it means to their future. This is a
difficult topic though. It’s very hard to reinforce what’s
called executive function, which is the function of being able
to not do something now because it will lead to benefits in
the distant future.
I mean, I couldn’t agree with Dr. Califf more and I think this
is really an important time in which people that we as physicians, public health experts, need to sit down with experts and with people in the Silicon Valley to really start thinking about A) identifying what are the broad implications or impacts that digital technology, the internet, social media are having on human health, and then maybe start to come together and find ways of mitigating some of these—some of its ill effects, but also thinking about how can we sort of take the next step and use the tools that we have, the connectivity that we have, to really be able to find synergy because as Dr. Califf has mentioned, so far, I think as a society, as a species really, we’re just grappling with understanding just how much human life has changed over such a short period time and what the impacts of that are. We’re just beginning to, I think, scratch the surface.
We’re hearing of course recently that men are living shorter lives today because of an increase of deaths from opioids, that is a general question but what can you think could be done to stem this epidemic?
Well, you’ve really—that’ a huge topic with many, many facets and many sort of culprits in the system who have been involved. But I do think there is this underlying theme of what’s been called diseases of despair and it’s addiction, overdose, suicide are the main components of this, and one interesting part of the suicide issue is that the proliferation of guns which tends to be dominant in men, leads to an increase in what’s been termed successful suicide, that is if you’re trying to commit suicide by other methods, it’s actually hard to do it and people end up not completing the suicide but if you use a gun, it happens and the dominant form of suicide in men is with the use of guns. On the opioids, I think that is men and women actually. Less of a divide there but men tend to be more extreme in their use of drugs and I think that does lead to some difference. Haider, I don’t know if you have a view on that.
I mean, I think that you’re right. I mean, I think that the opioid epidemic is a symptom of so many different things, trends have been going on. There’s a lot of economic disparities. There’s a big rural/urban divide that’s starting to open up in health and finances. There is this weakening of the social fabric that connects people together in communities and certainly, I think I’d be remiss not to say that the health system had at least if not a causative part, a small part in promoting the use of opioids without perhaps being able to forecast or foresee what this might turn into.
I mean, there was a time when—especially when I had started training that you know, pain was considered as a fifth vital sign along with heart rate, blood pressure, temperature, et cetera, and now a lot of medical societies like the MA, like the VA, et cetera have now realized that perhaps that was not the best approach. So, I mean this is
going to be—to solve this both for men and for women, I
think on the opioid epidemic, we all need to come together
and figure out ways that cut across some of these silos to
really be able to overcome it.
Well, let’s talk about cardiovascular disease because that
was traditionally seen as a disease of men, you know the
harried executive with a cigar in one hand and clutching his
chest with the other. But recent studies have shown that
women have caught up when it comes to cardiovascular
disease. How is this disease the same and different
between men and women?
Well, I’d say women have caught up, that’s sort of a yes and
no thing. In terms of lifetime risk, women have definitely
caught up but there is a difference in the incidence of
cardiovascular disease, particularly the premenopausal
phase in women is still significantly lower risk than men.
The good and bad news here is that these effects are mostly
mediated by risk factors that we understand, you know,
blood pressure, lipid levels, smoking behavior, lack of
exercise, obesity, and diabetes with high glucose levels
being bad. You know, the mediators of these problems are
pretty well understood, and the place where women catch
up particularly in older age, that’s a scenario where we still
have a lot to learn about the interaction of aging and these
I think that’s a great question and there has been a lot of
debate about whether women in fact have different
symptoms from men when it comes to—when they
experience heart disease. There are some data to suggest
that a lot of women have so called atypical symptoms and
not the classic symptoms of heart disease, that may lead to
potential misdiagnosis but other studies show that that may
not be the case. I think studies and surveys suggest that
despite the knowledge that diseases like heart disease
remain the number one killer of women as it is with men,
there is just not enough recognition that it is a disease that
affects both sexes at the same rate. So even though men
especially early on in their lives have a higher incidence of
heart disease, there is some data that we have cited that
shows that when women do in fact have heart disease early
on, their outcomes are in fact worse and now it’s hard to
know why that happens.
Some of it is because there is a delayed recognition both on
the part of the patient that you know, a lot of—there’s a lot
of qualitative data that suggest that you know, lot of women
who had had heart attacks didn’t really attribute their
symptoms to that. And a lot of physicians sometimes can
be, you know, less suspicious or less rigorous in trying to diagnose heart disease in women because the incidence is lower so I do think that this is something that disparity does need to be addressed further with more research.
Well, yeah, I just want to emphasize that in a discussion about men, while it’s definitely the case that we need to understand the differences that women face and we need to raise awareness about heart disease in women, I think this might a tendency to believe that we’ve got the problem solved as it relates to men when in fact that’s not what the data shows. And so, it’s not as if we know exactly what to do with men and are making tremendous strides, in fact death rates from cardiovascular disease have leveled off in our society in the U.S. in the last several years and it’s a very alarming trend. The stroke rates are actually going up. We need to understand women better but we also need to focus some attention on men since they’re dying at earlier ages from heart disease.
Okay, well since we are discussing men in this special issue of Clinical Chemistry, let’s end with this one, the term toxic masculinity. It’s a phrase that’s often misunderstood. What are your views on the use of this term, toxic masculinity, Dr. Califf?
Oh, I’ll let Haider take that one. He’s an expert in that area.
You know, I think that from time to time there is a certain term that becomes fashionable. But I do think that there is a ring of truth to this term. I think one of the things that as we’ve talked about already is that men, because of both biological differences but also behavioral differences and differences that occur because of how boys are raised, do end up more aggressive and violent and that’s something that we’ve seen throughout history. And a lot of times that has been used by people, that has been used by autocrats and dictators and generals to conquer other nations and to fulfill their own goals but at the same time I think what’s being missed is that a lot of these behaviors, the sort of classic, sort of masculine behavior or the sort of masculine form of, you know, I’m going to take care of myself, I don’t need help, et cetera, et cetera, is now coming back to hurt men. We know that men are less likely to seek help, we know that they are less likely to visit a doctor, they’re less likely to talk about things like depression and anxiety.
So, you know, I think a lot of people when they talk about this term, they think about the effect that the traditional or sort of the stereotypical masculinity has on other people, but I think what we’re trying to show and I think what the data supports is at this is also equally dangerous to men themselves, and that this is being born-out by this increase in the number of men dying prematurely of what are preventable reasons. So, I do think that there is some ring of truth to this term but we want to turn it around, we want to use this in a positive way to sort of focus on how can we help men take better care, not only of other people around them, but also of themselves.
Yeah, just to reemphasize one part of this that Haider, I thought, gave a great explanation of thinking about it, the self-reliance thing, which is very much reinforced in men whereas on average, women tend to be more involved socially and emotionally in the issues, you know, a very high proportion of decisions, health decisions, about men are made by the woman in the family. And it’s good that women help out and want to be involved but if men could seek help more actively and take better care of themselves, it would surely result in better outcomes and how to deal with that culturally, it’s probably not a biological thing. Haider has pointed out nicely in the writing that in some cultures, men do take better care of themselves and it’s something that we should strive for.
That was Dr. Robert Califf, Vice Chancellor for Health Data Science and Professor of Cardiology in the Duke University School of Medicine and a former Commissioner of Food and Drugs at the USFDA. He was joined by his colleague, Dr. Haider Warraich, a physician, writer, and clinical researcher with the Division of Cardiology, also at Duke. They have been our guests in this podcast covering differences in health outcomes between men and women. Their article on that topic appears in the January 2019 issue of Clinical Chemistry, a special issue devoted to the area of men’s health. I’m Bob Barrett. Thanks for listening.