1. Cardiovascular disease in men Susan Neal Nurse Practitioner North Street Medical Care

2. Sex is bad for you Burden of heart disease for men Some theories Issues for care and service delivery Some innovative approaches

3. The stronger sex? Mortality greater for males of all ages in all death causes Life expectancy lower Especially accentuated for lower social classes

4. Table showing deaths by gender and age – United Kingdom, 1998 (Death rates per 1000 in each age group) <1yr1-1516- 34 35- 54 55-6465-7475 +all ages Male6.40.21.03.012.534.8110.110.9 Female 5.20.20.41.97.521.188.711.5 Table showing expectation of life by gender, UK 1997 2021 MaleFemaleMaleFemale At birth74.679.678.682.7 Age 2055.560.359.163.1 Age 6018.822.622.025.1

5. Table showing life expectancy by social class – England and Wales, 1987-91 Men Women ClassYearsAt ageYearsAt age 1 and 274.915.080.218.7 3 (Non- manual) 73.514.179.418.3

6. Table showing death rates for selected causes of death – England, 1998 (Deaths per 100,000 population) Causes of Death MaleFemale All causes1014.01078.50 All cancers273.2242.6 Lung cancer73.541.6 Colon, rectum, bowel29.626.9 Prostate cancer33.1 ------- Breast cancer-------43.8 Ischaemic heart disease251.3203.9 Cerebrovascular disease82.0134.1 All accidents23.516.1 Road vehicle accidents8.93.3 Suicide15.54.8

7. Cardiovascular disease Annually 100,000 men die from CHD (80,000 women) Men below 50 have six fold higher risk than women 1/12 men die of CHD before retirement 50% of all deaths in working age group 2/3rds all deaths from heart attacks are men

8. Men develop CHD on average 10 years earlier than women Unskilled working men are 3 times more likely to die prematurely of CHD than men in professional/managerial classes Rates reducing but less so in lower social classes

9. A disease of men? Most research focused on men Perception of CHD as disease of men Sex difference in management becoming apparent Where are men in the NSF?

10. Some theories for the male excess of CHD Sex hormones – oestrogen increases levels of HDL cholesterol (25% higher in women) testosterone may cause lower levels of HDL Body fat distribution – accumulation to upper body (men), thighs and buttocks women. Waist to hip ratio may be associated with HDL:LDL ratio. Central obesity greater predictor of risk Stress reaction Mild to moderate vertex baldness associated with 40% increase in MI, severe baldness 340% increase.

11. Smoking – accounts for 25% of deaths from CHD In 2000 29% men & 25% women smoked Higher in manual groups 32% Highest prevalence men age 16-44 Rates falling but may be levelling off

12. Diet – women eat more fruit and veg hence have higher antioxidant intake. Men have higher dietary fat intake Exercise – men tend to take more than women

13. Health preservation and illness behaviour From early life boys perceive themselves less vulnerable and susceptible to illness Men more likely to engage in risk taking behaviour Reluctant to act on symptoms Reluctant to accept health promotion Adoption of “sick role” difficult

14. Table showing consultations with an NHS GP in past 14 days – Great Britain 1996 (percentages) AgeMalesFemales 16-441020 45-641519 All ages1319 Table showing average no. of NHS GP consultations per person per annum – Great Britain, 1996 AgeMalesFemales 16-4437 45-6456 All ages46

15. Visit doctor less Present at later stage of illness Have less intimate relationship with care providers Less able to discuss, disclose and share. Constrained by social taboos & embarrassment Less chance for opportunistic health promotion eg BP more likely to have been recorded in women Less likely to respond to invitations for screening Wives very instrumental in changing behaviour Role of other family members in determining lifestyle and illness behaviour (OXCHECK Study)

16. Views on exercise & fitness Normalise tendency to overweight with age Preoccupation with physical appearance is a “woman thing” Know little about nutritional content of food Keeping fit seen as “middle class” activity Team sports preferred to individual exercise Competitive element appreciated Awkward about group exercise Workplace seen as good place for health promotion

17. Implications for Service Delivery ? Is primary prevention for CHD in the surgery worthwhile? Secondary prevention needs to be targeted and appropriate Little evidence about what works Family centred approach Are surgery services man friendly?? Key stages of life may be targeted with different approaches ? Specialist workers Outreach Male friendly media

18. Outreach schemes Taking screening to the workplace and leisure place – pubs, clubs, factories, sports grounds, betting shops