Sex differences in coronary heart disease. Why are women so superior? The 1995 Ancel Keys Lecture.

Abstract

It was a great privilege to be asked to give the 1995 Ancel Keys lecture, following five very distinguished colleagues [Geoffrey Rose, Henry Blackburn, Jeremiah Stamler, Fred Epstein, and William Kannel] and honoring Ancel Keys. It is difficult to imagine how little we would know about CHD without their contributions. The subject of my lecture, “Why are women so superior with regard to coronary heart disease?,” is surely one of the most interesting of all epidemiological questions. My intention is to illustrate methodological problems and review old and new provocative results, making inferences from a variety of disciplines. My focus is on the origin of the gender gap, not postmenopausal estrogen therapy. There will be no conclusions, only reconstruction. My lecture is outlined in Fig 1⇓. Figure 1. Lecture outline. ### Unhealthy Behaviors For years it was thought that the excess male mortality was explained by unhealthy behaviors that were more socially acceptable for men than women. These behaviors might include cigarette smoking, heavy alcohol use, eating more red meat and fewer fruits and vegetables, and exposure to physical hazards. The usual view was that differences in behavior were more important determinants of the higher male mortality than inherent sex differences in physiology.1 More recently, studies adjusting for unhealthy behaviors show that they contribute to but do not fully explain the increased risk of CHD in men.2 ### Work Outside the Home It was also a popular premise that men were harmed by the stresses of the workplace; women were apparently protected by being at home relaxing with the children and the washing up. As Bernard notes, “. . . the husband went forth each day to grapple with the cruel cold world and the wife remained in the ‘heart’ of the home, generating sweetness and light to bind the wounds inflicted on the husband and …