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A new study of nearly 170,000 people found that lesbian and bisexual women may be less likely to have ideal heart health scores than heterosexual women. Interestingly, researchers also reported that gay or bisexual men scored higher than their straight peers in heart health measures, but only if they lived in urban areas.
The study, published on May 17 in the Journal of the American Heart Association, is the first to measure cardiovascular health disparities using the American Heart Association’s (AHA) Life’s Essential 8 checklist among gay, lesbian, and bisexual people, according to researchers.
“Improving these metrics is a great opportunity to prevent heart problems before they happen,” said lead author Omar Deraz, MD, a researcher with Inserm, the French National Institute of Health and Medical Research, and the Paris Cardiovascular Research Center’s Integrative Epidemiology of Cardiovascular Disease Team, in a news release.
What Is Life’s Essential 8?
Life’s Essential 8 (LE8) is a set of health behaviors and health factors developed by the AHA that promote good cardiovascular health.
- Eat better. A Mediterranean-type diet that focuses on whole foods (not processed) and eating lots of fruits, vegetables, lean proteins, and healthy fats.
- Be more active. Adults should get 2.5 hours of moderate or 75 minutes of vigorous physical activity per week.
- Quit tobacco. The use of traditional cigarettes, e-cigarettes, and vaping is the leading cause of preventable deaths.
- Get healthy sleep. Most adults need seven to nine hours of sleep each night.
- Manage weight. Achieving and maintaining a healthy weight can help in the prevention of many chronic diseases. Body mass index (BMI), as detailed by the Centers for Disease Control and Prevention (CDC), is one way to gauge weight; between 18.5 and 24.9 is considered the health range.
- Control cholesterol. Heart-healthy cholesterol numbers: total cholesterol of under 200, LDL cholesterol under 100, and HDL cholesterol of 60 and higher, per the Cleveland Clinic.
- Manage blood sugar. High levels of blood sugar can damage the heart, kidneys, eyes, and nerves. An A1C below 5.7 percent is normal, and a fasting blood sugar of 99 milligrams per deciliter (mg/dL) or lower is normal, according to the CDC.
- Manage blood pressure. Optimal blood pressure is 120/80 millimeters of mercury (mm Hg).
LE8 is the new version of AHA’s former health initiative Life’s Simple 7 (LS7). In 2022, healthy sleep was added as an additional essential health behavior.
Lesbians Had Lower Heart Health Scores in Diet and High Blood Pressure
The study used health data from about 169,400 adults in France who were enrolled in the nationwide Constances study. The participants were 53 percent women, free of heart disease, with an average age of 46.
Among the women, 93 percent identified as heterosexual, about 3.5 percent identified as bisexual, and 0.61 percent identified as lesbian. Among the men, 90 percent identified as heterosexual, 3.5 percent identified as bisexual, and 3 percent identified as gay. About 3 percent of subjects declined to answer questions about their sexual orientation.
Researchers controlled for factors that could impact the findings, including family history of cardiovascular disease, age, employment status, education, and household income.
Using AHA guidelines, heart health scores (both LE8 and LS7) were computed in each area and then averaged. Key findings include:
- Lesbian and bisexual women had lower cardiovascular health scores compared with heterosexual women.
- Gay and bisexual men living in urban areas scored higher than heterosexual men, however, those living in rural areas had lower cardiovascular health scores.
- Compared with heterosexual women, lesbian women scored lower for healthy diet and blood pressure. In contrast, bisexual women had higher scores for healthy diet and nicotine exposure.
- Lesbian, gay, and bisexual adults overall reported anxiety disorders, depression symptoms, or attempted suicide more frequently than heterosexual adults, but lesbian women reported fewer anxiety disorders and depression symptoms compared with heterosexual women.
Because France is a high-income country that offers universal healthcare insurance, the authors acknowledged that their findings may not apply to other countries.
The study is also limited by its single focus on assessing cardiovascular health by sexual orientation, and that heart health data was unavailable for those who identified as transgender, the authors wrote.
“I think these findings make a lot of sense in light of a few factors, including that the LGBTQ population are much less likely to seek out both mental health care and healthcare in general,” says Benjamin Laniakea, MD, a clinical assistant professor and board-certified family medicine physician specializing in full-spectrum LGBTQ+ health. Dr. Laniakea, who uses the gender-neutral pronouns they/them, was not involved in this research.
According to a 2020 survey of over 1,500 self-identified LGBTQ adults from the Center for American Progress (CAP), an independent nonpartisan policy institute, around 3 in 10 LGBTQ Americans faced difficulties accessing necessary medical care due to cost issues, including more than half of transgender Americans.
About 15 percent of LGBTQ people surveyed reported postponing or avoiding medical treatment due to discrimination, including nearly 30 percent transgender individuals.
Stress and Discrimination May Contribute to Unhealthy Behaviors
Many LGBTQ+ individuals report facing stigma and discrimination, which can be quite stressful, says Laniakea. “Most people don’t have to read about whether or not they have the right to exist in the world on a day in and day out basis,” they point out.
“This stress can be a huge mental burden, and some people may turn to things like alcohol, cigarettes, or other unhealthy practices such as overeating, in order to escape,” says Laniakea.
Disparities Found in France Might Be Even Greater in the U.S.
This is a landmark study, as it’s the first to evaluate the cardiovascular health disparities in those who identify as a sexual minority group, says Victor Ferrari, MD, a professor of medicine and cardiologist at Penn Medicine in Philadelphia.
“Other studies in the past have looked at health disparities in these populations in other areas of health such as sexual or mental health, but this is the first study to actually look at important cardiovascular risk factors such as blood sugar, blood pressure, and cholesterol,” says Dr. Ferrari, who was not involved in the research.
When interpreting the findings, we need to keep in mind that the study was conducted in France, a country with a national healthcare system, he points out.
“If these discrepancies are present in this type of healthcare environment, where everyone has access to healthcare, and people don’t have to worry about being insured or underinsured, I think the disparities found in this study could be even greater in the United States,” says Ferrari.
Why Were Disparities Found in Gay and Bisexual Women, But Not in Gay And Bisexual Men?
This study wasn’t set up to uncover the “why” behind the results, and so it’s not clear why these disparities were found in gay and bisexual women but not in men. “I think we need more data, and to make sure we’re not making generalizations to explain the findings, some of which might further perpetuate stereotypes,” says Ferrari.
Laniakea offers a potential theory that could help explain the differences found in this study. “This is only speculation, but more recently — in the last 10 or 12 years — there’s been a huge push to get HIV management, PreP management, and STI prevention, and the queer community has rallied around our young gay and bisexual men in getting them to the doctor. In our experience, the cisgender gay population, especially the cisgender white gay population, actually see their doctor — as long as there’s good medical access to care — as often or even more than their peers as opposed to the rest of the LGBTQ population.”
To Address Disparities, New Interventions Need to Be Developed and Tested
“To fully address discrimination and disparities that impact health, we must better recognize and understand the unique experiences of all individuals and populations, including sexual minorities,” said Connie Tsao, MD, an attending staff cardiologist at Beth Israel Deaconess Medical Center in Boston, who was not involved in the new study, in the news release.
In a Scientific Statement from 2020 by the AHA that addressed cardiovascular health in LGBTQ adults, the authors noted the evidence that LGBTQ adults — particularly lesbian, bisexual, and transgender women — experience disparities across several cardiovascular health metrics.
To begin to address these gaps, new interventions need to be developed and tested, the authors wrote. “Advancing the cardiovascular health of LGBTQ adults requires a multifaceted approach that includes stakeholders from multiple sectors to integrate best practices into health promotion and cardiovascular care of this population,” they concluded.
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