Mars vs. Venus: The gender gap in health

Ask any guy, and he'll tell you that men are the stronger sex. His reasoning is obvious: in general, men are bigger and more muscular than women. They can run faster, lift more, and throw things farther. Men rule on the playing field, but in medical terms, it's a very different story. When it comes to health, men are the weaker sex.

The longevity gap

Much has changed in the United States over the past 100 years. Medicine has evolved as much as any field, with dramatic advances in diagnosis and treatment. Changing, too, is the American lifestyle, with its new emphasis on healthier diets and regular exercise and its declining dependence on tobacco. As a result of these developments, life expectancy is also changing, rising slowly but steadily year after year (see Table 1). One thing, though, has not changed — the gender gap. People of both sexes are living longer, but decade after decade, women continue to outpace men. In fact, the gap is wider now than it was a century ago.

The longevity gap is responsible for the striking demographic characteristics of older Americans. More than half of all women older than 65 are widows, and widows outnumber widowers by at least three to one. At age 65, for every 100 American women, there are only 77 men. At age 85, the disparity is even greater, with women outnumbering men by 2.6 to 1. And the longevity gap persists even into very old age, long after hormones have passed their peak; among centenarians, there are four females for every male.

The gender gap is not unique to America. In fact, every country with reliable health statistics reports that women live longer than men. The longevity gap is present both in industrialized societies and in developing countries. It's a universal observation that suggests a basic difference between the health of men and women.

The health gap

Men die younger than women, and they are more burdened by illness during life. They fall ill at a younger age and have more chronic illnesses than women. For example, men are nearly 10 times more likely to get inguinal hernias than women, and five times more likely to have aortic aneurysms. American men are about four times more likely to be hit by gout; they are more than three times more likely than women to develop kidney stones, to become alcoholics, or to have bladder cancer. And they are about twice as likely to suffer from emphysema or a duodenal ulcer. Although women see doctors more often than men, men cost our society much more for medical care beyond age 65.

A lifelong gap

When it comes to health, males are the weaker sex throughout life. But why? It's the $64,000 question, but there is no single answer. Instead, the gap depends on a complex mix of biological, social, and behavioral factors (see Table 2).

Biological factors

Genes and chromosomes. Males and females are different from the very moment of conception. Each has 23 pairs of chromosomes, which carry the body's 20,000 to 25,000 genes. Twenty-two of these pairs are present in both males and females, but the 23rd separates the sexes. This final pair contains the sex chromosomes. In women, both members of the pair are X chromosomes, but in men one is an X and the other a Y.

The Y chromosome is only about a third as large as the X and contains far fewer genes than the female sex chromosome. Some of these genes may be linked to diseases that contribute to the excess male mortality throughout life. In addition, if a woman has a disease-producing gene on one of her X chromosomes, it may be counterbalanced by a normal gene on the other X, but if a man has the same bad gene on his X chromosome, he lacks the potential protection of a matching gene.

Hormones. It used to be so simple: testosterone got the blame for premature heart disease in men, while estrogen got the credit for protecting women. The theory was based on the observation that athletes who abuse androgens — male hormones — develop unfavorable cholesterol profiles and suffer an increased risk of cardiovascular disease. But research shows that in physiologic doses, testosterone neither impairs cholesterol levels nor damages the heart. In fact, small studies suggest that testosterone treatment may even help some men with heart disease. Moreover, women who take estrogen well beyond menopause, when their natural levels plummet, experience an increased risk of heart attacks, strokes, and blood clots.

Even if hormones don't account for the lion's share of the gender gap, they do play a role. Estrogen appears to have some protective effect against heart disease, perhaps explaining why heart disease typically begins about 10 years later in women than men. On the other hand, testosterone may contribute to the risk-taking and aggressive behavior that causes problems for many young men. And testosterone also fuels diseases of the prostate, both benign and malignant. Even so, the testosterone-prostate connection can't account for the longevity gap, since there are more deaths from breast cancer than prostate cancer.

Both sex hormones keep bones strong, but here, men actually have the edge. As men age, testosterone levels decline slowly, about 1% a year, but estrogen levels drop abruptly at menopause, boosting the risk of osteoporosis.

Reproductive anatomy. Many men view the prostate gland as a vulnerability. That may be, but reproductive factors actually hold down the health gap between men and women. The number of new prostate and breast cancers are closely matched, but women are about 45% more likely to die from their disease. Add malignant and benign diseases of the uterus and the perils of pregnancy and childbirth, and you'd suppose that women are the more fragile sex. Since they're not, males must have important problems in other areas.

Metabolism. Cholesterol may account for some of the health gap. Males and females have similar LDL ("bad") cholesterol levels, but women have substantially higher levels of HDL ("good") cholesterol (60.3 milligrams per deciliter, or mg/dL, versus 48.5 mg/dL on average). Higher HDL cholesterol is associated with a lower risk of heart disease.

Diabetes is a major problem for both sexes, and its prevalence is increasing in both.

Like diabetes, obesity is rapidly increasing in the United States. More than two-thirds of American adults are overweight or obese. The prevalence of obesity is slightly higher in American women than men; still, excess weight is more of a problem for males. That's because women tend to carry excess weight on their hips and thighs (the "pear shape"), while men add it to their waistlines (the "apple shape," or "beer belly"). Excess body fat is never a good thing, but abdominal obesity is much riskier than lower body obesity, sharply increasing the risk of heart attack and stroke. Aesthetics aside, women are shaped better.

Although obesity is often classified as a metabolic problem, it usually results from unwise health behaviors, another major misfortune for males. In fact, although metabolic, genetic, and hormonal factors may explain part of the health gap, particularly very early in life, social and behavioral factors play a larger role in adults.

Social factors

Work stress and hostility. It's a common explanation for excess male mortality, and there may be something to it. Indeed, the stereotype of the harried, hard-driving, overworked male executive has a basis in fact, and work stress can increase the risk of hypertension, heart attack, and stroke. In fact, karoshi, "death from overwork," is a recognized diagnosis in Japan, and it triggers compensatory payments to survivors. Type A behavior, stress, hostility, and anger have all been implicated as heart disease risk factors, and these traits tend to have a higher prevalence in men than women.

Work-related stress and heart-breaking personality factors may contribute to male vulnerability. But as more women enter the workplace and add financial obligations to their traditional roles at home, they may have the dubious honor of closing the gender gap by moving in the wrong direction.

Social networks and supports. It's true: people are good medicine. Strong interpersonal relationships and support networks reduce the risk of many problems, ranging from the common cold and depression to heart attacks and strokes. In contrast, social isolation has been identified as a heart disease risk factor.

Women have much larger and more reliable social networks than men. There is more than a germ of truth in the quip that two men can't take a walk together unless one is carrying a ball. In general, women are in touch with their feelings and with other women, and they have a remarkable ability to express their thoughts and emotions. Women may not really be from Venus any more than men are from Mars, but strong relationships and good communication seem to help explain why women live longer on Earth.

Behavioral factors

Biological factors account for part of the gender gap, social factors for another portion. But from adolescence onward, male behavior is the main reason that men fall ill sooner and die off faster than women.

Risky behavior. Is it nature or nurture, the Y chromosome and testosterone, or daredevil role models and cultural norms? Nobody knows, but the answer is not likely to be either/or but all of the above. Whatever the cause, from boyhood on, males take more risks than females, and they often pay the price in terms of trauma, injury, and death. Simple precautions like seat belts and bike helmets can help, but more complex measures involving education about alcohol, drugs, firearms, and safe sex are also essential. More than ever before, young males need role models who demonstrate that common sense and prudence are manly traits.

Aggression and violence. These are extreme forms of risky behavior, and they all have many of the same root causes. But there is a difference between risk taking and aggressive or violent behavior. A man who takes risks places himself in harm's way, but his unwise choices may not endanger others. Violent behavior, though, directly threatens the health and well-being of others, both male and female. A man is nearly four times more likely to die from homicide or suicide than a woman, but women are much more likely to be victims of domestic violence. Men need to learn self-control and anger management if they are to close this portion of the gender gap. Understanding that real men have feelings and that strong emotions are best expressed with words, not acts, is also important.

Smoking. It's the riskiest of all health habits, and since secondhand smoke is dangerous to others, it's also a form of undercover hostility.

In the old days, men smoked but women didn't. Those were good old days for women, but not for men. Times changed; when women began to smoke in large numbers, they started to catch up to men in heart disease, lung cancer, and emphysema.

Alcohol and substance abuse. Like smoking, drinking and drug abuse are traditionally male problems that are increasingly threatening to women as well. Still, males dominate in these self-destructive habits.

Diet. In most cases, women eat a healthier diet than men. In a Massachusetts survey, for example, women were about 50% more likely than men to meet the goal of eating at least five servings of fruits and vegetables a day. The masculine ideal of meat and potatoes should give way to vegetables, fruits, grains, and fish.

Exercise. When human survival depended on physical work, both men and women got plenty of exercise. As men moved behind desks, women who continued to haul groceries, climb stairs, scrub, and wash continued to get the many health benefits of physical activity. But as modern appliances replace muscles at home and women join men in sedentary jobs, American women have fallen slightly behind in exercise. It's small comfort to men, though, since most men don't come close to getting the exercise they need for health.

Medical care. Women think about health, and they do more about it. Women are more likely than men to have health insurance and a regular source of health care. According to a major survey conducted by the Commonwealth Fund, three times as many men as women had not seen a doctor in the previous year; more than half of all men had not had a physical exam or cholesterol test in the previous year. In general, men who have the most traditional, macho views about masculinity are the least likely to get routine check-ups and necessary medical care.

Call it the ostrich mentality or the John Wayne Syndrome; by any name, men who skip tests and treatments, minimize symptoms, and disregard medical advice are asking for trouble. Men who look under the hood every time the engine coughs should be as quick to get help when they cough.

It is hard to know why men make such poor patients; busy work schedules and competing responsibilities and interests may play a role, but the macho mentality appears to be the chief culprit. Who can blame men for wanting to be John Wayne? But by following the example of that quintessential American he-man, men fail to take the simple steps that can protect them from heart disease and lung cancer — the very same illnesses that plagued John Wayne before his death at age 72.

Closing the gap

Men can't change their chromosomes and genes, and very few would change their hormones. Still, men can catch up to women in some other areas. That doesn't mean "going girly," though it does mean following some simple rules. But will men change their behavior?

An incident reported in The Wall Street Journal may help you decide about making changes. In the 1960s, when Muhammad Ali was a brash and fearless boxing sensation still known as Cassius Clay, he boarded a plane to fly to a big fight. While preparing for takeoff, a flight attendant noticed that the boxer had not fastened his seat belt. She asked him to buckle up, but he ignored her. When she asked again, he replied, "Superman don't need no seat belt." Her retort: "Superman don't need no airplane. Buckle up." And he did.

Men who think they are too tough to get sick are risking a medical crash-landing. To stay healthy, we all need to follow the rules (including the one about seat belts). Here are 10 tips to help you wing your way to a long and healthy life.

1. Avoid tobacco in all its forms.

2. Eat well. That means eating more healthful foods and fewer harmful foods.

• Eat more: whole grains, fruits, vegetables and legumes, fish, low- or non-fat dairy products, and nuts and seeds.
• Eat less: red meat, whole-milk dairy products, poultry skin, high-sodium (salty) processed foods, sweets, sugary drinks and refined carbohydrates, and if you need to lose weight, calories.

3. Exercise regularly, including:

• At least 30 minutes of moderate exercise nearly every day.
• Exercises for strength two to three times a week.
• Exercises for flexibility and balance according to need.

4. Stay lean. It's equally hard for men and women, but even partial success will help.

5. If you choose to drink, limit yourself to one to two drinks a day, counting 5 ounces of wine, 12 ounces of beer, and 1.5 ounces of liquor as one drink.

6. Reduce stress. Get enough sleep. Build social ties and community support.

7. Avoid risky behavior, including drug abuse, unsafe sex, dangerous driving, unsafe firearm use, and living in hazardous household conditions.

8. Reduce exposure to toxins and radiation, including sunlight and medical x-rays.

9. Get regular medical check-ups, screening tests, and immunizations. Listen to your body and report sounds of discord to your doctor.

10. Seek joy and share it with others. Laughter is good medicine. Fun and optimism improve health as well as happiness. And if you make changes 1 to 9 slowly, steadily, and reasonably, you will actually come to enjoy your healthful lifestyle.

As things now stand, men are from Mars, women from Venus. But gents who get their planets aligned correctly can enjoy the best of both worlds — and good health right here on Earth.

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