March 2010 Issue
Women’s Special Needs — Better Understanding Leads to Better Care
By Rita E. Carey, MS, RD, CDE
Vol. 12 No. 3 P. 14
Approximately 24 million people in the United States have either diagnosed or undiagnosed diabetes, according to 2007 statistics. There is an almost equal proportion of men to women in this group. However, available evidence indicates that the two genders experience this disease in very different ways.
As is the case with other pathologies, men and women with diabetes do not share the same risk factors for complications and do not even experience the same pathophysiology of the disease. In many ways, diabetes may be even more deadly for women, especially when considering mortality from cardiovascular disease.
Awareness of women’s special needs is key to ensuring that this population receives the best possible care.
Increased Risks Begin Early
During adolescence, girls with type 1 diabetes demonstrate a greater risk for poor control than boys. In fact, research indicates that compared with boys, girls show a greater increase of hemoglobin A1c levels from prepuberty to postpuberty, tend to exhibit more distress about having and managing the disease, adhere less to healthy eating patterns during stress, and have a greater tendency to struggle with eating disorders and depression.1-4
Because treatment for diabetes is complex and based largely on behavioral adaptation and change, difficulties in management can easily contribute to feelings of helplessness and inadequacy at this (or any) age. A 2004 study by Maharaj et al published in Diabetes Care demonstrated that teenage girls’ self-concept was particularly important in predicting behaviors that support metabolic control. In this study, a positive self-concept, often developed out of strong and intimate familial relationships, predicted good metabolic control in teenage girls. The researchers found that healthy mother-daughter relationships were particularly important; girls who were able to maintain an intimate relationship with their mother while still developing independence demonstrated the best self-care.
The Threat of Heart Disease
A 2007 study by Gregg et al published in the Annals of Internal Medicine demonstrated that between 1971 and 2000, American men with diabetes had a reduction in both all-cause and cardiovascular mortality, whereas American women did not. In fact, the age-adjusted all-cause mortality rate for men dropped 43% during that time, making it similar to men without diabetes. In contrast, women with diabetes had no reduction in total or cardiovascular mortality, and the all-cause mortality rate difference between women with and without diabetes more than doubled.
Researchers cite several possible reasons for this disparity in outcomes: Women often receive less aggressive medical treatment and tend to experience worse outcomes after revascularization and hospitalization, and women tend to have greater endothelial dysfunction, a greater inflammatory response to hyperglycemia, more complicated patterns of symptoms, and less accurate diagnoses of coronary heart disease.5 In fact, it seems that cardiovascular risk factors such as inflammation, obesity, dyslipidemia, and hypertension, when combined, have a greater negative synergistic impact on the health of women than men. In other words, diabetes may actually diminish the cardioprotective effects of estrogen and place women at greater risk of macrovascular complications than their male peers.
Sexual Dysfunction Differs Between Sexes
Although the rates of sexual dysfunction in men and women with diabetes are similar, gender differences in risk factors and pathology do exist. Erectile dysfunction (ED) in men is strongly correlated with elevated hemoglobin A1c levels, duration of disease, cardiovascular disease, and neuropathy. Female sexual dysfunction (FSD), on the other hand, is most strongly associated with issues related to quality of life.
A study by Enzlin et al published in Diabetes Care in 2009 listed depression and marital status as the greatest predictors of FSD in a cohort of women enrolled in the Epidemiology of Diabetes Interventions and Complications study. In this study, married women and women with depressive symptoms were more than twice as likely to struggle with FSD than their age-matched peers.
An earlier study by Enzlin et al published in Diabetes Care in 2002 also identified quality-of-life issues as contributing factors. In this study, researchers noted that women with both diabetes and FSD had more problems adjusting emotionally to diabetes, were less satisfied with their treatment, indicated inadequate emotional support from their spouses, and experienced more negative impacts of treatment on daily life.
Researchers in these and other studies note that even though the rates of sexual dysfunction among men and women with diabetes are similar, FSD has received far less attention than ED. Consequently, the pathophysiology of FSD remains unclear.
Women with diabetes may have a greater risk of developing osteoporosis than their nondiabetic peers. A very large study by Nicodemus and Folsom published in Diabetes Care in 2001 demonstrated a significant increased risk of hip fracture for postmenopausal women with either type 1 or type 2 diabetes. Women with type 1 diabetes had the highest risk of fracture (12.25 times more likely than women without diabetes), followed by women with type 2 diabetes of long duration and women with type 2 diabetes taking either oral medications or insulin.
Researchers speculate that women with type 1 diabetes experience greater rates of bone turnover along with other risk factors for osteoporosis, such as lower body mass index, chronically low dietary protein intake, vascular disease, and neuropathy. Factors contributing to increased hip fracture rates in women with type 2 diabetes are less clear but may be related primarily to issues of nutrition and self-care.
Additional factors uniquely affecting the lives of women with diabetes include changes in metabolic control during menses, maternal and fetal health risks during pregnancy, potential interactions between oral birth control and antihyperglycemic agents, and the metabolic effects of hormone replacement therapy.
Some of the ways in which men and women experience diabetes differently are clearly physiologic. Others may simply reflect general personality differences between the two sexes (eg, how we communicate emotions, need different types of support, or interact with healthcare professionals). It is encouraging to see new research examining the ways in which men and women experience diabetes and other diseases. After all, the more information we gather, the better care we will provide.
— Rita E. Carey, MS, RD, CDE, is a clinical dietitian and diabetes educator at Yavapai Regional Medical Center and the Pendleton Wellness Center in Prescott, Ariz.
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2. Kovacs M, Iyengar S, Goldston D, et al. Psychological functioning of children with insulin-dependent diabetes mellitus: A longitudinal study. J Pediatr Psychol. 1990;15(5):619-632.
3. Rovert J, Ehrlich R, Hoppe M. Behaviour problems in children with diabetes as a function of sex and age of onset of disease. J Child Psychol Psychiatry. 1987;28(3):477-491.
4. Jones JM, Lawson ML, Daneman D, Olmsted MP, Rodin G. Eating disorders in adolescent females with and without type 1 diabetes: Cross sectional study. BMJ. 2000;320(7249):1563-1566.
5. Auryan S, Itamar R. Gender-specific care of diabetes mellitus: Particular considerations in the management of diabetic women. Diabetes Obes Metab. 2008;10(12):1135-1156.