Gender-specific care of the patient with diabetes: review and recommendations

Abstract

Background: Men and women differ in their experience of diabetes mellitus (DM). For optimal prevention and treatment of the disease, these differences must be acknowledged. Unfortunately, most studies of diabetes have focused almost exclusively on men.

Objective: The purpose of this review was to survey the literature about the sex-specific features of DM and to make recommendations for the gender-specific care of patients.

Methods: An initial literature search was performed with Google Scholar and MEDLINE (1995-2005) using the search terms sex/gender, women, diabetes mellitus, and coronary artery disease, and specific topic headings such as polycystic ovary syndrome. The bibliographies of articles were used extensively to augment the search, and more specific search terms were included. The strength of each recommendation was assessed.

Results: : Even when women were included in clinical trials, investigators typically made no attempt to assess the impact of sex differences on the reported results. Existing studies, however, reveal several differences between men and women with diabetes. The prevalence of DM is growing fastest for older minority women. Women with diabetes, regardless of menopausal status, have a 4- to 6-fold increase in the risk of developing coronary artery disease (CAD), whereas men with diabetes have a 2- to 3-fold increase in risk. Women with diabetes have a poorer prognosis after myocardial infarction and a higher risk of death overall from cardiovascular disease than do men with diabetes. Women with type 2 DM experience more symptoms of hyperglycemia than do their male counterparts. Obesity, an important contributor to type 2 DM, is more prevalent in women. Women with diabetes have an increased risk of hypertension compared with men with diabetes. Women have a more severe type of dyslipidemia than do men (low levels of high-density lipoprotein cholesterol, small particle size of low-density lipoprotein cholesterol, and high levels of triglycerides), and these risk factors for CAD have a stronger influence in women. Oxidative stress may confer a greater increase in the risk of CAD for women with diabetes than for men with diabetes. Many other sex differences in DM are due to women's reproductive physiology. Polycystic ovary syndrome is an important correlate of insulin resistance and the metabolic syndrome. Gestational diabetes mellitus (GDM) increases the risk of cardiovascular disease and type 2 DM. Women are less likely than men to receive aggressive treatment for CAD and to achieve treatment goals. Critical recommendations for women include exercise, testing for CAD, daily aspirin to counteract the prothrombotic state, depression screening, careful treatment to avoid weight gain, long-term follow-up of children of women with GDM, control of risk factors for CAD, and aggressive treatment with coronary angioplasty for CAD. Disease management programs for patients with diabetes have been shown to save money and improve outcomes, and should continue to incorporate information about sex-specific differences in DM as it becomes available.

Conclusion: Gender-specific care of the patient with diabetes should be informed by evidence-based recommendations.