Spotlight on gender differences

The differences in outcomes between men and women with diabetes were the focus of a scientific statement and a study published this month.

The American Heart Association statement, published by Circulation on Dec. 7, reviewed the current state of knowledge about sex differences in the cardiovascular consequences of diabetes. The statement reported that cardiovascular disease is leading cause of morbidity and mortality in patients with type 2 diabetes, and that, in contrast to patients without diabetes, diabetic women have a doubled risk of coronary heart disease risk compared with men. It covered epidemiology, hormonal differences, ethnic and racial differences, and differences in the types of cardiovascular disease affecting men and women. The statement also discussed risk factors specific to women, including gestational diabetes and polycystic ovary syndrome. The paper also reviewed evidence and offered advice on treatment to prevent cardiovascular events. Regarding statins, the statement noted that evidence for their primary preventive effect is less marked in women than men but that “it is reasonable, on the basis of expert opinion and the cholesterol theory of atheroma progression, to use statins in women at high risk.” Data on aspirin for primary prevention in diabetic women is “far from conclusive,” the statement said, seconding recommendations that it be considered in intermediate-risk patients. Lifestyle interventions may have more benefit for prediabetic women than men, the statement concluded, but women with diabetes may require greater frequency and intensity of physical activity to reduce cardiovascular events—at least 2 hours per week.

The study, published by Diabetologia on Nov. 26, was a post hoc analysis of a trial that randomized newly diagnosed type 2 patients to usual care or 6 years of structured personal care, including regular follow-up, individualized goal setting, and clinician education. This analysis compared outcomes in men and women 13 years after the conclusion of the intervention and found that the structured care was associated with a reduction in all-cause mortality and diabetes-related death in women, but not men (P=0.005 and 0.015 for interactions, respectively). Women who received structured care did have more associated improvement in HbA1c but not enough to explain the differences, the study authors said. They speculated that the findings support the importance of social and cultural gender differences, in addition to biological sex differences, to diabetes outcomes. For example, women may have appreciated the social support of the intervention more or perceived more benefit in diabetes self-management, or the intervention could have compensated for existing biases in treatment. The results should be considered observational, but they show “a need to rethink treatment schemes for both men and women to gain benefit from intensified treatment efforts,” the authors concluded.