Addressing Unique Health care needs of Women with Diabetes by Technology #ATTD2022
What an honor to be awarded a full scholarship to attend one of the extraordinary conferences in the world by the #dedoc° (an international network of diabetes advocates) and because of this program since 2020, I have been able to attend ISPAD and ATTD. since the time I joined, the core principle is an always has been #PyItForward and the entire network has that responsibility. Therefore, kindly accept my humble 2nd takehome message (summary from one of the sessions i thought could benefit everyone).
Glycemic Control and Health Complications of T1D & T2D: Women vs. Men
- Type 1 diabetes affects both men and women;
- Type 2 diabetes prevalence could be region-specific;
- Females have higher rates of T2D in youth, and men have a higher prevalence in midlife (roughly there are 200million women living with diabetes in the world)
Are Diabetes Outcomes Gender Neutral?
- Women with T2D are less likely to reach the goals for HbA1c;
- Women have higher HbA1c levels than men, and glucose control is significantly worse in patients aged <25y;
- Women face an increased risk factor burden because they are less likely to achieve their goals for A1c, cholesterol, and blood pressure.
Complications & Comorbidities:
- Acute Complications: DKA higher in women with T1D;
- Chronic Complication: Macrovascular (Cardiovascular disease, Stroke); Microvascular (Retinopathy, Nephropathy, Neuropathy)
Cardiovascular Disease- A higher cardiovascular disease risk factor in women compared to men.
Women- 40-44% greater relative risk of coronary heart disease (CHD)
- Greater susceptibility to cardiomyopathy;
- Higher atherothrombotic risk for women with T2D
- Stroke: Women have a 27% greater relative risk of stroke;
- The recurrence of stroke within the next years was increased for women with T2D
- Nephropathy: Faster progression of diabetic nephropathy in men;
- More males on dialysis therapy and with kidney transplantations;
- Higher risk of proteinuria and renal disease in women with T2D
- Retinopathy: Greater risk of blindness due to diabetic retinopathy for women with T1D;
- Neuropathy: Men develop neuropathy earlier. Women with T1D are more likely to suffer from neuropathy related to pain
- Sexual Dysfunction: 25 – 30% of men erectile dysfunction; 50% women with sexual dysfunction
- Cognitive function: higher risk of cognitive impairment, depression, and falls in women
NB. There is a higher burden of comorbidities and physical limitations in women.
- Cancer: T2D is a stronger risk factor for women than men (6% excess risk).
- Mortality: More years of life lost at age 40y in women;
- Women with T1D have a 40% higher excess risk of premature death than men;
- The effect of diabetes on all-cause (17%) and CHD (97%) mortality is greater for women than men;
- Pre-menopausal women with diabetes lose the protection against heart disease than non-diabetic women have and are 50% more likely to die from heart disease than men;
- Women with T2D and end-stage renal disease have a significantly higher risk of death than men with similar problems;
- Higher mortality rates from cancer for female cancer patients with T2D
Pathogenic Drivers of Excess Vascular Complication Risk with Diabetes
Biological & Physiological
- Hormonal and vascular pathophysiology;
- Lost benefits of sex hormones in reducing cardiovascular disease;
- Cardiac energy supply
Disparities in disease management (genetic, cultural, and lifestyle factors)
- Women with diabetes are affected by depression, and anxiety and may have a lower quality of life which can negatively affect attitudes towards self-management and in turn disease outcome;
- Further, these factors also affect women’s access to health services and health-seeking behavior and amplify the impact of diabetes on women, particularly in developing countries.
NB. Unique aspects of diabetes in women differ across the lifespan (from childhood – to puberty – adulthood – perinatal – to menopause.
Diabetes Technology: an essential means to address sex disparities through:
- Data collection and analysis; Device design; and Precision medicine to address specific health needs for women and men and to improve diabetes treatment outcomes.
Psycho-Behavioral Challenges faced by Women with Diabetes
- Anorexia Nervosa – Severe restriction of eating;
- Bulimia Nervosa – Purging to eliminate excess calories, usually through vomiting;
- Binge Eating – Severe overeating.
Subclinical Eating Disorders
More common in women with type 1 diabetes
- Restricted Eating – having very rigorous rules about what you eat, eating only certain foods, or perhaps skipping a number of meals or fasting over a prolonged period;
- Over-exercise, Laxatives – a method used to eliminate excess calories or perceived excess calories;
- Over- Eating – is a method that can lead to a number of health problems, weight problems and a number of other issues.
NB. Most relevant for diabetes is a completely unique eating disorder that is called Diabulimia (the omission or restriction of Insulin in order to lose weight to control weight. This can cause a number of health problems with long-term diabetes control and also leads to an increased number of DKA episodes.
|Statements expressed by patients|
Emotional Distress and Quality of Life Indicators
- Depression – the rate of depression is extraordinarily higher in women than it is in men.
- Diabetes Distress – higher in women compared to men, an individual can have very high levels of diabetes distress and not be clinically depressed. Negative impact on self-care and Diabetes Management.
The first thing about pregnancy is the incredibly rigorous glucose control that women are asked to maintain throughout their pregnancy.
Recommended BG Targets during Pregnancy
- Fasting glucose 70-95 mg/dL (3.9-5.3 mmol/L) and either;
- One-hour postprandial glucose 110-140 mg/dL (6.1-7.8 mmol/L) or
- Two-hour postprandial glucose 100-120 mg/dL (5.6-6.7 mmol/L)
Psychological Challenges During Pregnancy for Women with type 1 diabetes
- Diabetes-related distress
- Disconnectedness from health professionals
- Medicalization of Pregnancy
Mothers (and Primary Caretakers) of Children with Type 1 Diabetes
Of course, fathers also partake in the care of their children with diabetes and other caretakers, grandparents, and even non-parental caretakers. However, all of the research shows that by far, mothers are bearing most of the weight of managing a child’s diabetes. Further, most parents receive a lot of patient education after the initial diagnosis, but then after that, they’re often pretty much left on their own.
Menstrual Cycle- T1D: what we know and what to do
Glucose control (glucose metabolism) seems to differ in the follicular and luteal phases, probably due to a hormonal effect or additionally to the presence of premenstrual symptoms or premenstrual syndrome, indicating that in women with type 1 diabetes, the two phases of the menstrual cycle should be taken into consideration when planning insulin therapy.
- Insulin dosing in T1d is a challenging task: in women with T1D, this task may be further complicated by the menstrual cycle;
- A general agreement has been reached regarding the relevant impact of the menstrual cycle on insulin needs and glycemic control, in at least a proportion of premenopausal women with T1D.
- These women tend to experience decreased insulin sensitivity in the luteal phase, with the possibility of experiencing hypoglycemia during menstruation and premenstrual hyperglycemia;
- The reasons behind this variability are yet to be fully elucidated.
- To mitigate the impact of cycle-related insulin sensitivity variability on glycemic control, accurate planning of insulin therapy has shown successful results in simulation; clinical validation is warranted
- Similarly, insulin sensitivity changes across the cycle seem to be mitigated by hormonal contraception.
Use of Technology to improve diabetes management in women with type 2 diabetes
- Females have high rates of T2D in youth (men have a higher prevalence in midlife);
- Absolute rates of CVD are higher in men vs women without T2D; however, T2D negates the female advantage.
- A previous diagnosis of gestational diabetes mellitus (GDM) carries a lifetime risk of progression to T2D of up to 60%
- Modifiable social factors, like educational level, occupation and income, contribute to social disparities and unfavorable lifestyle behaviors in women.
- Relative undertreatment of women vs men
Diabetes in pregnancy – A vicious cycle
- Women with GDM have a 10-fold higher of developing T2D compared with women without GDM;
- GDM increases T2D risk in offspring; >2/3rds of offspring of Pima Indian mothers with GDM developed T2D by 4 years;
- Women with T2D are more likely to come from socioeconomically disadvantaged backgrounds and identify as a person of color compared to women with T1D
- The risk of serious adverse pregnancy outcomes (congenital anomaly, stillbirth, and neonatal death) is higher in T2D vs T1D pregnancies.
- We need to do screening for depression, diabetes distress, eating disorders, and other conditions;
- More education, research, and intervention related to women’s issues including child-bearing and child-rearing;
- Move research beyond gender comparisons. Women are not a homogenous group;
- Women with T2D face unique challenges and disease burdens across the lifespan;
- Use of CGM during pregnancy is associated with improved glycemic control and neonatal outcomes and a lower risk of LGA births;
- CGM improves glycemic control in adults with T2D; feasible and acceptable to adolescents with T2D;
- The use of smart insulin pen systems, insulin pumps, and HCL systems improve glycemic control in T2D
- Mobile health tools can augment conventional management to improve glycemic control in women.
- Fully closed-loop control improves glucose control compared to standard insulin therapy in adults with T2D requiring dialysis and in inpatient settings
- CGM improves glycemic control and neonatal outcomes in pregnant women with T1D.