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)

NB. Diabetes is the world’s eighth leading cause of death among both sexes and the fifth leading cause of death among women. 

Are Diabetes Outcomes Gender Neutral?

Glycemic Control:

• 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;
• Coagulation;
• 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 

Diagnosed Condition

• 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.
• Anxiety
• 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.

Pregnancy

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

Increases in:

1. Anxiety
2. Diabetes-related distress
3. Guilt
4. Disconnectedness from health professionals
5. 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

Unique aspects of T2D risk and burden in women

• 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.

Conclusion

1. We need to do screening for depression, diabetes distress, eating disorders, and other conditions;
2. More education, research, and intervention related to women’s issues including child-bearing and child-rearing;
3. Move research beyond gender comparisons. Women are not a homogenous group;
4. Women with T2D face unique challenges and disease burdens across the lifespan;
5. Use of CGM during pregnancy is associated with improved glycemic control and neonatal outcomes and a lower risk of LGA births;
6. CGM improves glycemic control in adults with T2D; feasible and acceptable to adolescents with T2D;
7. The use of smart insulin pen systems, insulin pumps, and HCL systems improve glycemic control in T2D
8. Mobile health tools can augment conventional management to improve glycemic control in women.
9. Fully closed-loop control improves glucose control compared to standard insulin therapy in adults with T2D requiring dialysis and in inpatient settings
10. CGM improves glycemic control and neonatal outcomes in pregnant women with T1D.

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