Understanding disparities in lipid management among patients with type 2 diabetes: gender differences in medication nonadherence after treatment intensification

Sex differences in the intensity of statin prescriptions at initiation in a primary care setting

BACKGROUND

Current guidelines for the prevention and management of cardiovascular diseases (CVD) provide similar recommendations for the use of statins in both women and men. In this study, we assessed sex differences in the intensity of statin prescriptions at initiation and in the achievement of treatment targets, among individuals without and with CVD, in a primary care setting.

METHODS

Electronic health record data from statin users were extracted from the PHARMO Data Network. Poisson regressions were used to investigate sex differences in statin intensity and in the achievement of treatment targets. Analyses were stratified by age group, disease status and/or CVD risk category.

RESULTS

We included 82 714 individuals (46% women) aged 40-99 years old. In both sexes, the proportion of individuals with a dispensed prescription for high-intensity statin at initiation increased between 2011 and 2020. Women were less likely to be prescribed high-intensity statins as compared with men, both in the subgroups without a history of CVD (risk ratio (RR) 0.69 (95% CI: 0.63 to 0.75)) and with CVD (RR 0.77 (95% CI: 0.74 to 0.81)). Women were less likely than men to achieve target levels of low-density lipoprotein cholesterol following statin initiation in the subgroup without CVD (RR 0.98 (95% CI: 0.97 to 1.00)) and with a history of CVD (RR 0.94 (95% CI: 0.89 to 0.98)).

CONCLUSION

Compared with men, women were less likely to be prescribed high-intensity statins at initiation and to achieve treatment targets, both in people without and with a history of CVD, and independent of differences in other individual and clinical characteristics.

Benefits of 12-month peer support for diabetes self management sustained at 18 months

AIMS

To evaluate sustainability of peer support (PS) benefits in diabetes management.

METHODS

Supporting a Peer Leader program through Community Health Centers (CHCs) included trainings and consultations from baseline to 12 months. Evaluation at baseline, 12-month, and 18-month follow-up included primary outcome, HbA1c, and other outcomes of SBP, DBP, LDLc, PHQ-8, diabetes distress, and EQ-5D.

RESULTS

1284 participants with type 2 diabetes mellitus were recruited from 9 CHCs. Mean (SD) for age = 68.00 (7.55) years, 43.07 % male, mean (SD) for diabetes duration = 11.79 (7.34) years. Across 18-months, linear mixed model analyses controlling for confounders found the least square mean (SE) of HbA1c improved significantly from 7.62 % (0.06 %) to 7.53 % (0.06 %) for all, and from 9.25 % (0.09 %) to 8.52 % (0.11 %) among those ≥8 % at baseline. Parallel improvements were found among all for SBP, DBP, PHQ-8, diabetes distress, and, among those elevated at baseline for all outcomes. EQ-5D showed significant but modest increase from baseline to 18 months. No significant reversals between 12 and 18 months were found except for LDLc. Supporting robustness of findings, patterns were similar across age, diabetes duration, and gender.

CONCLUSIONS

Relative to the fundamentally progressive nature of diabetes, it is striking that improvements associated with PS were generally sustained after program support ended.

Gender Disparities in Patients' Decisions about the Management of Myocardial Infarction in East Chinese Province

Background

Previous studies showed that there are gender disparities in various respects of acute myocardial infarction (AMI), including risk factors, symptoms, and outcomes. However, few of them noticed the gender disparities in patients' decision about the management of AMI, which might also be associated with the outcome.

Aims

To identify gender disparities in patients' decisions about the management of myocardial infarction.

Methods

In this cohort study, the critical time points including the time of symptom onset, visiting hospital, diagnosis of AMI, consent to coronary angiography (CAG), beginning of CAG, and balloon dilation were recorded. Medication and major adverse cardiac event (MACE) within 6 months were also recorded.

Results

Female patients took more time from symptom onset to visiting hospital (P = 0.001), from diagnosis of AMI to consent to CAG (P < 0.05), and from door to needle/balloon than male (P < 0.05). Less female patients accepted CAG (P < 0.05) and coronary intervention/bypass grafting (P < 0.05). Less female patients kept good inherence to antiplatelet therapy (P < 0.05) and statins (P < 0.05) than male, more female preferred traditional Chinese medicine (TCM) than male patient (P < 0.05), and most of them had MACE within 6 months (P < 0.05). Patients' good adherence to antiplatelet therapy and statins and accepting coronary intervention/bypass grafting were associated with a reduced risk of MACE.

Conclusion

Female patients were more reluctant to make decisions about emergency management of AMI and tended to choose conservative treatment. More female patients preferred TCM than evidence-based medicine. Their reluctance about the critical management of AMI and poor adherence to evidence-based medicine were associated with an elevated risk of MACE.

Uncovering Predictors of Lipid Goal Attainment in Type 2 Diabetes Outpatients Using Logic Learning Machine: Insights from the AMD Annals and AMD Artificial Intelligence Study Group

Identifying and treating lipid abnormalities is crucial for preventing cardiovascular disease in diabetic patients, yet only two-thirds of patients reach recommended cholesterol levels. Elucidating the factors associated with lipid goal attainment represents an unmet clinical need. To address this knowledge gap, we conducted a real-world analysis of the lipid profiles of 11.252 patients from the Annals of the Italian Association of Medical Diabetologists (AMD) database from 2005 to 2019. We used a Logic Learning Machine (LLM) to extract and classify the most relevant variables predicting the achievement of a low-density lipoprotein cholesterol (LDL-C) value lower than 100 mg/dL (2.60 mmol/L) within two years of the start of lipid-lowering therapy. Our analysis showed that 61.4% of the patients achieved the treatment goal. The LLM model demonstrated good predictive performance, with a precision of 0.78, accuracy of 0.69, recall of 0.70, F1 Score of 0.74, and ROC-AUC of 0.79. The most significant predictors of achieving the treatment goal were LDL-C values at the start of lipid-lowering therapy and their reduction after six months. Other predictors of a greater likelihood of reaching the target included high-density lipoprotein cholesterol, albuminuria, and body mass index at baseline, as well as younger age, male sex, more follow-up visits, no therapy discontinuation, higher Q-score, lower blood glucose and HbA1c levels, and the use of anti-hypertensive medication. At baseline, for each LDL-C range analysed, the LLM model also provided the minimum reduction that needs to be achieved by the next six-month visit to increase the likelihood of reaching the therapeutic goal within two years. These findings could serve as a useful tool to inform therapeutic decisions and to encourage further in-depth analysis and testing.

Women with type 2 diabetes have LDL cholesterol levels higher than those of men, regardless of their treatment and their cardiovascular risk level

BACKGROUND AND AIMS

Several works have shown that control of the principal cardiovascular risk factors, especially LDL-C, is poorer among women with type 2 diabetes than men with this disease. Our objectives were to compare the statin treatments and LDL-C levels between men and women with type 2 diabetes, according to the potency of the statin they take, while taking their cardiovascular risk level into account.

METHOD AND RESULTS

This is a descriptive cross-sectional study within the French CONSTANCES cohort. At inclusion, each individual completed several self-administered questionnaires. Data were then matched to their health insurance fund reimbursement data. The study population comprises cohort members with pharmacologically treated type 2 diabetes. We identified 2541 individuals with type 2 diabetes; 2214 had an available LDL-C value. In the total sample, treatment by statins did not differ between men and women, while the women had a higher mean LCL-C level than men. The analyses stratified by cardiovascular risk showed that women at very high cardiovascular risk received significantly less frequent statin delivery than men (OR = 0.72 [0.56-0.92]; p = 0.01). At the same time, women received the same rate of high-potency statins as men. Women taking equivalently potent statins had significantly higher LDL-C levels than men did.

CONCLUSION

For the same cardiovascular risk level and the same statin treatment, women had an LDL-C level higher than that of men. They thus present a residual cardiovascular risk that justifies intensification of their statin treatment if tolerance allows.

Sex differences in cardiovascular risk, lifestyle, and psychological factors in patients with type 2 diabetes: the Fukuoka Diabetes Registry

BACKGROUND

The excess risk of cardiovascular diseases associated with diabetes is greater in women than in men. The present study aimed to examine sex differences in the control of cardiovascular risk factors, as well as lifestyle and psychological factors, in patients with type 2 diabetes.

METHODS

A total of 4923 Japanese patients with type 2 diabetes were included in this cross-sectional study. Female/male differences in cardiovascular risk factor levels, and corresponding odds ratios for achieving recommended ranges for preventing cardiovascular diseases and having unhealthy lifestyle and psychological factors were computed by linear and logistic regression models.

RESULTS

Women were less likely than men to achieve recommended ranges for glycated hemoglobin, low-density lipoprotein cholesterol, non-high-density lipoprotein cholesterol, and obesity-related anthropometric indices such as body mass index and waist circumference, but were more likely than men to be on target for high-density lipoprotein cholesterol and triglycerides. Women were also more likely than men to have an unhealthy lifestyle and psychological factors, including less dietary fiber intake, less leisure-time physical activity, shorter sleep duration, more constipation, and more depressive symptoms. Similar findings were observed when the participants were subgrouped by age (< 65 and ≥ 65 years) and past history of cardiovascular disease.

CONCLUSIONS

We observed significant sex differences for a range of cardiovascular risk factors, as well as lifestyle and psychological factors, suggesting the importance of adopting a sex-specific approach for the daily clinical management of diabetes.

Adherence to Oral Antidiabetic Drugs in Patients with Type 2 Diabetes: Systematic Review and Meta-Analysis

Poor adherence to oral antidiabetic drugs (OADs) in patients with type 2 diabetes (T2D) can lead to therapy failure and risk of complications. The aim of this study was to produce an adherence proportion to OADs and estimate the association between good adherence and good glycemic control in patients with T2D. We searched in MEDLINE, Scopus, and CENTRAL databases to find observational studies on therapeutic adherence in OAD users. We calculated the proportion of adherent patients to the total number of participants for each study and pooled study-specific adherence proportions using random effect models with Freeman-Tukey transformation. We also calculated the odds ratio (OR) of having good glycemic control and good adherence and pooled study-specific OR with the generic inverse variance method. A total of 156 studies (10,041,928 patients) were included in the systematic review and meta-analysis. The pooled proportion of adherent patients was 54% (95% confidence interval, CI: 51-58%). We observed a significant association between good glycemic control and good adherence (OR: 1.33; 95% CI: 1.17-1.51). This study demonstrated that adherence to OADs in patients with T2D is sub-optimal. Improving therapeutic adherence through health-promoting programs and prescription of personalized therapies could be an effective strategy to reduce the risk of complications.

Sex and gender differences in the use of oral anticoagulants for non-valvular atrial fibrillation: A population-based cohort study in primary health care in catalonia

Objectives: To describe the sex and gender differences in the treatment initiation and in the socio-demographic and clinical characteristics of all patients initiating an oral anticoagulant (OAC), and the sex and gender differences in prescribed doses and adherence and persistence to the treatment of those receiving direct oral anticoagulants (DOAC). Material and methods: Cohort study including patients with non-valvular atrial fibrillation (NVAF) who initiated OAC in 2011-2020. Data proceed from SIDIAP, Information System for Research in Primary Care, in Catalonia, Spain. Results: 123,250 people initiated OAC, 46.9% women and 53.1% men. Women were older and the clinical characteristics differed between genders. Women had higher risk of stroke than men at baseline, were more frequently underdosed with DOAC and discontinued the DOAC less frequently than men. Conclusion: We described the dose adequacy of patients receiving DOAC, finding a high frequency of underdosing, and significantly higher in women in comparison with men. Adherence was generally high, only with higher levels in women for rivaroxaban. Persistence during the first year of treatment was also high in general, being significantly more persistent women than men in the case of dabigatran and edoxaban. Dose inadequacy, lack of adherence and of persistence can result in less effective and safe treatments. It is necessary to conduct studies analysing sex and gender differences in health and disease.

Patient-related factors associated with medication adherence behavior in patients with end-stage renal disease: A systematic review

Objectives

This systematic review aims to identify influencing factors of medication adherence behavior in patients with end-stage renal disease (ESRD), with a special interest in patient-related factors based on the World Health Organization adherence model.

Materials and Methods

Primary electronic databases comprising PubMed, Scopus, Web of Science, Embase and Cochrane Library, as well as ProQuest (Health and Medical), ProQuest (Psychology), and EBSCOHost (APA PsychARTICLES) were used to search for literature on patient-related factors in medication adherence, from inception till August 31, 2021.

Results

479 articles were identified and six articles meeting eligibility criteria were reviewed and remained in this systematic review. The present review found that despite different tools being used to measure ESRD's perception of medication's necessity and beliefs, there was a profound association between perception and beliefs with medication adherence behavior. There is a positive relationship between knowledge, belief, educational level, ethnicity, female, and medication adherence behavior. Mixed finding was reported between perception, age, and medication adherence behavior. However, there were no studies on patients' attitudes and medication adherence behavior as suggested in the WHO adherence model.

Conclusion

Only a limited number of patient-related factors were available for evaluation in the current systematic review. Additional research is needed to advance the understanding of medication adherence behavior affected by patient-related factors on the medication and illness. However, the findings must be taken with caution because of the limited studies included in this review.

Correlation between the triglyceride-to-high-density lipoprotein cholesterol ratio and other unconventional lipid parameters with the risk of prediabetes and Type 2 diabetes in patients with coronary heart disease: a RCSCD-TCM study in China

Objective

Type 2 diabetes mellitus (T2DM) is often accompanied by undiagnosed dyslipidemia. Research on the association of unconventional lipid markers with prediabetes (pre-DM) and T2DM simultaneously is limited in coronary heart disease (CHD) patients.

Methods

This study included 28,476 patients diagnosed with CHD. Their lipid levels, including triglycerides (TG), total cholesterol (TC), high-density lipoprotein cholesterol (HDL-C), and low-density lipoprotein cholesterol (LDL-C), were measured, and non-traditional lipid parameters were calculated. The patients were divided into three groups based on the diabetic status including normoglycemic (NG), pre-DM, and T2DM. Multiple logistic regression was used to compare the association of TG/HDL-C and other non-traditional lipid parameters with pre-DM and T2DM. The tertiles of TG/HDL-C included T1 (TG/HDL-C < 1.10), T2 (1.10 ≤ TG/HDL-C ≤ 1.89) and T3 (TG/HDL-C > 1.89). Low and high TG/HDL-C was defined with sex-specific cutoff points.

Results

Multiple logistic regression results showed that the non-traditional lipid parameters, including non-HDL-C, LDL-C/HDL-C, TC/HDL-C, non-HDL-C/HDL-C and TG/HDL-C, were all correlated with the risk of pre-DM and T2DM. Meanwhile TG/HDL-C showed the strongest correlation (odds ratio [OR]: 1.19; 95% confidence interval [CI] 1.16–1.23), (OR: 1.36; 95% CI 1.33–1.39). When dividing TG/HDL-C into tertiles, using T1 as a reference, T3 was observed to have the highest association with both pre-DM and T2DM (OR: 1.60; 95% CI 1.48–1.74), (OR: 2.79; 95% CI 2.60–3.00). High TG/HDL-C was significantly associated with pre-DM and T2DM (OR: 1.69; 95% CI 1.52–1.88), (OR: 2.85; 95% CI 2.60–3.12). The association of TG/HDL-C with T2DM and pre-DM existed across different sex, age, smoking, and drinking statuses.

Conclusion

Elevated non-traditional lipid parameters were significantly associated with pre-DM and T2DM in CHD patients, especially TG/HDL-C. High TG/HDL-C was the risk factor with a strong correlation with the risk of pre-DM and T2DM.

Health Disparities: Statin Prescribing Patterns Among Patients with Diabetes in a Family Medicine Clinic

Purpose:

To analyze the impact of gender and race on statin prescribing patterns in patients with diabetes in a family medicine clinic.

Methods:

This study (n=192) was a single-center, cross-sectional study that examined statin prescribing patterns at a family medicine clinic. Patients were obtained from January 2015 to November 2018, who were considered eligible for statin therapy based on a documented diagnosis of diabetes. The patients were divided into four subgroups for analysis (white males, non-white males, white females, and non-white females).

Results:

Females were found to have higher rates of prescribed statin therapy and appropriate statin intensity therapy when compared to males (p>0.05). When evaluating gender and race, white females were more likely to be prescribed an appropriate statin when compared to non-white females (p<0.05).

Conclusion:

The study shows that although males had a significantly higher mean 10-year atherosclerotic cardiovascular disease risk score, they were less likely than females to receive the appropriate intensity statin. Previous studies have shown race and gender disparities exist in the prevention of cardiovascular disease. A more collective, unified approach to improve prescribing patterns for statin therapy can eliminate these disparities.

The Diabetes-Cardiovascular Connection in Women: Understanding the Known Risks, Outcomes, and Implications for Care

PURPOSE OF REVIEW

Cardiovascular disease (CVD) complications constitute about 50-70% of mortality in people with diabetes. However, there remains a persistently greater relative increase in CVD morbidity and mortality in women with diabetes than in their male counterparts. This review presents recent evidence for the risks, outcomes, and management implications for women with diabetes.

RECENT FINDINGS

Compared to men, women have higher BMI and more adverse cardiovascular risk profile at time of diabetes diagnosis with greater risk for coronary heart disease, stroke, vascular dementia, and heart failure. Pregnancy-specific risk factors of gestational diabetes and pre-eclampsia are associated with future type 2 diabetes (T2D) and CVD. Women with T2D may experience greater benefits than men from GLP-1 receptor agonists. Women with diabetes are at greater relative risk for CVD complications than men, with poorer outcomes, superimposed on preexisting gender disparities in social determinants of health, lower likelihood of being offered cardioprotective interventions, and enrollment in trials. Further research and the utilization of SGLT-2 inhibitors, GLP-1 receptor agonists, and other CVD prevention strategies will help reduce morbidity and mortality.

Patient experiences with a phone-based cardiovascular risk reduction intervention: Are there differences between women and men?

OBJECTIVES

To explore gender-based differences in experiences with a telehealth-delivered intervention for reduction of cardiovascular risk.

METHODS

We conducted 23 semi-structured qualitative interviews by telephone with 11 women and 12 men who received a 12-month, pharmacist-delivered, telephone-based medication and behavioral management intervention. We used content analysis to identify themes.

RESULTS

We identified three common themes for both men and women: ease and convenience of phone support, preference for proactive outreach, and need for trust building in the context of telehealth. While both genders appreciated the social support from the intervention pharmacist, women voiced appreciation for accountability whereas men generally spoke about encouragement.

CONCLUSIONS

Rapport building may differ between telehealth and in-person healthcare visits; our work highlights how men and women's experiences can differ with telehealth care and which can inform the development of future, purposeful rapport building activities to strengthen the clinician-patient interaction.

PRACTICE IMPLICATIONS

Clinicians should seek opportunities to provide frequent and routine support for patients with chronic disease. Telehealth interventions may benefit from gender-specific tailoring of social support.

Challenges in Optimizing Lipid Management in Women

While there are physiologic differences in lipid metabolism in men and women, pharmacologic therapy is very effective in both with similar management strategies recommended in the current guidelines for the management of dyslipidemia. Despite similar guidelines for treatment, studies have shown that women have worse control of dyslipidemia than their male counterparts. This may stem from multiple contributing factors including underestimation of cardiovascular disease risk in women, decreased prescription and utilization of lipid-lowering therapies, decreased medication adherence, and higher risk of statin intolerance, all of which may contribute to lower attainment of lipid targets. Furthermore, heart disease is the leading cause of mortality in women, with heart disease noted an average of 7-10 years later than in men. This has historically led to the misperception that women are protected from heart disease and can be treated less aggressively. In fact, traditional risk factors for atherosclerotic cardiovascular disease often impact risk in women to a greater extent than they do in men. Unique risk factors such as pregnancy-related disorders also contribute to the level of risk and therefore warrant consideration in risk stratification. This review summarizes the efficacy of contemporary lipid-lowering therapies in women versus men and discusses the challenges that arise with lipid management in women along with potential ways to tackle these obstacles.

Sex Disparities in Cardiovascular Risk Factor Assessment and Screening for Diabetes-Related Complications in Individuals With Diabetes: A Systematic Review

Background

Insight in sex disparities in the detection of cardiovascular risk factors and diabetes-related complications may improve diabetes care. The aim of this systematic review is to study whether sex disparities exist in the assessment of cardiovascular risk factors and screening for diabetes-related complications.

Methods

PubMed was systematically searched up to April 2020, followed by manual reference screening and citations checks (snowballing) using Google Scholar. Observational studies were included if they reported on the assessment of cardiovascular risk factors (HbA1c, lipids, blood pressure, smoking status, or BMI) and/or screening for nephropathy, retinopathy, or performance of feet examinations, in men and women with diabetes separately. Studies adjusting their analyses for at least age, or when age was considered as a covariable but left out from the final analyses for various reasons (i.e. backward selection), were included for qualitative analyses. No meta-analyses were planned because substantial heterogeneity between studies was expected. A modified Newcastle-Ottawa Quality Assessment Scale for cohort studies was used to assess risk of bias.

Results

Overall, 81 studies were included. The majority of the included studies were from Europe or North America (84%).The number of individuals per study ranged from 200 to 3,135,019 and data were extracted from various data sources in a variety of settings. Screening rates varied considerably across studies. For example, screening rates for retinopathy ranged from 13% to 90%, with half the studies reporting screening rates less than 50%. Mixed findings were found regarding the presence, magnitude, and direction of sex disparities with regard to the assessment of cardiovascular risk factors and screening for diabetes-related complications, with some evidence suggesting that women, compared with men, may be more likely to receive retinopathy screening and less likely to receive foot exams.

Conclusion

Overall, no consistent pattern favoring men or women was found with regard to the assessment of cardiovascular risk factors and screening for diabetes-related complications, and screening rates can be improved for both sexes.

Impaired neuropsychological functioning in patients with hypopituitarism

Background

Treatment of pituitary pathology mostly does not result in complete recovery of impairment in cognitive functioning. The primary aim of the current study was to assess cognitive impairment in patients with stable replacement therapy for hypopituitarism during the last 6 months prior to inclusion. It was expected that patients showed subjective and objective subnormal scores on neuropsychological functioning.

Methods

Forty-two patients (40% men, 49 ± 15 years) treated for hypopituitarism conducted a neuropsychological test battery, including the Cognitive Failures Questionnaire (CFQ), 15-Word test (15-WT), Cambridge Neuropsychological Test Automated Battery (CANTAB) Motor Screening Task (MOT), Spatial Working Memory (SWM) and Affective Go/No-go (AGN). Results were compared to reference values of healthy norm groups.

Results

Male and female participants scored significantly worse on the CFQ (P < .01, d = 0.91-4.09) and AGN mean correct latency (P < .01, d = 1.66 and 1.29, respectively). Female participants scored significantly worse on 15-WT direct recall (P = .01, d = 0.66), 15-WT delayed recall (P = .01, d = 0.79), SWM total errors (P = .05, d = 0.41), SWM strategy (P = .04, d = 0.43), AGN errors of commission (P = .02, d = 0.56) and omission (P = .04, d = 0.41).

Conclusion

This study shows that subjective cognitive functioning is worse in patients treated for hypopituitarism compared to reference data. Also, female participants treated for hypopituitarism score worse on objective aspects of memory and executive functioning compared to reference data. Besides worse focus attention, this objective cognitive impairment was not found in male participants. It is recommended to conduct additional research, which focuses on the design and evaluation of a cognitive remediation therapy, aimed at compensation of impairments in different aspects of memory and executive functioning.

Gender differences of relationship between serum lipid indices and type 2 diabetes mellitus: a cross-sectional survey in Chinese elderly adults

Background

To investigate the gender differences of the relationships between clinical serum lipid indices and type 2 diabetes mellitus (T2DM) in Chinese elderly adults.

Methods

Between 2014 and 2016, participants selected from three communities in an urban district of Shanghai were measured for serum lipid indices of low-density lipoprotein cholesterol (LDL-c), high-density lipoprotein cholesterol (HDL-c), total cholesterol (TC), and triglyceride (TG). Age and multivariate adjusted logistic regression models were utilized to estimate the odds ratios (ORs) and 95% confidence intervals (CIs) of serum lipid indices on T2DM prevalence.

Results

In total, 4,023 male and 3,862 female participants were included in this study, with the T2DM prevalence proportions of 13.03% and 11.73%, respectively. In association analysis, the serum levels of LDL-c, HDL-c, TC were significant between non-T2DM individuals and T2DM patients in men, but the HDL-c and TG in women. LDL-c/HDL-c, TG/HDL-c, and TC/HDL-c ratios were associated with the T2DM prevalence only in women. In the multivariate analysis, a higher serum LDL-c level was positively associated with a reduced risk of T2DM prevalence in men with OR (95% CI) of 0.57 (0.39–0.85) (P=0.006). Higher ratios of LDL-c/HDL-c, TG/HDL-c, and TC/HDL-c were all more likely associated with the decreased risks of T2DM prevalence with the ORs ranging from 0.45 to 0.62 in men (all P<0.05), but not in women.

Conclusions

High LDL-c concentration was significantly associated with a lower T2DM prevalence in men. A gender difference of the associations between the lipid ratios and T2DM prevalence was observed for LDL-c/HDL-c and TC/HDL-c ratios, which might be validated in female T2DM prevalence in the future.

Interventions to Improve Adherence to Cardiovascular Medication: What About Gender Differences? A Systematic Literature Review

BACKGROUND

Compared to men, women have lower treatment rates for cardiovascular disease (CVD), are at higher risk for medication non-adherence and have different reasons for being non-adherent. The aim of this study was to synthesize and evaluate gender-specific adherence-promoting interventions for cardiovascular medication and gender-specific effects of gender-neutral interventions.

METHODS

A systematic literature search was performed in PubMed, Embase, PsycINFO, CINAHL and Cochrane Library from January 2007 to October 2019. Intervention studies (with control group) aimed at improving cardiovascular medication adherence with minimally 14 weeks follow-up were included. Two reviewers independently screened titles and abstracts. Full text was obtained for selected abstracts and screened for final inclusion. Data extraction included gender-specific targeting or analysis.

RESULTS

The search identified 6502 citations. After screening title and abstract, full text was obtained from 127 potentially eligible articles. Ultimately, 11 articles were included that analyzed gender differences in gender-neutral interventions. Two reported a gender-specific intervention effect. Using an electronic reminder device, one study increased statin adherence in women. The other found a larger increase in adherence to CVD medication following telephone counseling for men than women. Nine studies did not identify a gender-specific effect.

CONCLUSION

Despite differences in levels of and reasons for non-adherence, most studies addressing adherence did not analyze potential differences in effect by gender. Moreover, none of the identified studies used gender-specific adherence promoting interventions. Increasing awareness about gender differences in adherence might lead to better tailoring of interventions to gender-specific needs and better results in improving adherence.

The Gut Microbiota-Produced Indole-3-Propionic Acid Confers the Antihyperlipidemic Effect of Mulberry-Derived 1-Deoxynojirimycin

Hyperlipidemia is a worldwide epidemic with an obvious gender disparity in incidence. Modulations on gut microbiota by traditional Chinese medicines (TCM) are emerging as a potential rationale governing the profitable effects of drugs on hyperlipidemia. However, it is unclear how gut microbes regulate the progression of hyperlipidemia. Here, we found that mulberry leaf extract (MLE) and its active component 1-deoxynojirimycin (DNJ) diminished hyperglycemia and hypertriglyceridemia with similar efficacy in male and female mice but preferentially alleviated hypercholesterolemia in female mice. Further investigations showed that DNJ sex-specifically downregulated the expression of lipogenic genes, especially cholesterol-biosynthetic genes. Oral administration of DNJ imposed more profound modulation on gut microbiota in female mice than in male ones, as estimated by 16S rRNA metatranscriptomic analysis. DNJ markedly enriched Akkermansia and Clostridium group XIVa and promoted the production of indole-3-propionic acid (IPA) in a sexually dimorphic way. Importantly, IPA tightly associates with the antihyperlipidemic effect of DNJ and exhibited a potent lipid-lowering effect both in vitro and in vivo Together, our results have established a regulatory mechanism by which DNJ sex-specifically improves hyperlipidemia, offering an in-depth theoretical basis for therapeutic exploitation of DNJ as a sex-specific intervention against hyperlipidemia.IMPORTANCE Hyperlipidemia has been intensively focused on by researchers around the world owing to its major contribution to cardiovascular diseases. Various evidence reveals that women are more susceptible than male counterparts to dyslipidemia, making sex-dependent therapeutic strategies and drugs urgently needed. In the present work, we demonstrate that DNJ, the main active component of mulberry leaves, exerts an obvious female-preferential antihyperlipidemic effect through specifically enriching Akkermansia and Clostridium XIVa and elevating an active microbial metabolite, indole-3-propionic acid (IPA), in female mice. Moreover, we have corroborated the potent lipid-lowering efficacy of IPA both in vitro and in vivo These findings not only indicate a potential mechanism by which gut microbes and their metabolites confer the beneficial role of DNJ in ameliorating hyperlipidemia but also provide an in-depth theoretical basis for therapeutic exploitation of DNJ as a female-specific intervention against hyperlipidemia.

Dyslipidemia: A Trigger for Coronary Heart Disease in Romanian Patients with Diabetes

Previous studies have reported age and gender disparities in the occurrence and therapeutic approach of dyslipidemia and (or) coronary heart disease (CHD) in patients with type 2 diabetes mellitus (T2DM). We aimed to investigate these differences in Romanian patients with T2DM. A cross-sectional, observational, retrospective study was conducted using the medical records of T2DM patients who attended the outpatient facility of the Internal Medicine Clinic of the Clinical Emergency Hospital of Bucharest, Romania for routine check-ups in a six-month period. We analyzed the records of 217 diabetic patients (mean age 69 ± 11 years; 51.15% women). We found no significant gender differences in the occurrence of dyslipidemia, CHD or CHD + dyslipidemia or in terms of statin prescription. However; patients aged 65 years or older were significantly more affected by dyslipidemia, CHD or CHD + dyslipidemia, versus subjects aged <65 years. Further, they were more likely to be prescribed statin therapy (p < 0.0001 for all). Statins were prescribed to 67.24% of the patients with dyslipidemia; 61.01% of the subjects with CHD; and to 91.48% of the patients who had both conditions. e recorded no gender differences in the occurrence of CHD and (or) dyslipidemia in Romanian T2DM patients. Patients aged 65 years or older had a higher prevalence of CHD and/or dyslipidemia, and were more likely to be prescribed statins, versus younger counterparts. However, many T2DM patients with CHD and (or) dyslipidemia were undertreated: Nearly 33% of the subjects with dyslipidemia, and nearly 40% of the ones with CHD were not prescribed statins.

Sex differences in the risk of vascular disease associated with diabetes

Diabetes is a strong risk factor for vascular disease. There is compelling evidence that the relative risk of vascular disease associated with diabetes is substantially higher in women than men. The mechanisms that explain the sex difference have not been identified. However, this excess risk could be due to certain underlying biological differences between women and men. In addition to other cardiometabolic pathways, sex differences in body anthropometry and patterns of storage of adipose tissue may be of particular importance in explaining the sex differences in the relative risk of diabetes-associated vascular diseases. Besides biological factors, differences in the uptake and provision of health care could also play a role in women’s greater excess risk of diabetic vascular complications. In this review, we will discuss the current knowledge regarding sex differences in both biological factors, with a specific focus on sex differences adipose tissue, and in health care provided for the prevention, management, and treatment of diabetes and its vascular complications. While progress has been made towards understanding the underlying mechanisms of women’s higher relative risk of diabetic vascular complications, many uncertainties remain. Future research to understanding these mechanisms could contribute to more awareness of the sex-specific risk factors and could eventually lead to more personalized diabetes care. This will ensure that women are not affected by diabetes to a greater extent and will help to diminish the burden in both women and men.

The Mediating Role of Diabetes Distress and Depressive Symptoms in Type 2 Diabetes Medication Adherence Gender Differences

Background. Medication adherence is negatively related to both diabetes distress (DD) and depressive symptoms (DS). Past research suggests gender differences in adherence, DD, and DS. A gap exists in determining if gender differences in adherence are mediated by DD and DS, or if gender moderates differences in adherence by DD/DS. Aims. This study investigated the relationship between gender, DD, DS, and medication adherence and tested for mediating and moderating effects on medication adherence among American Indian adults with type 2 diabetes. Method. The Maawaji idi-oog mino-ayaawin (Gathering for Health) study was a community-based participatory research collaboration with five American Indian tribes. Participants, randomly recruited from clinic records, shared information during computer-assisted personal interviews. This study includes the 166 participants who reported using medications to treat their diabetes. The relationship between gender, DD, DS, and medication adherence are explored. Possible mediating and moderating effects on medication were tested using regression and path analysis. Results. Females had higher levels of DD and DS and lower levels of medication adherence. Higher levels of DD and DS were both associated with lower medication adherence. No evidence was found that gender moderates the relationship between DD or DS and medication adherence. Instead, DD and DS mediated the relationship between gender and medication adherence. Conclusions. Medication adherence differences in male and female patients may be attributable to DD and DS. The present research highlights both DD and DS as targets for clinicians and researchers alike.

Correlates of low-adherence to oral hypoglycemic medications among Hispanic/Latinos of Mexican heritage with Type 2 Diabetes in the United States

AIMS

We examined psychosocial- and social/economic factors related to low medication adherence, and sex differences, among 279 adults of Mexican heritage with Type 2 Diabetes.

METHODS

Self-report and health record data were used for cross-sectional analyses. Bivariate analyses tested the association of demographic, psychosocial (depression, anxiety, stress) and social/economic factors (insurance type, health literacy, social support) and medication adherence measured by proportion of days covered. Hierarchical regression analyses examined associations between demographic, psychosocial- and social/economic- related factors and low medication adherence stratified by sex.

RESULTS

More males than females demonstrated low adherence to hypoglycemic medications (75.0.% vs. 70.3%) (p < 0.05). We found significant differences between levels social support and medication adherence (p < 0.05). In hierarchical models, being US born and higher levels of social support were associated with low adherence among males (p < 0.05, and p < 0.001).

CONCLUSIONS

Approximately 72% of Mexican heritage adults demonstrated low adherence (PDC ≤ 0.50) to their hypoglycemic regimen, and gender differences exist. Interventions should address gender differences in preferences for social support to improve medication-taking behaviors among Mexican heritage males.

Evaluation of Dyslipidaemia Using an Algorithm of Lipid Profile Measures among Newly Diagnosed Type II Diabetes Mellitus Patients: A Cross-Sectional Study at Dormaa Presbyterian Hospital, Ghana

Background and Objectives: Dyslipidaemia and its associated complications have been reported to increase mortality among type 2 diabetes mellitus (T2DM) patients. However, there is a dearth of data on the incidence of dyslipidemia among Ghanaian patients with T2DM. This study evaluated dyslipidemia among newly diagnosed T2DM patients at Dormaa Presbyterian Hospital, Ghana. Materials and Methods: This cross-sectional study recruited a total of 215 participants at the Presbyterian Hospital, Dormaa-Ghana. A well-structured questionnaire was administered to collect demographic data. Predisposing factors of dyslipidemia such as BMI, hypertension, and family history of diabetes were also obtained. Lipid profile was performed on the serum obtained from each respondent. Dyslipidaemia was defined as total cholesterol (TC) >200 mg/dL, triglyceride (TG) >150 mg/dL, low density lipoprotein cholesterol (LDL-c) >100 mg/dL, and high-density lipoprotein cholesterol (HDL-c) <40 in males and <50 mg/dL in females. Combinations of the individual parameters of dyslipidaemia were further evaluated. Results: Of the total (215) participants, 86 (40%) were males and 129 (60%) were females, representing a ratio of 1:1.5. High total cholesterol was more prevalent in females (69.0%) than males (53.5%). Generally, dyslipidaemia was predominant among those aged >40 years, with the exception of increased LDL-c (25.1%), which was higher among the 20–40 years age group. The male participants exhibited significantly (p < 0.001) higher percentages of all combined measures of dyslipidaemia—such as high TG and reduced HDL-c (77.9%), high TG and elevated LDL-c (75.6%) and high LDL and low HDL (65.1%). BMI was significantly associated with HDL levels (p = 0.02), whereas family history of diabetes was associated with TC (p = 0.004) and TG levels (p = 0.019). Conclusion: Combined dyslipidaemia is relatively high among newly diagnosed T2DM patients in Ghana, and in those >40 years. Gender is significantly associated with combined dyslipidaemia in T2DM, and males may be at a higher risk than females. BMI and family history of diabetes are potential risk factors of dyslipidaemia in T2DM.

Cigarette Smoking among Economically Disadvantaged African-American Older Adults in South Los Angeles: Gender Differences

The current study aims to explore gender differences in the risk of cigarette smoking among African-American (AA) older adults who live in economically disadvantaged urban areas of southern Los Angeles. This cross-sectional study enrolled 576 older AA adults (age range between 65 and 96 years) who were residing in Service Planning Area 6 (SPA 6), one of the most economically challenged areas in southern Los Angeles. All participants had cardiometabolic disease (CMD). Data were collected using structured face-to-face interviews. Demographic factors (age and gender), socioeconomic status (educational attainment and financial difficulty), health (number of comorbid medical conditions and depressive symptoms), and health behaviors (current alcohol drinking and current smoking) were measured. Logistic regressions were used to analyze the data without and with interaction terms between gender and current drinking, depressive symptoms, and financial difficulty. AA men reported more smoking than AA women (25.3% versus 9.3%; p < 0.05). Drinking showed a stronger association with smoking for AA men than AA women. Depressive symptoms, however, showed stronger effects on smoking for AA women than AA men. Gender did not interact with financial difficulty with regard to current smoking. As AA older men and women differ in psychological and behavioral determinants of cigarette smoking, gender-specific smoking cessation interventions for AA older adults who live in economically deprived urban areas may be more successful than interventions and programs that do not consider gender differences in determinants of smoking. Gender-tailored smoking cessation programs that address drinking for AA men and depression for AA women may help reduce the burden of smoking in AA older adults in economically disadvantaged urban areas. Given the non-random sampling, there is a need for replication of these findings in future studies.

Cardiovascular Disease in Type 2 Diabetes: A Review of Sex-Related Differences in Predisposition and Prevention

Type 2 diabetes mellitus is a major risk factor for cardiovascular disease. However, compiled data suggest that type 2 diabetes affects the risk of cardiovascular disease differentially according to sex. In recent years, large meta-analyses have confirmed that women with type 2 diabetes have a higher relative risk of incident coronary heart disease, fatal coronary heart disease, and stroke compared with their male counterparts. The reasons for these disparities are not completely elucidated. A greater burden of cardiometabolic risk in women was proposed as a partial explanation. Indeed, several studies suggest that women experience a larger deterioration in major cardiovascular risk factors and put on more weight than do men during their transition from normoglycemia to overt type 2 diabetes. This excess weight is associated with higher levels of biomarkers of endothelial dysfunction, inflammation, and procoagulant state. Moreover, sex differences in the prescription and use of some cardiovascular drugs may compound an "existing" disparity. We searched PubMed for articles published in English and French, by using the following terms: ("cardiovascular diseases") AND ("diabetes mellitus") AND ("sex disparity" OR "sex differences" OR "sex related differences" OR "sex-related differences" OR "sex disparities"). In this article, we review the available literature on the sex aspects of primary and secondary prevention of cardiovascular disease in people with type 2 diabetes, in the predisposition to cardiovascular disease in those people, and in the control of diabetes and associated cardiovascular risk factors.

Methods for Measuring Multiple Medication Adherence: A Systematic Review-Report of the ISPOR Medication Adherence and Persistence Special Interest Group

BACKGROUND

A broad literature base exists for measuring medication adherence to monotherapeutic regimens, but publications are less extensive for measuring adherence to multiple medications.

OBJECTIVES

To identify and characterize the multiple medication adherence (MMA) methods used in the literature.

METHODS

A literature search was conducted using PubMed, PsycINFO, the International Pharmaceutical Abstracts, the Cumulative Index to Nursing and Allied Health Literature and the Cochrane Library databases on methods used to measure MMA published between January 1973 and May 2015. A two-step screening process was used; all abstracts were screened by pairs of researchers independently, followed by a full-text review identifying the method for calculating MMA. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed to conduct this systematic review. For studies that met the eligibility criteria, general study and adherence-specific characteristics and the number and type of MMA measurement methods were summarized.

RESULTS

The 147 studies that were included originated from 32 countries, in 13 disease states. Of these studies, 26 used proportion of days covered, 23 used medication possession ratio, and 72 used self-reported questionnaires (e.g., the Morisky Scale) to assess MMA. About 50% of the studies included more than one method for measuring MMA, and different variations of medication possession ratio and proportion of days covered were used for measuring MMA.

CONCLUSIONS

There appears to be no standardized method to measure MMA. With an increasing prevalence of polypharmacy, more efforts should be directed toward constructing robust measures suitable to evaluate adherence to complex regimens. Future research to understand the validity and reliability of MMA measures and their effects on objective clinical outcomes is also needed.

How Do Gender Differences in Quality of Care Vary Across Medicare Advantage Plans?

BACKGROUND

Healthcare Effectiveness Data and Information Set (HEDIS) quality measures have long been used to compare care across health plans and to study racial/ethnic and socioeconomic disparities among Medicare Advantage (MA) beneficiaries. However, possible gender differences in seniors' quality of care have received less attention.

OBJECTIVE

To test for the presence and nature of any gender differences in quality of care across MA Plans, overall and by domain; to identify those most at risk of poor care.

DESIGN

Cross-sectional analysis of individual-level HEDIS measure scores from 23.8 million records using binomial mixed-effect models to estimate the effect of gender on performance. For each measure, we assess variation in gender gaps and their correlation with plan performance.

PARTICIPANTS

Beneficiaries from 456 MA plans in 2011-2012 HEDIS data.

MAIN MEASURES

Performance on 32 of 34 HEDIS measures which were available in both measurement years. The two excluded measures had mean performance scores below 10%.

KEY RESULTS

Women experienced better quality of care than men for 22/32 measures, with most pertaining to screening or treatment. Men experienced better quality on nine measures, including four related to cardiovascular disease and three to potentially harmful drug-disease interactions. Plans varied substantially in the magnitude of gender gaps for 21/32 measures; in general, the gender gap in quality of care was least favorable to men in low-performing plans.

CONCLUSIONS

Women generally experienced better quality of care than men. However, women experienced poorer care for cardiovascular disease-related intermediate outcomes and potentially harmful drug-disease interactions. Quality improvement may be especially important for men in low-performing plans and for cardiovascular-related care and drug-disease interactions for women. Gender-stratified reporting could reveal gender gaps, identify plans for which care varies by gender, and motivate efforts to address faults and close the gaps in the delivery system.

Gender Disparities in Lipid Goal Attainment among Type 2 Diabetes Outpatients with Coronary Heart Disease: Results from the CCMR-3B Study

Our study was aimed to investigate the gender disparities in lipid goal attainment among type 2 diabetes outpatients with concomitant coronary heart disease (CHD) and explore potential risk factors. We performed the present analysis using data from a nationally representative epidemiologic study. The therapeutic goal was defined as achieving a low-density lipoprotein cholesterol (LDL-C) <1.8 mmol/L. A total of 1721 male and 2072 female type 2 diabetes outpatients with established CHD were identified. Compared with men, women had higher levels of total cholesterol (4.98 vs. 4.46 mmol/L; p < 0.001), LDL-C (2.82 vs. 2.54 mmol/L; p < 0.001), and triglycerides (2.02 vs. 1.79 mmol/L; p < 0.001), but not hemoglobin A1c (7.47% vs. 7.50%; p = 0.597). The proportion of women received lipid-lowering therapy was lower (38.1% vs. 48.2%; p < 0.001). The percentages of patients who achieved the LDL-C goal were higher among men. Multivariable regression analysis indicated that the odds ratio for lipid goal attainment due to the gender difference was 0.61 after adjusting confounders. The inability to achieve LDL-C goals in women with type 2 diabetes and CHD is apparently greater than that in men. This finding underscores the importance of initiatives to establish a more aggressive lipid management strategy for women to overcome gender imbalances.

Sex and gender differences in therapy of type 2 diabetes

Clinical guidelines for the management of type 2 diabetes recommend individual therapy considering age, duration of disease, presence of complication and risk of hypoglycaemia. However, at present, the patient's sex has no impact on clinical decisions. Yet, there is mounting data pointing at biological and psychosocial differences between men and women with great impact on progression of disease and complications. Moreover, choices and preferences of therapeutic strategies as well as adherence to lifestyle and pharmacological interventions differ in both sexes. In addition, drug therapy may have sex-specific side effects. Therefore, there is need of more research on biological differences and of evidence-based individualised targeted sex-sensitive therapeutic concepts. Clinical guidelines must consider relevant sex-differences. Development and implementation of sex-specific programs may help to improve adherence to therapy and to reduce progression of disease and development of complications. A more gender-sensitive clinical approach may improve quality of life and increase health and life expectancy in men and women with type 2 diabetes.

Sociodemographic factors are associated with utilisation of statins after ischaemic stroke/TIA

OBJECTIVES

To analyse if there are sociodemographic differences in the utilisation of statins 9-12 months after ischaemic stroke or transitory ischaemic attack.

METHODS

Anonymised linkage of registry data on all patients >18 years discharged from the hospitals in Stockholm, Sweden 2006-2010 with diagnosis of ischaemic stroke (ICD-10: I63.0-9) or TIA (ICD-10: G45.9) was performed. Data on hospitalisations and diagnoses were collected from the Stockholm County Council administrative databases on healthcare consumption. Dispensed prescriptions with statins and, for comparative purposes, antihypertensive agents 9-12 months after discharge were acquired from the National Swedish Prescribed Drug Register. Data about socioeconomic factors were obtained from Statistics Sweden. The dispensing of statins and antihypertensive agents, relative to sociodemographic variables were analysed. Using logistic regression odds ratios, crude, and adjusted with education, income, origin of birth, age, and sex as predictors where calculated.

RESULTS

Of 24 312 patients with ischaemic stroke/TIA, 19 335 were alive 12 months after discharge. Statins were dispensed to 44% of all patients in the cohort, more frequently to men of all age groups, to patients with higher education, and to those with higher income. Antihypertensive agents were dispensed to 68% of all patients and there were no differences related to sex and income whilst patients with lower education were dispensed with antihypertensives more frequently.

CONCLUSION

We find a low utilisation of statins one year after ischaemic stroke/TIA. Patients with low education, low income, and female sex were dispensed fewer prescriptions of statins indicating a need for improvement.

Impact of Gender on Satisfaction and Confidence in Cholesterol Control Among Veterans at Risk for Cardiovascular Disease

BACKGROUND

Compared with men, women have poorer lipid control. Although potential causes of this disparity have been explored, it is unknown whether patient-centered factors such as satisfaction and confidence contribute. We evaluated (1) whether satisfaction with lipid control and confidence in ability to improve it vary by gender and (2) whether sociodemographic characteristics modify the association.

MATERIALS AND METHODS

We evaluated baseline survey responses from the Cardiovascular Intervention Improvement Telemedicine Study, including self-rated satisfaction with cholesterol levels and confidence in controlling cholesterol. Participants had poorly controlled hypertension and/or hypercholesterolemia.

RESULTS

A total of 428 veterans (15% women) participated. Compared with men, women had higher low-density lipoprotein values at 141.2 versus 121.7 mg/dL, respectively (p < 0.05), higher health literacy, and were less likely to have someone to help track their medications (all p < 0.05). In an adjusted model, women were less satisfied with their cholesterol levels than men with estimated mean scores of 4.3 versus 5.6 on a 1-10 Likert scale (p < 0.05). There was no significant difference in confidence by gender. Participants with support for tracking medications reported higher confidence levels than those without, estimated mean 7.8 versus 7.2 (p < 0.05).

CONCLUSIONS

Women veterans at high risk for cardiovascular disease were less satisfied with their lipid control than men; however, confidence in ability to improve lipid levels was similar. Veterans without someone to help to track medications were less confident, and women were less likely to have this type of social support. Lack of social support for medication tracking may be a factor in lingering gender-based disparities in hyperlipidemia.

Contacting dropouts from type 2 diabetes care in public primary health care: description of the patient population

OBJECTIVE

To characterize dropouts from type-2 diabetes (T2D) care in communal primary health care.

DESIGN

An observational study.

SETTING

In a Finnish city, patients with T2D who had not contacted the public primary health care system during the past 12 months were identified with a computer based search and contacted by a trained diabetes nurse.

SUBJECTS

Dropouts from T2D treatment.

MAIN OUTCOME MEASURES

Demographic factors, laboratory parameters, examinations, medications, and comorbidities.

RESULTS

Of the patients with T2D, 10% (n = 356) were dropouts and 60% of them were men. Median HbA1c was 6.5 (QR for 25% and 75%: 6.0, 7.7) %, (45 [42,61] mmol/mol). Of the dropouts, 14% had HbA1c ≥ 9.0% (75 mmol/mol), and these patients were younger than the other dropouts (mean age 54.4 [SD 10.8] years vs. 60.6 [9.4] years, p < 0.001). Median low-density lipoprotein (LDL) cholesterol level was 2.8 (QR 2.1, 3.4) mmol/l. Median systolic blood pressure (BP) was 142 (QR 130, 160) mm Hg. Median diastolic BP was 86 (78, 94) mm Hg. Of the dropouts, 83% had comorbidities and 62% were prescribed metformin as a treatment.

CONCLUSIONS

Ten percent of T2D patients were dropouts of whom those with a poor glycaemic control were younger than the other dropouts. BP and LDL cholesterol concentrations were non-optimal among the majority of the dropouts. Metformin was prescribed less frequently to the dropouts than is usual for T2D patients. The comorbidities were equally common among the dropouts as among the other T2D patients. KEY POINTS   Which kinds of patients are dropouts from type-2 diabetes care is not known. • One-tenth of the patients with T2D were dropouts and they generally had good glycaemic control. • Blood pressure and LDL cholesterol concentrations were non-optimal among the majority of the dropouts. • Fourteen percent of these dropouts had HbA1c > 9% (75 mmol/mol) and they were more often younger than the other dropouts.

Sex-specific differential in risk of diabetes-related macrovascular outcomes

Reports from recent studies suggest that diabetes confers a higher risk of cardiovascular disease in women compared to men. Larger studies, including meta-analyses, report that women with diabetes have a 44 % greater risk of incident coronary heart disease and a 27 % greater risk of incident stroke compared to men with diabetes. In this article, we summarize results from longitudinal studies that examine sex differences in risk factors for and rates of macrovascular complications from diabetes. We also discuss possible mechanisms for increased cardiovascular risk associated with diabetes in women compared to men, including the clustering of hypertension, obesity, and elevated triglycerides, the possible contribution of hormonal differences, and sex differences in the prescription of and adherence to pharmacologic treatment. In conclusion, diabetes is associated with a slightly higher risk of cardiovascular disease in women compared to men. Future studies should further explore the reasons underlying imperfect use of medications that lower cardiovascular risk in both women and men with diabetes.

Mental health symptoms and patient-reported diabetes symptom burden: implications for medication regimen changes

AIMS

To examine the relative contribution of glycaemic control (HbA1C) and depressive symptoms on diabetes-related symptom burden (hypoglycaemia and hyperglycaemia) in order to guide medication modification.

METHODS

Secondary analysis of medical records data and questionnaires collected from a racially/ethnically diverse sample of adult patients with type 2 diabetes (n = 710) from seven outpatient clinics affiliated with an academic medical centre over a 1-year period as part of the Reducing Racial Disparities in Diabetes: Coached Care (R2D2C2) study.

RESULTS

Results from linear regression analysis revealed that patients with high levels of depressive symptoms had more diabetes-related symptom burden (both hypoglycaemia and hyperglycaemia) than patients with low levels of depressive symptoms (βs = 0.09-0.17, Ps < 0.02). Furthermore, results from two logistic regression analyses suggested that the odds of regimen intensification at 1-year follow-up was marginally associated with patient-reported symptoms of hypoglycaemia [adjusted odds ratio (aOR) = 1.24, 95% CI: 0.98-1.58; P = 0.08] and hyperglycaemia (aOR = 1.21, 95% CI: 1.00-1.46; P = 0.05), after controlling for patients' HbA1C, comorbidity, insulin use and demographics. These associations, however, were diminished for patients with high self-reported hypoglycaemia and high levels of depressive symptoms, but not low depressive symptoms (interaction terms for hypoglycaemia by depressive symptoms, aOR = 0.98, 95% CI: 0.97-0.99; P = 0.03).

CONCLUSIONS

Mental health symptoms are associated with higher levels of patient-reported of diabetes-related symptoms, but the association between diabetes-related symptoms and subsequent regimen modifications is diminished in patients with greater depressive symptoms. Clinicians should focus attention on identifying and treating patients' mental health concerns in order to address the role of diabetes-related symptom burden in guiding physician medication prescribing behaviour.