Sex differences in cardiometabolic risk factors, pharmacological treatment and risk factor control in type 2 diabetes: findings from the Dutch Diabetes Pearl cohort

Sex differences in risk of incident microvascular and macrovascular complications: a population-based data-linkage study among 25 713 people with diabetes

BACKGROUND

The global prevalence of diabetes is similar in men and women; however, there is conflicting evidence regarding sex differences in diabetes-related complications. The aim of this study was to investigate sex differences in incident microvascular and macrovascular complications among adults with diabetes.

METHODS

This prospective cohort study linked data from the 45 and Up Study, Australia, to administrative health records. The study sample included 25 713 individuals (57% men), aged ≥45 years, with diabetes at baseline. Incident cardiovascular disease (CVD), eye, lower limb, and kidney complications were determined using hospitalisation data and claims for medical services. Multivariable Cox proportional hazards models were used to assess the association between sex and incident complications.

RESULTS

Age-adjusted incidence rates per 1000 person years for CVD, eye, lower limb, and kidney complications were 37, 52, 21, and 32, respectively. Men had a greater risk of CVD (adjusted hazard ratio (aHR) 1.51, 95% CI 1.43 to 1.59), lower limb (aHR 1.47, 95% CI 1.38 to 1.57), and kidney complications (aHR 1.55, 95% CI 1.47 to 1.64) than women, and a greater risk of diabetic retinopathy (aHR 1.14, 95% CI 1.03 to 1.26). Over 10 years, 44%, 57%, 25%, and 35% of men experienced a CVD, eye, lower limb, or kidney complication, respectively, compared with 31%, 61%, 18%, and 25% of women. Diabetes duration (<10 years vs ≥10 years) had no substantial effect on sex differences in complications.

CONCLUSIONS

Men with diabetes are at greater risk of complications, irrespective of diabetes duration. High rates of complications in both sexes highlight the importance of targeted complication screening and prevention strategies from diagnosis.

Clinical characteristics and degree of cardiovascular risk factor control in patients with newly-diagnosed type 2 diabetes in Catalonia

Introduction

Women with type 2 diabetes mellitus (T2DM) face a greater risk of cardiovascular disease (CVD) and encounter challenges in managing cardiovascular risk factors (CVRF); however, limited data are available in individuals with newlydiagnosed T2DM.

Methods

This study aimed to examine differences between women and men at the onset of T2DM in terms of clinical characteristics, glycaemic status, and CVRF management. This was a retrospective cohort study including subjects with newly-diagnosed T2DM from the System for the Development of Research in Primary Care (SIDIAP) database in Catalonia (Spain). Sex differences (Dif) were assessed at baseline and 1-year post-diagnosis, by calculating the absolute difference of means or proportions.

Results

A total of 13,629 subjects with newly-diagnosed T2DM were analyzed. Women were older and had a higher BMI than men. At baseline, women had higher total cholesterol [Dif (95%CI) 10 mg/dL (9.1/10.8)] and low-density lipoprotein cholesterol (LDL-c) [Dif (95%CI) 7 mg/dL (6.3/7.7)], while men had higher rates of smoking and alcohol intake. Lipid target achievement was lower in women, in both primary prevention (LDL-c < 100 mg/dL) [Dif (95%CI) -7.3 mg/dL (-10.5/-4.1)] and secondary prevention (LDL-c < 70 mg/dL) [Dif (95%CI) -8.3 mg/dL (-17.3/0.7)], along with lower statin and antiplatelet prescriptions, especially one year after diagnosis. Changes in clinical and laboratory data one year post-diagnosis revealed that, in the primary prevention group, men experienced greater improvements in total cholesterol, LDL-c and triglycerides, while women had less success in achieving CVRF control targets compared to men. Additionally, cardiovascular events, such as coronary artery disease and peripheral artery disease increased more in men than in women within the first year of diagnosis, especially in primary prevention subjects.

Conclusion

Differences between men and women CVRF are already apparent at the onset of T2DM, particularly in primary prevention, with notable differences in lipid profile and target level attainment.

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.

Achievement of treatment targets among patients with type 2 diabetes in 2015 and 2020 in Canadian primary care

BACKGROUND

An update on the degree to which patients with type 2 diabetes in Canada achieve treatment targets is needed to document progress and identify subgroups that need attention. We sought to estimate the frequency with which patients managed in primary care met treatment targets (i.e., HbA_1c ≤ 7.0%, blood pressure < 130/80 mm Hg and low-density lipoprotein cholesterol [LDL-C] < 2.00 mmol/L), guideline-based use of statins and of angiotensin-convertingenzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs), and the effects of patient age and sex.

METHODS

We conducted a cross-sectional study of 32 503 and 44 930 adults with diabetes in Canada on June 30, 2015, and 2020, respectively, using electronic medical record data from primary care practices across 5 provinces. We grouped achievement of diabetes targets by age and sex, and compared between groups using logistic regression with adjustment for cardiovascular comorbidities.

RESULTS

In 2020, target HbA_1c levels were achieved for 63.8% of women and 58.9% of men. Blood pressure and LDL-C targets were achieved for 45.6% and 45.8% of women, and for 43.1% and 59.4% of men, respectively. All 3 treatment targets were achieved for 13.3% of women and 16.5% of men. Overall, 45.3% and 54.0% of women and men, respectively, used statins; 46.5% of women used ACE inhibitors or ARBs, compared with 51.9% of men. With the exception of blood pressure and HbA_1c levels among women, target achievement was lower among younger patients. Achievement of the LDL-C target, statin use and ACE inhibitor or ARB use were lower among women at any age. From 2015 to 2020, target achievement increased for HbA_1c, remained consistent for LDL-C and declined for blood pressure; use of statins and of ACE inhibitors or ARBs also declined.

INTERPRETATION

Target achievement for blood pressure and use of statins and of ACE inhibitors and ARBs declined between 2015 and 2020, and was suboptimal in all patient groups. Widespread quality improvement is needed to increase evidence-based therapy for people with diabetes.

Long-Term Effects of Anxiety on the Metabolic Control of Recently Diagnosed Type 2 Diabetes Patients: Results from the CAIPaDi Cohort Study

INTRODUCTION

Anxiety disorders (AXD) are among the most prevalent mental health conditions in patients with type 2 diabetes (T2D). Previous data have established an association of other psychiatric conditions with poor metabolic control and increased odds of diabetes-related complications. Nonetheless, follow-up information about the effects of AXD on the metabolic control of patients with TD2 is still limited.

OBJECTIVE

Evaluate the effects of AXD on the metabolic parameters of patients with T2D over 12 months of follow-up in a multidisciplinary comprehensive care model.

METHODS

Prospective study of T2D subjects enrolled in a comprehensive care program with follow-up at 3 and 12 months of treatment. Patients were assessed using the Mini-International Neuropsychiatric Interview and the Hospital Anxiety and Depression Scale (HADS). We registered clinical and metabolic characteristics from each visit. Metabolic parameters over time were analyzed with a mixed model of repeated measures using AXD and time as interaction variables.

RESULTS

Our sample included 2703 patients at baseline, and 1161 (43%) subjects continued the follow-up at 12 months. The AXD group had more females, lower age, and fewer years of formal education compared with subjects without AXD at baseline, 3 and 12 months. Patients with AXD also reported higher mean fasting glucose at three months, and higher HbA1c at three and 12 months. Our MMRM for HbA1c reported significant differences over time in subjects with and without AXD. The differences in means between groups increased from 0.17% at three months to 0.31% at 12 months. The variables from the HADS anxiety score, sex, age, years of diagnosis, and insulin treatment were also associated with HbA1c parameters over time.

CONCLUSION

Patients with AXD had the worst glycemic control at 3 and 12 months of follow-up. HbA1c differences in patients with AXD compared with non-AXD subjects increases over time in association with anxiety symptoms.

The Socio-Economic Cost of Diabetes Mellitus in Korea Using National Health Insurance Claim Data, 2017

(1) Purpose: As the economy develops and lifestyles become more westernized, diabetes is on the rise in Korea. This study tried to measure the socio-economic cost of diabetes by estimating the direct medical expenses and indirect costs used in Korea during the year due to diabetes mellitus. (2) Methods: This study extracted the insurance claim records from the Korea National Health Insurance claim database to determine the healthcare services provided to patients with diabetes mellitus in 2017. The total diabetes mellitus-related cost was the sum of the direct medical care costs: the costs paid by insurers and patients, the non-covered care costs and the prescribed pharmaceuticals costs, and also the direct non-medical care costs: the transportation costs for visits in outpatients and inpatients and the guardian’s cost for hospitalized patients, as well as the indirect cost: lost productivity. (3) Findings: The total socio-economic cost of diabetic patients in 2017 measured in this study was KRW 3.2 trillion, of which 48.3% was used for medical expenses, 10% was non-medical expenses, and 41.7% was estimated as indirect expenses. (4) Implications: Korea is considered to be aging significantly, and it is considered that more attention should be paid to reducing medical expenses through diabetes management.

Sex-Specific Associations of Diabetes With Brain Structure and Function in a Geriatric Population

Introduction

Globally, women with dementia have a higher disease burden than men with dementia. In addition, women with diabetes especially are at higher risk for cognitive impairment and dementia compared to men with diabetes. Differences in the influence of diabetes on the cerebral vasculature and brain structure may contribute to these sex-specific differences. We examined sex-specific patterns in the relationship between diabetes and brain structure, as well as diabetes and cognitive function.

Methods

In total, 893 patients [age 79 ± 6.6 years, 446 (50%) women] from the Amsterdam Ageing Cohort with available data on brain structures (assessed by an MRI or CT scan) and cognitive function were included. All patients underwent a thorough standardized clinical and neuropsychological assessment (including tests on memory, executive functioning, processing speed, language). Brain structure abnormalities were quantified using visual scales.

Results

Cross-sectional multivariable regression analyses showed that diabetes was associated with increased incidence of cerebral lacunes and brain atrophy in women (OR 2.18 (1.00–4.72) but not in men. Furthermore, diabetes was associated with decreased executive function, processing speed and language in women [B −0.07 (0.00–0.13), −0.06 (0.02–0.10) and −0.07 (0.01–0.12) resp.] but not in men.

Conclusions

Diabetes is related to increased risk of having lacunes, brain atrophy and impaired cognitive function in women but not in men. Further research is required to understand the time trajectory leading up to these changes and to understand the mechanisms behind them in order to improve preventive health care for both sexes.

Sex Differences in Cardiovascular Prevention in Type 2: Diabetes in a Real-World Practice Database

Women with type 2 diabetes mellitus (T2DM) have a 40% excess risk of cardiovascular diseases (CVD) compared to men due to the interaction between sex and gender factors in the development, risk, and outcomes of the disease. Our aim was to assess differences between women and men with T2DM in the management and degree of control of cardiovascular risk factors (CVRF). This was a matched cross-sectional study including 140,906 T2DM subjects without previous CVD and 39,186 T2DM subjects with prior CVD obtained from the System for the Development of Research in Primary Care (SIDIAP) database. The absolute and relative differences between means or proportions were calculated to assess sex differences. T2DM women without previous CVD showed higher levels of total cholesterol (12.13 mg/dL (0.31 mmol/L); 95% CI = 11.9−12.4) and low-density lipoprotein cholesterol (LDL-c; 5.50 mg/dL (0.14 mmol/L); 95% CI = 5.3−5.7) than men. The recommended LDL-c target was less frequently achieved by women as it was the simultaneous control of different CVRF. In secondary prevention, women showed higher levels of total cholesterol (16.89 mg/dL (0.44 mmol/L); 95% CI = 16.5−17.3), higher levels of LDL-c (8.42 mg/dL (0.22 mmol/L); 95% CI = 8.1−8.8), and higher levels of triglycerides (11.34 mg/dL (0.13 mmol/L); 95% CI = 10.3−12.4) despite similar rates of statin prescription. Recommended targets were less often achieved by women, especially LDL-c < 100 mg/dL (2.59 mmol/L). The composite control was 22% less frequent in women than men. In conclusion, there were substantial sex differences in CVRF management of people with diabetes, with women less likely than men to be on LDL-c target, mainly those in secondary prevention. This could be related to the treatment gap between genders.

Association of fruit and vegetable color with incident diabetes and cardiometabolic risk biomarkers in the United States Hispanic/Latino population

Background

Color groups of fruits and vegetables (FV) are part of a healthy diet, but evidence for an association with cardiometabolic outcomes is inconsistent.

Objective

To examine the association between intake of FV of different colors with incident diabetes and cardiometabolic risk biomarkers among U.S. Hispanics/Latinos.

Subjects/methods

We used data from 9206 adults ages 18–74 years who were free of diabetes at baseline (2008–2011) and had follow-up data at visit 2 (2014–2017) in the Hispanic Community Health Study/Study of Latinos (HCHS/SOL), a multicenter, prospective cohort study of self-identified Hispanics/Latinos. Dietary intake was assessed using two 24 h recalls at baseline. FV were categorized into five color groups: green, white, yellow/orange, red/purple, and uncategorized. Diabetes was defined based on laboratory measures and self-reported antihyperglycemic medication. We used survey logistic regression models to evaluate the association between FV color groups and incident diabetes and survey linear regression models to evaluate the association of FV color groups with cardiometabolic risk biomarkers at visit 2.

Results

During ~6 years of follow-up, 970 incident cases of diabetes were documented. The red/purple FV color group was the least consumed (0.21 servings/day), whereas white FV were the most consumed (0.92 servings/day). For each serving of total FV intake, body mass index (BMI) was lower by 0.24% (p = 0.03) and insulin by 0.69% (p = 0.03). For each serving of red/purple FV intake, HDL was 1.59% higher (p = 0.04). For each serving of white FV intake (with potato), post-OGTT was 0.83% lower (p = 0.04) and triglycerides 1.43% lower (p = 0.04). There was no association between FV intake and incident diabetes.

Conclusions

Specific FV colors were associated with cardiometabolic benefits though the associations were of relatively small magnitudes. Dietary recommendations could consider varying colors of FV intake, especially white and red/purple color groups, for a healthy diet.

Sex differences in the association between diabetes and hypertension and the risk of stroke: cohort of the Tehran Lipid and Glucose Study

Background

We assessed the sex differences in the association between blood pressure categories and glucose intolerance status with overall and ischemic stroke among Iranian adults.

Methods

This prospective study was conducted on 5349 individuals (2446 men) aged ≥ 40 years. Cox models were used to estimate adjusted hazard ratios (HRs) and men-to-women ratios of HRs (RHRs) of overall and ischemic stroke for systolic (SBP) and diastolic (DBP) blood pressure, pre-hypertension, hypertension, fasting plasma glucose (FPG), pre-diabetes and type 2 diabetes (T2D).

Results

Each 0.55 mmol/L increase in FPG was associated with a higher HR of overall stroke in men than women [RHRs 1.05 (1.01–1.09)]. The associations between each 10 mmHg increase in DBP and stroke events were stronger in men than women, with RHRs of 1.20 (1.00–1.45) and 1.29 (1.04–1.60) for overall and ischemic stroke, respectively. Hypertension was associated with a higher HR of overall [RHRs: 2.41 (1.21–4.8)] and ischemic stroke [2.37 (1.12–5.01)] in men than women. We also found that T2D was associated with higher risks of overall and ischemic stroke in men than women: the RHRs were 2.16 (1.24–3.75) and 1.93 (1.05–3.55) for overall and ischemic stroke, respectively.

Conclusion

Hypertension and T2D induced higher risk of overall and ischemic stroke in men than women among Iranian population.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13293-022-00421-7.

The associations between diastolic blood pressure and stroke events were stronger in men than women.

The fasting blood plasma level was associated with higher risk of stroke events in men than women.

Hypertension and diabetes were associated with higher risk of stroke events in men than women.

The association between systolic blood pressure with ischemic stroke was higher in men than women.

Healthy eating index patterns in adults by sex and age predict cardiometabolic risk factors in a cross-sectional study

BACKGROUND

Associations between diet and cardiometabolic disease (CMD) risk may vary in men and women owing to sex differences in eating habits and physiology. The current secondary analysis sought to determine the ability of sex differences in dietary patterns to discriminate groups with or without CMD risk factors (CMDrf) in the adult population and if this was influenced by age.

METHODS

Diet patterns and quality were evaluated using 24 h recall-based Healthy Eating Index (HEI-2015) in free-living apparently healthy men (n = 184) and women (n = 209) 18-65 y of age with BMIs of 18-44 kg/m2. Participants were stratified into low- and high-CMDrf groups based on the presence/absence of at least one CMDrf: BMI > 25 kg/m2; fasting triglycerides > 150 mg/dL; HDL cholesterol < 50 mg/dL-women or < 40 mg/dL-men; HOMA > 2; HbA1c > 5.7. Sex by age dietary patterns were stratified by multivariate analyses, with metabolic variable associations established by stepwise discriminant analysis.

RESULTS

Diet quality increased with age in both sexes (P < 0.01), while women showed higher fruit, vegetable and saturated fat intake as a percentage of total energy (P < 0.05). The total-HEI score (i.e. diet quality) was lower in the high-CMDrf group (P = 0.01), however, diet quality parameters predicted CMDrf presence more accurately when separated by sex. Lower 'total vegetable' intake in the high-CMDrf group in both sexes, while high-CMDrf men also had lower 'total vegetables', 'greens and beans' intake, and high-CMDrf women had lower 'total fruits', 'whole-fruits', 'total vegetables', 'seafood and plant-proteins', 'fatty acids', and 'saturated fats' intakes (P < 0.05). Moreover, 'dairy' intake was higher in high-CMDrf women but not in men (sex by 'dairy' interaction P = 0.01). Sex by age diet pattern models predicted CMDrf with a 93 and 89% sensitivity and 84 and 92% specificity in women and men, respectively.

CONCLUSIONS

Sex and age differences in dietary patterns classified participants with and without accepted CMDrfs, supporting an association between specific diet components and CMD risk that differs by sex. Including sex specific dietary patterns into health assessments may provide targeted nutritional guidance to reduce the burden of cardiovascular disease.

TRIAL REGISTRATION

ClinicalTrials.gov : NCT02367287 . ClinicalTrials.gov : NCT02298725 .

Sex Differences in Lipid Profile across the Life Span in Patients with Type 2 Diabetes: A Primary Care-Based Study

We assessed sex differences across the life span in the lipid profile of type 2 diabetes (T2D) patients treated and not treated with statins. We used the Groningen Initiative to ANalyze Type 2 diabetes Treatment database, which includes T2D patients from the north of the Netherlands. Patients with a full lipid profile determined between 2010 and 2012 were included. We excluded patients treated with other lipid-lowering drugs than statins. Sex differences in low- and high-density lipoprotein cholesterol (LDL-c and HDL-c) and triglyceride (TG) levels across 11 age groups stratified by statin treatment were assessed using linear regression. We included 26,849 patients (51% women, 55% treated with statins). Without statins, women had significantly lower LDL-c levels than men before the age of 45 years, similar levels between 45 and 49 years, and higher levels thereafter. With statins, similar LDL-c levels were shown up to the age of 55, and higher levels in women thereafter. Women had significantly higher HDL-c levels than men, regardless of age or statin treatment. Men had significantly higher TG levels up to the age of 55 and 60, depending on whether they did not take or took statins, respectively, and similar levels thereafter. When managing cardiovascular risk in patients with T2D, attention is needed for the menopausal status of women and for TG levels in younger men.

Sex and ethnic differences in the cardiovascular complications of type 2 diabetes

Diabetes mellitus represents a global health concern affecting 463 million adults and is projected to rapidly rise to 700 million people by 2045. Amongst those with type 2 diabetes (T2D), there are recognised differences in the impact of the disease on different sex and ethnic groups. The relative risk of cardiovascular complications between individuals with and without T2D is higher in females than males. People of South Asian heritage are two to four times more likely to develop T2D than white people, but conversely not more likely to experience cardiovascular complications. Differences in the pathophysiological responses in these groups may identify potential areas for intervention beyond glycaemic control. In this review, we highlight key differences of diabetes-associated cardiovascular complications by sex and ethnic background, with a particular emphasis on South Asians. Evidence assessing therapeutic efficacy of new glucose lowering drugs in minority groups is limited and many major cardiovascular outcomes trials do not report ethnic specific data. Conversely, lifestyle intervention and bariatric surgery appear to have similar benefits regardless of sex and ethnic groups. We encourage future studies with better representation of women and ethnic minorities that will provide valuable data to allow better risk stratification and tailored prevention and management strategies to improve cardiovascular outcomes in T2D.