Sex Differences in the Effect of Type 2 Diabetes on Major Cardiovascular Diseases: Results from a Population-Based Study in Italy

Sex-specific trends in incidence of first myocardial infarction among people with and without diabetes between 1985 and 2016 in a German region

BACKGROUND

The reduction of myocardial infarction (MI) and narrowing the gap between the populations with and without diabetes are important goals of diabetes care. We analyzed time trends for sex-specific incidence rates (IR) of first MI (both non-fatal MI and fatal MI) as well as separately for first non-fatal MI and fatal MI in the population with and without diabetes.

METHODS

Using data from the KORA myocardial infarction registry (Augsburg, Germany), we estimated age-adjusted IR in people with and without diabetes, corresponding relative risks (RR), and time trends from 1985 to 2016 using Poisson regression.

RESULTS

There were 19,683 people with first MI (34% fatal MI, 71% men, 30% with diabetes) between 1985 and 2016. In the entire study population, the IR of first MI decreased from 359 (95% CI: 345-374) to 236 (226-245) per 100,000 person years. In men with diabetes, IR decreased only in 2013-2016. This was due to first non-fatal MI, where IR in men with diabetes increased until 2009-2012, and slightly decreased in 2013-2016. Overall, fatal MI declined stronger than first non-fatal MI corresponding to IRs. The RR of first MI substantially increased among men from 1.40 (1.22-1.61) in 1985-1988 to 2.60 (2.26-2.99) in 1997-2000 and moderately decreased in 2013-2016: RR: 1.75 (1.47-2.09). Among women no consistent time trend for RR was observed. Time trends for RR were similar regarding first non-fatal MI and fatal MI.

CONCLUSIONS

Over the study period, we found a decreased incidence of first MI and fatal MI in the entire study population. The initial increase of first non-fatal MI in men with diabetes needs further research. The gap between populations with and without diabetes remained.

[Diabetes and women, why are we different?]

Diabetes affects men and women differently and the mistaken assumption of equality in its clinical expression can lead to errors and delays in the diagnostic process and the therapeutic strategy adopted. The objective is to show the gender differences that influence the approach to this pathology and what the role of the family doctor is in the monitoring of women with diabetes. It is a review of the impact of diabetes at different stages of a woman's life, how hormonal changes affect glycemic control, gestational diabetes, how diabetes affects the development of chronic complications in women and their consequences, the existing differences in the control of cardiovascular risk factors and the differential aspects by sex of the different families of drugs used in the treatment of diabetes.

Trends in incidence of ischaemic stroke in people with and without diabetes in Ireland 2005-2015

AIMS

We aim to describe the epidemiology of ischaemic stroke and in-hospital mortality associated with stroke among men and women with and without diabetes from 2005 to 2015.

METHODS

Secondary data analysis of national hospital discharge data from the Hospital Inpatient Enquiry database. Stroke incidence and in-hospital mortality rates in people with and without diabetes were calculated. Poisson regression models were used to estimate the incidence rate ratio (IRR) and assess trends over time.

RESULTS

The age-adjusted incidence of stroke was twice as high in people with diabetes compared to those without diabetes (men IRR 2.0 [95% CI 1.95-2.06] and women IRR 2.2 [95% CI 2.12-2.27]). The incidence of ischaemic stroke decreased by an average 1.7% per year in men with diabetes and 3.3% per year in women with diabetes. In people without diabetes, the average annual reduction was smaller (0.2% per year in men and 1% per year in women). In-hospital mortality associated with admission with ischaemic stroke was approximately twice as high in those with diabetes compared to those without diabetes among men [IRR 1.81 (1.67-1.97)] and women [IRR 2 (95% CI 1.84-2.18)].

CONCLUSION

Despite decreases in incidence of ischaemic stroke and associated in-hospital mortality, there remains a twofold increased risk of ischaemic stroke and mortality in people with diabetes. Therefore, priority must be given to management of risk factors for ischaemic stroke in people with diabetes as well as continued development of targeted stroke prevention strategies.

The interaction between CRY1 Polymorphism and Alternative Healthy Eating Index (AHEI) on cardiovascular risk factors in overweight women and women with obesity: a cross-sectional study

BACKGROUND

According to some studies, diet can be interaction with CRY1 polymorphism and may be related to obesity and the risk of cardiovascular diseases (CVD). So, this study examined the interaction between CRY1 polymorphism and AHEI on cardiovascular risk factors in overweight women and women with obesity.

METHODS

This cross-sectional study was performed on 377 Iranian women with overweight and obesity aged 18-48(BMI ≥ 25 kg/m2). Dietary intake was evaluated by the use of a food frequency questionnaire (FFQ) with 147 items. The AHEI was calculated based on previous studies. Anthropometric and biochemical measurements were assessed and the bioelectrical impedance analysis method was used for body analysis. The rs2287161 was genotyped by the restriction fragment length polymorphism (PCR-RFLP) method. Objects were divided into three groups based on rs2287161 genotypes.

RESULTS

Our findings determined that the prevalence of the C allele was 51.9% and the G allele was 48.0%. The mean age and BMI were 36.6 ± 9.1years and 31 ± 4 kg/m2 respectively. After controlling for confounders (BMI, age, total energy intake, and physical activity), this study demonstrated that there was a significant interaction between CC genotype and adherence to AHEI on odds of hyper LDL (OR = 1.94, 95% CI = 1.24-3.05, P for interaction = 0.004), hypertension (OR = 1.80, 95% CI = 1.11-2.93, P for interaction = 0.01) and hyperglycemia (OR = 1.56, 95% CI = 0.98-2.47, P for interaction = 0.05).

CONCLUSIONS

This study indicated that adherence to AHEI can reduce the odds of hyper LDL, hypertension, and hyperglycemia in the CC genotype of rs2287161.

Risk Factors, Use of Preventive Drugs, and Cardiovascular Events in Diabetes Mellitus: The PURE Türkiye Cohort

BACKGROUND

The risk of cardiovascular disease is correlated with the frequency and control of associated risk factors in diabetes mellitus and may vary according to country. We evaluated risk factors for cardiovascular disease, cardiovascular events, and the use of preventive medications in patients with diabetes mellitus using the Prospective Urban and Rural Epidemiological Türkiye cohort.

METHODS

Patients with diabetes mellitus versus without diabetes mellitus were compared for risk factors, cardioprotective drugs (angiotensin-converting enzyme inhibitors or angiotensin-II receptor antagonists, statins, and antiplatelets), and cardiovascular events. The primary outcome was major cardiovascular events (composite of cardiovascular death, myocardial infarction, stroke, or heart failure).

RESULTS

Among 4041 participants, 549 (13.6%) had diabetes mellitus. The mean age (54.8 ± 8.4 vs. 49.3 ± 9.0 years, P <.001) and proportion of women (65.4% vs. 59.9%, P =.014) were higher in diabetics compared with non-diabetics. Hypertension, history of coronary heart disease, and use of statin, antiplatelets, and angiotensin-converting enzyme inhibitors or angiotensin-II receptor antagonists were more common in diabetics; however, the use of these medications at baseline was lower than optimal even in patients with diabetes mellitus and concomitant coronary heart disease (statin 31.2%, antiplatelets 46.9%, and angiotensin-converting enzyme inhibitors or angiotensin-II receptor antagonists 54.7%). During 11.5 years of follow-up, major cardiovascular events occurred in 288 (7.1%) patients, and the risk was higher in diabetics [hazard ratio (95% confidence interval) 1.71 (1.30-2.24); P <.001]. The increase in the risk of future events was comparable for those with diabetes mellitus alone without cardiovascular disease [hazard ratio 1.62 (1.20-2.20)] versus those with cardiovascular disease alone without diabetes mellitus [hazard ratio 1.31 (0.83-2.07)] and was additive in those with both conditions [hazard ratio 2.79 (1.65-4.69)]. The risk of major coronary events (myocardial infarction, angina, percutaneous, or surgical coronary intervention) was also higher in diabetes mellitus [hazard ratio 1.64 (1.26-2.15); P <.001].

CONCLUSION

Patients with diabetes mellitus have a higher risk of major cardiovascular events, and the risk is comparable to that observed in those with cardiovascular disease but no diabetes mellitus. The use of preventive medicines for cardiovascular diseases is disturbingly low in diabetics.

Long-term quality-of-care score for predicting the occurrence of acute myocardial infarction in patients with type 2 diabetes mellitus

BACKGROUND

Cardiovascular disease (CVD) is the leading cause of death globally, and diabetes mellitus (DM) is a well-established risk factor. Among the risk factors for CVD, DM is a major modifiable factor. In the fatal CVD outcomes, acute myocardial infarction (AMI) is the most common cause of death.

AIM

To develop a long-term quality-of-care score for predicting the occurrence of AMI among patients with type 2 DM on the basis of the hypothesis that good quality of care can reduce the risk of AMI in patients with DM.

METHODS

Using Taiwan’s Longitudinal Cohort of Diabetes Patient Database and the medical charts of a medical center, we identified incident patients diagnosed with type 2 DM from 1999 to 2003 and followed them until 2011. We constructed a summary quality-of-care score (with values ranging from 0 to 8) with process indicators (frequencies of HbA_1c and lipid profile testing and urine, foot and retinal examinations), intermediate outcome indicators (low-density lipoprotein, blood pressure and HbA_1c), and co-morbidity of hypertension. The associations between the score and the incidence of AMI were evaluated using Cox regression models.

RESULTS

A total of 7351 patients who had sufficient information to calculate the score were enrolled. In comparison with participants who had scores ≤ 1, those with scores between 2 and 4 had a lower risk of developing AMI [adjusted hazard ratio (AHR) = 0.71; 95% confidence interval (95%CI): 0.55-0.90], and those with scores ≥ 5 had an even lower risk (AHR = 0.37; 95%CI: 0.21-0.66).

CONCLUSION

Good quality of care can reduce the risk of AMI in patients with type 2 DM. The quality-of-care score developed in this study had a significant association with the risk of AMI and thus can be applied to guiding the care for these patients.

Sex-Based Differences in Clinical Profile and Complications among Individuals with Type 2 Diabetes Seen at a Private Tertiary Diabetes Care Centre in India

This study aimed to compare the clinical and biochemical profiles as well as the complications in males and females with type 2 diabetes (T2DM) presenting to a private tertiary diabetes care centre in India. This is a retrospective study, conducted between 1 January 2017 and 31 December 2019, and included 72,980 individuals with T2DM, aged ≥ 18 years (age and sex-matched-males-36,490; females-36,490). Anthropometric measurements, blood pressure, fasting plasma glucose (FPG), post-prandial plasma glucose (PPPG), glycated haemoglobin (HbA1c), lipids, urea, and creatinine were measured. Retinopathy was screened using retinal photography, neuropathy using biothesiometry, nephropathy measuring urinary albumin excretion, peripheral vascular disease (PVD) using Doppler, and coronary artery disease (CAD) based on the history of myocardial infarction and/or drug treatment for CAD and/or electrocardiographic changes. Obesity (73.6% vs. 59.0%) rates were significantly higher in females compared to males. FPG, PPPG, and HbA1c were higher among younger age groups among both sexes, with males having higher values compared to females. However, after the age of 44 years, control of diabetes was worse among females. In addition, only 18.8% of the females achieved glycemic control (HbA1c < 7%) compared to 19.9% in males (p < 0.001). Males had higher prevalence of neuropathy (42.9% vs. 36.9%), retinopathy (36.0% vs. 26.3%), and nephropathy (25.0% vs. 23.3%) compared to females. Males had 1.8- and 1.6-times higher risk of developing CAD and retinopathy compared to females. Hypothyroidism (12.5% vs. 3.5%) and cancers (1.3% vs. 0.6%) were significantly higher in females compared to males. In this large sample of T2DM seen at a chain of private tertiary diabetes centres, females had higher prevalence of metabolic risk factors and poorer diabetes control compared to males, emphasizing the need for better control of diabetes in females. However, males had higher prevalence of neuropathy, retinopathy, nephropathy, and CAD compared to females.

Electrocardiogram abnormalities and renal impairment in patients with type 2 diabetes mellitus: A healthcare facilities-based cross-sectional study in Dang district of Nepal

AIMS/INTRODUCTION

The global burden of diabetes mellitus is rising substantially, with a further increase in cardiovascular and kidney disease burden. These public health problems are highly prevalent in low- and middle-income countries, including Nepal. However, there is limited evidence on cardiac and renal conditions among patients with type 2 diabetes mellitus. We determined the status of electrocardiogram (ECG) abnormalities and renal impairment among patients with type 2 diabetes mellitus in Nepal.

METHODS

We carried out a cross-sectional study in Tulsipur Sub-Metropolitan City of Nepal using a multistage stratified sampling technique to recruit patients with type 2 diabetes mellitus. We used World Health Organization stepwise approach to surveillance (WHO STEPS) questionnaires and carried out resting ECG to collect data of 345 patients with type 2 diabetes mellitus. Logistic regression analysis assessed the factors associated with ECG abnormalities and renal impairment.

RESULTS

The study showed that 6.1% of participants had major ECG abnormalities (95% confidence interval [CI] 3.8-8.6%), which were associated with hypertension (P = 0.01%) and low socioeconomic status (P = 0.01). The proportion of major and/or minor ECG abnormalities was 47.8% (95% CI 40.5-51%), and were significantly associated with age (odds ratio [OR] 1.04, 95% CI 1.01-1.07), higher education (OR 3.50, 95% CI 1.31-9.33), unemployment (OR 3.02, 95% CI 1.08-8.48), body mass index (OR 1.09, 95% CI 1.02-1.17) and duration of type 2 diabetes mellitus >5 years (OR 2.42, 95% CI 1.19-4.93). The proportion of renal impairment was 3.5% (95% CI 1.5-4.5%) which was associated with older age (OR 1.08, 95% CI 1.00-1.17) and hypertension (OR 12.12, 95% CI 1.07-138.22).

CONCLUSION

A significant proportion of patients with type 2 diabetes mellitus had ECG abnormalities and renal impairment, which were significantly associated with hypertension. Therefore, hypertension management and early screening are essential to prevent future cardiorenal complications among patients with type 2 diabetes mellitus.

Impact of Sex and Gender on Clinical Management of Patients with Advanced Chronic Liver Disease and Type 2 Diabetes

Gender differences in the epidemiology, pathophysiological mechanisms and clinical features in chronic liver diseases that may be associated with type 2 diabetes (T2D) have been increasingly reported in recent years. This sexual dimorphism is due to a complex interaction between sex- and gender-related factors, including biological, hormonal, psychological and socio-cultural variables. However, the impact of sex and gender on the management of T2D subjects with liver disease is still unclear. In this regard, sex-related differences deserve careful consideration in pharmacology, aimed at improving drug safety and optimising medical therapy, both in men and women with T2D; moreover, low adherence to and persistence of long-term drug treatment is more common among women. A better understanding of sex- and gender-related differences in this field would provide an opportunity for a tailored diagnostic and therapeutic approach to the management of T2D subjects with chronic liver disease. In this narrative review, we summarized available data on sex- and gender-related differences in chronic liver disease, including metabolic, autoimmune, alcoholic and virus-related forms and their potential evolution towards cirrhosis and/or hepatocarcinoma in T2D subjects, to support their appropriate and personalized clinical management.

Clinical cardiovascular phenotypes and the pattern of future events in patients with type 2 diabetes

IMPORTANCE

Updated guidelines on diabetes recommend targeting sodium-glucose cotransporter-2 inhibitors (SGLT2i) at patients at risk of heart failure (HF) and glucagon-like peptide-1 receptor agonists (GLP1-RA) at those at greater risk of atherothrombotic events.

OBJECTIVE

We estimated the risk of different cardiovascular events in patients with type 2 diabetes (T2D) and newly established cardiovascular disease.

DESIGN, SETTING AND PARTICIPANTS

Patients with T2D and newly established cardiovascular disease from 1998 to 2016 were identified using Danish healthcare registers and divided into one of four phenotype groups: (1) HF, (2) ischemic heart disease (IHD), (3) transient ischemic stroke (TIA)/ischemic stroke, and (4) peripheral artery disease (PAD). The absolute 5-year risk of the first HF- or atherothrombotic event occurring after inclusion was calculated, along with the risk of death.

MAIN OUTCOMES AND MEASURES

The main outcome was the first event of either HF or an atherothrombotic event (IHD, TIA/ischemic stroke or PAD) in patients with T2D and  new-onset cardiovascular disease.

RESULTS

Of the 37,850 patients included, 40% were female and the median age was 70 years. Patients with HF were at higher 5-year risk of a subsequent HF event (17.9%; 95% confidence interval (CI) 17.1-18.8%) than an atherothrombotic event (15.8%; 15.0-16.6%). Patients with IHD were at higher risk of a subsequent atherothrombotic event (24.6%; 23.9-25.3%) than developing HF, although the risk of HF was still substantial (10.6%; 10.2-11.1%). Conversely, patients with PAD were at low risk of developing HF (4.4%; 3.8-5.1%) but at high risk of developing an atherothrombotic event (15.9%; 14.9-17.1%). Patients with TIA/ischemic stroke had the lowest risk of HF (3.2%; 2.9-3.6%) and the highest risk of an atherothrombotic event (20.6%; 19.8-21.4).

CONCLUSIONS

In T2D, a patient's cardiovascular phenotype can help predict the pattern of future cardiovascular events.

The association of Carbohydrate Quality Index with cardiovascular disease risk factors among women with overweight and obesity: A cross-sectional study

Purpose

Diet is one of the most important factors influencing cardiovascular disease (CVD). The negative relationship between carbohydrate intake with lipid profiles and body weight has been previously investigated. However, this is the first study seeking to assess the association of carbohydrate quality index (CQI) with CVD risk factors.

Methods

This cross-sectional study was conducted on 291 Iranian overweight and obese women, with a body mass index (BMI) ranging between 25 and 40 kg/m², and aged 18–48 years. CQI scores were calculated by using a validated 168-item semi-quantitative food frequency questionnaire (FFQ). Biochemical and anthropometric measures were assessed using standard methods, and bioelectrical impedance was used to measure body composition.

Results

We observed that fruits (P < 0.001), vegetables (P < 0.001), and protein (P = 0.002) intake were higher in participants with a higher score of the CQI. When we adjusted for potential confounders, we observed that the CQI was negatively related to systolic blood pressure (SBP) (β = −6.10; 95% CI = −10.11, −2.10; P = 0.003) and DBP (β = −3.11; 95% CI = −6.15, −0.08; P = 0.04). Also, greater adherence to a high CQI dietary pattern, compared to the reference group, was negatively related to HOMA-IR (β = −0.53; 95% CI = −0.94, −0.12) (P for trend = 0.01), WC (β = −3.18; 95% CI = −6.26, −0.10) (P for trend = 0.04), BMI (β = −1.21; 95% CI = −2.50, 0.07) (P for trend = 0.06), and BF (β = −2.06; 95% CI = −3.82, −0.30) (P for trend = 0.02).

Conclusion

In line with previous studies, the CQI was inversely associated with blood pressure, WC, BMI, and BF. Further prospective and clinical trial studies are suggested to confirm these data.

The relationship between body mass index, blood pressure, and atherosclerosis risk factors in type 1 and 2 diabetic patients from northwestern Algeria

Objective. The present work was framed to study the relationship between body mass index (BMI), blood pressure, and atherosclerosis risk factors on the basis of three lipid ratios in type 1 (T1D) and type 2 diabetic (T2D) patients.

Methods. A prospective, comparative, and cross-sectional study was performed at the level of three health facilities in Sidi-Bel-Abbes city (north-western Algeria). Anthropometric parameters, systolic and diastolic blood pressures, and lipid profiles were assessed in adults T1D and T2D patients over a period of eleven months. Individual atherogenic risk factors were estimated based on lipid ratios in relation to corpulence and hypertension.

Results. From the total 237 adult diabetic patients, 90 T1D and 147 T2D ones were involved in the study. Total cholesterol (TC)/high-density lipoprotein (HDL) and triglycerides (TG)/HDL ratios were significantly higher in normal weight T2D comparing to T1D. The TC/HDL ratio was significantly higher (p=0.046) in obese men. Nevertheless, no significant differences were revealed in low-density lipoprotein (LDL)/HDL ratio between T1D and T2D patients. Higher TC/HDL ratios were observed in T2D patients (males and females) with normal blood pressure (systolic blood pressure, SBP ≤13.5 mmHg and diastolic blood pressure, DBP ≤8 mmHg) comparing to T1D patients. Likewise, the LDL/HDL ratio was significantly higher in T2D men with normal DBP (p=0.044).

Conclusion. The lipid ratios constitute good indices while managing diabetes. It is also recommended to screen T1D and T2D patients for hypertension, dyslipidemia, and obesity and initiate the management at early stages to prevent the related complications, such as atherosclerosis, as a priority.

Heterogenicity of diabetes as a risk factor for all-cause mortality after acute myocardial infarction: Age and sex impact

AIM

Type 2 diabetes mellitus (T2DM) is a risk factor for mortality after acute myocardial infarction (AMI). We studied the impact of T2DM related to sex and age on post-AMI long-term mortality.

METHODS

A retrospective study included post-AMI patients. Data were obtained from electronic medical records. We defined the study groups by T2DM, stratified by age-sex.

OUTCOME

up-to-10 years post-discharge all-cause mortality.

RESULTS

16,168 patients were analyzed, 40.3% had T2DM. Ten-year mortality rates were 50.3% with T2DM vs. 33.1% without T2DM, adjHR = 1.622 (p < 0.001). Females (adjHR = 1.085, p = 0.052) and increased age (adjHR = 1.056 for one-year increase, p < 0.001) were associated with a higher risk of mortality (borderline statistical significance for sex). The relationship between T2DM and mortality was stronger in females than in males at < 50 and 60-69 years (p-for-interaction 0.025 and 0.009 respectively), but not for other age groups.

CONCLUSIONS

The study implies heterogeneity in the impact of T2DM on mortality of post-AMI patients, being greater among young patients, particularly females, and no significant impact in octogenarians. That implies that young women with T2DM should have advanced measures for early detection of coronary artery disease and tight control of cardiovascular risk factors to lower the propensity to develop AMI.

Sex differences in the intestinal microbiome: interactions with risk factors for atherosclerosis and cardiovascular disease

Background

There are clearly sex differences in cardiovascular disease. On average, women experience cardiovascular events at an older age, and at any age, women, on average, have less atherosclerotic plaque than men. The role of the human intestinal microbiome in health and disease has garnered significant interest in recent years, and there have been indications of sex differences in the intestinal microbiome. The purpose of this narrative review was to evaluate evidence of sex differences in the interaction between the intestinal microbiome and risk factors for cardiovascular disease. Several studies have demonstrated changes in microbiota composition and metabolic profile as a function of diet, sex hormones, and host metabolism, among other factors. This dysbiosis has consequently been associated with several disease states, including atherosclerosis and cardiovascular disease. In this respect, there is a growing appreciation for the microbiota and its secreted metabolites, including trimethylamine N-oxide (TMAO), derived from intestinal bacterial metabolic pathways involving dietary choline and l-carnitine, as novel risk factors for atherosclerosis and cardiovascular outcomes. Although traditional risk factors for vascular disease have been studied broadly over the years, there exists little research to evaluate interactions of cardiovascular risk factors with a potentially sexually dimorphic intestinal microbiome. This review evaluates the role of sex differences in the composition of the intestinal microbiome, including effects of sex hormones on the microbiome, and the effects of these sex differences on cardiovascular risk factors. Diabetes and obesity exhibit sexual dimorphism, while the data concerning hypertension and dyslipidemia remain inconclusive based on the available literature. In addition, an increased proportion of gram-negative species capable of driving metabolic endotoxemia and a low-grade inflammatory response, as well as decreased numbers of butyrate-producing species, have been observed in relation to traditional vascular risk factors. In this context, circulating SCFAs and TMAO are recognized as key metabolites of the intestinal microbiome that can be readily measured in the blood for the evaluation of metabolic profile.

Conclusion

Novel strategies focused on resolving intestinal dysbiosis as a means to slow progression of atherosclerosis and reduce the risk of cardiovascular disease should be evaluated through a lens of sex differences.

Prevalence of Cardiovascular Disease and Associated Factors Among Type 2 Diabetes Patients in Selected Hospitals of Harari Region, Eastern Ethiopia

Background: Cardiovascular disease (CVD) is the most prevalent complication and the leading cause of death among patients with diabetes mellitus (DM). Type 2 diabetes mellitus (T2DM) patients have a 2- to 4-fold increased risk of CVD. There is a scarcity of data about the magnitude of CVD among patients with diabetes in Ethiopia. This study aimed to assess the prevalence and associated factors of CVD among T2DM patients at selected hospitals of Harari regional state of Ethiopia. Methods: This hospital-based retrospective data review was conducted among T2DM patients on follow-up in the diabetes clinics of selected hospitals of Harari regional state. The records of T2DM patients who have been diagnosed between January 1, 2013, and December 31, 2017, were reviewed from March to April 2018. Data were collected by using structured checklists from all necessary documents of T2DM patients. Statistical analysis was done using STATA 14.1. Bivariate and multivariate logistic regressions were used to identify factors associated with CVD. Result: The records of 454 T2DM patients were extracted from three government hospitals in Harari regional state. Their age was ranging from 15 to 86 years with a mean age (±SD) of 45.39 (14.76). The overall prevalence of CVD among T2DM patients was 42.51%, composed of hypertensive heart diseases (38.99%), heart failure (6.83%), and stroke (2.20%). The final multivariate logistic regression model revealed that age older than 60 years [adjusted odds ratio (AOR) = 3.22; 95% CI: 1.71-6.09], being physically inactive (AOR = 1.45; 95 CI: 1.06-2.38), drinking alcohol (AOR = 2.39; 95% CI: 1.17-6.06), hypertension (AOR = 2.41; 95% CI: 1.52-3.83), body mass index >24.9 kg/m2 (AOR = 1.81; 95% CI: 1.07-3.07), and experiencing microvascular diabetic complications (AOR = 3.62; 95% CI: 2.01-6.53) were significantly associated with the odds of having CVD. Conclusion: The prevalence of CVD was high and associated with advanced age, physical inactivity, drinking alcohol, higher body mass index, hypertension, and having microvascular complications. Health care workers should educate T2DM patients about healthy lifestyles like physical activity, weight reduction, blood pressure control, and alcohol secession, which can reduce the risk of CVD.

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.

Diabetes as a risk factor for incident peripheral arterial disease in women compared to men: a systematic review and meta-analysis

Aims/hypothesis

Previous meta-analyses have suggested that diabetes confers a greater excess risk of coronary heart disease, stroke, vascular dementia, and heart failure in women compared to men. While the underlying mechanism that explains such greater excess risk is unknown, in the current meta-analysis we hypothesized that we would find a similar sex difference in the relationship between diabetes and peripheral arterial disease (PAD).

Methods

PubMed MEDLINE, the Cochrane Database of Systematic Reviews, and Embase were systematically searched for prospective population-based cohort studies, with no restriction on publication date, language, or country. We included studies that reported the relative risk (RR), and its variability, for incident PAD associated with diabetes in both sexes. We excluded studies that did not adjust at least for age, and in which participants had pre-existing PAD. In cases where sex-specific results were not reported, study authors were contacted. Random-effects meta-analyses with inverse variance weighting were used to obtain summary sex-specific RRs and the women: men ratio of RRs for PAD. The Newcastle–Ottawa scale was used to assess study quality.

Results

Data from seven cohorts, totalling 2071,260 participants (49.8% women), were included. The relative risk for incident PAD associated with diabetes compared with no diabetes was 1.96 (95% CI 1.29–2.63) in women and 1.84 (95% CI 1.29–2.86) in men, after adjusting for potential confounders. The multiple-adjusted RR ratio was 1.05 (95% CI 0.90–1.22), with virtually no heterogeneity between studies (I² = 0%). All studies scored 6–8, on the Newcastle–Ottawa scale of 0–9, indicating good quality. Eleven of the 12 studies that met review inclusion criteria did not report sex-specific relative risk, and these data were collected through direct correspondence with the study authors.

Conclusion/interpretation

Consistent with other studies, we found evidence that diabetes is an independent risk factor for PAD. However, in contrast to similar studies of other types of cardiovascular disease, we did not find evidence that diabetes confers a greater excess risk in women compared to men for PAD. More research is needed to explain this sex differential between PAD and other forms of CVD, in the sequelae of diabetes. In addition, we found that very few studies reported the sex-specific relative risk for the association between diabetes and PAD, adding to existing evidence for the need for improved reporting of sex-disaggregated results in cardiovascular disease research.

Diabetes, Glycated Hemoglobin, and the Risk of Myocardial Infarction in Women and Men: A Prospective Cohort Study of the UK Biobank

OBJECTIVE

Diabetes has shown to be a stronger risk factor for myocardial infarction (MI) in women than men. Whether sex differences exist across the glycemic spectrum is unknown. We investigated sex differences in the associations of diabetes status and glycated hemoglobin (HbA1c) with the risk of MI.

RESEARCH DESIGN AND METHODS

Data were used from 471,399 (56% women) individuals without cardiovascular disease (CVD) included in the UK Biobank. Sex-specific incidence rates were calculated by diabetes status and across levels of HbA1c using Poisson regression. Cox proportional hazards analyses estimated sex-specific hazard ratios (HRs) and women-to-men ratios by diabetes status and HbA1c for MI during a mean follow-up of 9 years.

RESULTS

Women had lower incidence rates of MI than men, regardless of diabetes status or HbA1c level. Compared with individuals without diabetes, prediabetes, undiagnosed diabetes, and previously diagnosed diabetes were associated with an increased risk of MI in both sexes. Previously diagnosed diabetes was more strongly associated with MI in women (HR 2.33 [95% CI 1.96; 2.78]) than men (1.81 [1.63; 2.02]), with a women-to-men ratio of HRs of 1.29 (1.05; 1.58). Each 1% higher HbA1c, independent of diabetes status, was associated with an 18% greater risk of MI in both women and men.

CONCLUSIONS

Although the incidence of MI was higher in men than women, the presence of diabetes is associated with a greater excess relative risk of MI in women. However, each 1% higher HbA1c was associated with an 18% greater risk of MI in both women and men.

Diabetes mellitus and risk of new-onset and recurrent heart failure: a systematic review and meta-analysis

Despite mounting evidence of the positive relationship between diabetes mellitus (DM) and heart failure (HF), the entire context of the magnitude of risk for HF in relation to DM remains insufficiently understood. The principal reason is because new‐onset HF (HF occurring in participants without a history of HF) and recurrent HF (HF re‐occurring in patients with a history of HF) are not discriminated. This meta‐analysis aims to comprehensively and separately assess the risk of new‐onset and recurrent HF depending on the presence or absence of DM. We systematically searched cohort studies that examined the relationship between DM and new‐onset or recurrent HF using EMBASE and MEDLINE (from 1 Jan 1950 to 28 Jul 2019). The risk ratio (RR) for HF in individuals with DM compared with those without DM was pooled with a random‐effects model. Seventy‐four and 38 eligible studies presented data on RRs for new‐onset and recurrent HF, respectively. For new‐onset HF, the pooled RR [95% confidence interval (CI)] of 69 studies that examined HF as a whole [i.e. combining HF with preserved ejection fraction (HFpEF) and HF with reduced ejection fraction (HFrEF)] was 2.14 (1.96–2.34). The large between‐study heterogeneity (I² = 99.7%, P < 0.001) was significantly explained by mean age [pooled RR (95% CI) 2.60 (2.38–2.84) for mean age < 60 years vs. pooled RR (95% CI) 1.95 (1.79–2.13) for mean age ≥ 60 years] (P < 0.001). Pooled RRs (95% CI) of seven and eight studies, respectively, that separately examined HFpEF and HFrEF risk were 2.22 (2.02–2.43) for HFpEF and 2.73 (2.71–2.75) for HFrEF. The risk magnitudes between HFpEF and HFrEF were not significantly different in studies that examined both HFpEF and HFrEF risks (P = 0.86). For recurrent HF, pooled RR (95% CI) of the 38 studies was 1.39 (1.33–1.45). The large between‐study heterogeneity (I² = 80.1%, P < 0.001) was significantly explained by the proportion of men [pooled RR (95% CI) 1.53 (1.40–1.68) for < 65% men vs. 1.32 (1.25–1.39) for ≥65% men (P = 0.01)] or the large pooled RR for studies of only participants with HFpEF [pooled RR (95% CI), 1.73 (1.32–2.26) (P = 0.002)]. Results indicate that DM is a significant risk factor for both new‐onset and recurrent HF. It is suggested that the risk magnitude is large for new‐onset HF especially in young populations and for recurrent HF especially in women or individuals with HFpEF. DM is associated with future HFpEF and HFrEF to the same extent.

Obesity and cardiovascular disease in women

As the prevalence of obesity continues to grow worldwide, the health and financial burden of obesity-related comorbidities grows too. Cardiovascular disease (CVD) is clearly associated with increased adiposity. Importantly, women are at higher risk of CVD when obese and insulin resistant, in particular at higher risk of developing heart failure with preserved ejection fraction and ischemic heart disease. Increased aldosterone and mineralocorticoid receptor activation, aberrant estrogenic signaling and elevated levels of androgens are among some of the proposed mechanisms explaining the heightened CVD risk. In addition to traditional cardiovascular risk factors, understanding nontraditional risk factors specific to women, like excess weight gain during pregnancy, preeclampsia, gestational diabetes, and menopause are central to designing personalized interventions aimed to curb the epidemic of CVD. In the present review, we examine the available evidence supporting a differential cardiovascular impact of increased adiposity in women compared with men and the proposed pathophysiological mechanisms behind these differences. We also discuss women-specific cardiovascular risk factors associated with obesity and insulin resistance.

Achievement of cardiovascular risk factor targets according to sex and previous history of cardiovascular disease in type 2 diabetes: A population-based study

AIMS

The main objective was to assess, using real-practice primary care records, the degree of control of cardiovascular risk factor targets. Records were stratified by the presence of previous history or cardiovascular disease (CVD), and sex differences in the fulfillment profile were analyzed.

METHODS

This is a cross-sectional population-based study conducted in Spain. Type 2 diabetes patients over 20 years old (n = 32,638) were identified from primary care electronic health records, and the following information was extracted: glycated hemoglobin (HbA1c), systolic and diastolic blood pressure (SBP and DBP), LDL and HDL cholesterol levels, triglycerides, BMI and smoking history.

RESULTS

Patients with CVD had worse control of HbA1c than patients without it, (HbA1c < 7% 56.9% vs. 61.2%) but better control of BP (<130/80: 43.5% vs 38.2%) and lipids. In the group without prior CVD history, women had worse control of HbA1c, LDL, HDL, BMI and triglycerides and better control of blood pressure and smoking. These differences were maintained or accentuated in the group with previous CVD.

CONCLUSIONS

Women had poorer control of CV risk factors in both groups, and the sex-gap is accentuated in patients with previous CVD.

Diabetes as a risk factor for heart failure in women and men: a systematic review and meta-analysis of 47 cohorts including 12 million individuals

AIMS/HYPOTHESIS

The prevalence of diabetes and heart failure is increasing, and diabetes has been associated with an increased risk of heart failure. However, whether diabetes confers the same excess risk of heart failure in women and men is unknown. The aim of this study was to conduct a comprehensive systematic review with meta-analysis of possible sex differences in the excess risk of heart failure consequent to diabetes. Our null hypothesis was that there is no such sex difference.

METHODS

A systematic search was conducted in PubMed for population-based cohort studies published between January 1966 and November 2018. Studies were selected if they reported sex-specific estimates of RRs for heart failure associated with diabetes, and its associated variability, which were adjusted at least for age. Random-effects meta-analyses with inverse variance weighting were used to obtain pooled sex-specific RRs and women-to-men ratio of RRs (RRRs) for heart failure associated with diabetes.

RESULTS

Data from 47 cohorts, involving 12,142,998 individuals and 253,260 heart failure events, were included. The pooled multiple-adjusted RR for heart failure associated with type 1 diabetes was 5.15 (95% CI 3.43, 7.74) in women and 3.47 (2.57, 4.69) in men, leading to an RRR of 1.47 (1.44, 1.90). Corresponding pooled RRs for heart failure associated with type 2 diabetes were 1.95 (1.70, 2.22) in women and 1.74 (1.55, 1.95) in men, with a pooled RRR of 1.09 (1.05, 1.13).

CONCLUSIONS/INTERPRETATION

The excess risk of heart failure associated with diabetes is significantly greater in women with diabetes than in men with diabetes. PROSPERO registration: CRD42019135246.

Social inequality and diabetes mellitus - developments over time among the adult population in Germany

The connection between social disadvantage and the presence of known diabetes and specific risk factors is well documented. This article summarises the results from the Robert Koch Institute examination surveys that were conducted between 1997 and 1999 as well as 2008 and 2011 to address social inequality – operationalised by level of education – with regard to prevalences of known and unknown diabetes, risk of diabetes and care of diabetes as well as their development over time. Both survey periods showed that the low education group has higher prevalences of known and unkown diabetes as well as a higher risk of developing diabetes within the next five years compared to the medium and high education group. Over time, prevalence tended to increase for known diabetes and to decrease for unknown diabetes for all education groups. For the 5-year diabetes risk, only the high education group showed a clear decrease over time. The chosen indicators of diabetes care indicated no clear differences between education groups and an improvement of diabetes care over time. For some indicators of care (foot examination, statins), improvements were only seen in the low education group. In conclusion, social inequalities in the prevalence of known and unknown diabetes as well as in diabetes risk remain in Germany; for the indicators of care, however, no clear education gradient is evident. Over time, inequality regarding the prevalence of diabetes has not increased further. However, with regard to diabetes risk, inequality has become slightly more evident. For individual care indicators, improvements are limited to specific education groups.

Prevalence of diabetes and its effects on stroke outcomes: A meta-analysis and literature review

AIMS/INTRODUCTION

Diabetes mellitus is an established risk factor for stroke and maybe associated with poorer outcomes after stroke. The aims of the present literature review were to determine: (i) the prevalence of diabetes in acute stroke patients through a meta-analysis; (ii) the association between diabetes and outcomes after ischemic and hemorrhagic stroke; and (iii) to review the value of glycated hemoglobin and admission glucose-based tests in predicting stroke outcomes.

MATERIALS AND METHODS

Ovid MEDLINE and EMBASE searches were carried out to find studies relating to diabetes and inpatient stroke populations published between January 2004 and April 2017. A meta-analysis of the prevalence of diabetes from included studies was undertaken. A narrative review on the associations of diabetes and different diagnostic methods on stroke outcomes was carried out.

RESULTS

A total of 66 eligible articles met inclusion criteria. A meta-analysis of 39 studies (n = 359,783) estimated the prevalence of diabetes to be 28% (95% confidence interval 26-31). The rate was higher in ischemic (33%, 95% confidence interval 28-38) compared with hemorrhagic stroke (26%, 95% confidence interval 19-33) inpatients. Most, but not all, studies found that acute hyperglycemia and diabetes were associated with poorer outcomes after ischemic or hemorrhagic strokes: including higher mortality, poorer neurological and functional outcomes, longer hospital stay, higher readmission rates, and stroke recurrence. Diagnostic methods for establishing diagnosis were heterogeneous between the reviewed studies.

CONCLUSIONS

Approximately one-third of all stroke patients have diabetes. Uniform methods to screen for diabetes after stroke are required to identify individuals with diabetes to design interventions aimed at reducing poor outcomes in this high-risk population.

Sex differences in risk factors for myocardial infarction: cohort study of UK Biobank participants

OBJECTIVES

To investigate sex differences in risk factors for incident myocardial infarction (MI) and whether they vary with age.

DESIGN

Prospective population based study.

SETTING

UK Biobank.

PARTICIPANTS

471 998 participants (56% women; mean age 56.2) with no history of cardiovascular disease.

MAIN OUTCOME MEASURE

Incident (fatal and non-fatal) MI.

RESULTS

5081 participants (1463 (28.8%) of whom were women) had MI over seven years' mean follow-up, resulting in an incidence per 10 000 person years of 7.76 (95% confidence interval 7.37 to 8.16) for women and 24.35 (23.57 to 25.16) for men. Higher blood pressure indices, smoking intensity, body mass index, and the presence of diabetes were associated with an increased risk of MI in men and women, but associations were attenuated with age. In women, systolic blood pressure and hypertension, smoking status and intensity, and diabetes were associated with higher hazard ratios for MI compared with men: ratio of hazard ratios 1.09 (95% confidence interval 1.02 to 1.16) for systolic blood pressure, 1.55 (1.32 to 1.83) for current smoking, 2.91 (1.56 to 5.45) for type 1 diabetes, and 1.47 (1.16 to 1.87) for type 2 diabetes. There was no evidence that any of these ratios of hazard ratios decreased with age (P>0.2). With the exception of type 1 diabetes, the incidence of MI was higher in men than in women for all risk factors.

CONCLUSIONS

Although the incidence of MI was higher in men than in women, several risk factors were more strongly associated with MI in women compared with men. Sex specific associations between risk factors and MI declined with age, but, where it occurred, the higher relative risk in women remained. As the population ages and the prevalence of lifestyle associated risk factors increase, the incidence of MI in women will likely become more similar to that in men.

Diabetes mellitus, blood glucose and the risk of heart failure: A systematic review and meta-analysis of prospective studies

BACKGROUND AND AIM

The strength of the association between diabetes and risk of heart failure has differed between previous studies and the available studies have not been summarized in a meta-analysis. We therefore quantified the association between diabetes and blood glucose and heart failure in a systematic review and meta-analysis.

METHODS AND RESULTS

PubMed and Embase databases were searched up to May 3rd 2018. Prospective studies on diabetes mellitus or blood glucose and heart failure risk were included. A random effects model was used to calculate summary relative risks (RRs) and 95% confidence intervals (CIs). Seventy seven studies were included. Among the population-based prospective studies, the summary RR for individuals with diabetes vs. no diabetes was 2.06 (95% CIs: 1.73-2.46, I² = 99.8%, n = 30 studies, 401495 cases, 21416780 participants). The summary RR was 1.23 (95% CI: 1.15-1.32, I² = 78.2%, n = 10, 5344 cases, 91758 participants) per 20 mg/dl increase in blood glucose and there was evidence of a J-shaped association with nadir around 90 mg/dl and increased risk even within the pre-diabetic blood glucose range. Among the patient-based studies the summary RR was 1.69 (95% CI: 1.57-1.81, I² = 85.5%, p_{heterogeneity}<0.0001) for diabetes vs. no diabetes (n = 41, 100284 cases and >613925 participants) and 1.25 (95% CI: 0.89-1.75, I² = 95.6%, p_{heterogeneity}<0.0001) per 20 mg/dl increase in blood glucose (1016 cases, 34309 participants, n = 2). In the analyses of diabetes and heart failure there was low or no heterogeneity among the population-based studies that adjusted for alcohol intake and physical activity and among the patient-based studies there was no heterogeneity among studies with ≥10 years follow-up.

CONCLUSIONS

These results suggest that individuals with diabetes are at an increased risk of developing heart failure and there is evidence of increased risk even within the pre-diabetic range of blood glucose.

Does self-efficacy in diabetes management differ by type of diabetes and gender? Results from network analysis

This study aims to analyze the correlations and relevance of self-efficacy items in 411 patients with diabetes using network analysis. We found that the self-efficacy items structure is consistent between genders and types of diabetes. However, the strength of item correlations was significantly higher in type 2 diabetes. The items central to the network were following a regular diet in type 2 diabetes and adjusting diet when ill in type 1 diabetes. No significant gender differences were found. Knowledge of the most central aspects of self-efficacy and their interconnections can help clinicians to target psychoeducational interventions aimed at empowering patients.

Dietary Advanced Glycation End Products Have Sex- and Age-Dependent Effects on Vertebral Bone Microstructure and Mechanical Function in Mice

Back pain is a leading cause of global disability that can arise from vertebral fracture and osteoporosis. Although poor general health and obesity are among the strongest risk factors for back pain, there is remarkably little known about how diet influences spinal diseases. Advanced glycation end-products (AGEs) are implicated in increased fracture risk, yet no studies investigated how dietary AGEs affect spinal health. We tested the hypothesis that high dietary AGE ingestion will diminish vertebral structure and function in a sex- and age-dependent manner. Female and male mice were fed low-AGE (L-AGE) or high-AGE (H-AGE) isocaloric diets for 6 and 18 months and multiple measurements of bone structure and function were taken. AGE levels in serum and cortical vertebrae were increased only for 6-month-old H-AGE female mice while blood glucose and body weight remained normal for all animals. When fed an H-AGE diet, 6-month-old female mice had inferior vertebral trabecular structure with decreased bone mineral density (BMD) and bone volume fraction. Biomechanical testing and analytical modeling further showed functional deterioration in 6-month-old H-AGE females with reduced shear and compression moduli, and maximum load to failure. At 18 months, H-AGE mice of both sexes had significant but small decreases in cortical BMD and thickness, yet functional biomechanical behaviors were not distinguishable from other aging changes. We conclude that an H-AGE diet, without diabetic or overweight conditions, diminished vertebral microstructure, mechanical behaviors, and fracture resistance in young female mice in a manner suggesting accelerated bone aging. © 2017 American Society for Bone and Mineral Research.

Gender differences in hospital admissions for major cardiovascular events and procedures in people with and without diabetes in England: a nationwide study 2004-2014

Background

Secondary prevention of cardiovascular disease (CVD) has improved immensely during the past decade but controversies persist on cardiovascular benefits among women with diabetes. We investigated 11-year trends in hospital admission rates for acute myocardial infarction (AMI), stroke, percutaneous coronary intervention (PCI), and coronary artery bypass graft (CABG) in people with and without diabetes by gender in England.

Methods

We identified all hospital admissions for cardiovascular disease causes among people aged 17 years and above between 2004 and 2014 in England. We calculated diabetes-specific and non-diabetes-specific rates for study outcomes by gender. To assess temporal changes, we fitted negative binomial regression models.

Results

Diabetes-related admission rates remained unchanged for AMI (incidence rate ratio (IRR) 0.99 [95% CI 0.98–1.01]), increased for stroke by 2% (1.02 [1.01–1.03]) and PCI by 3% (1.03 [1.01–1.04]) and declined for CABG by 3% (0.97 [0.96–0.98]) annually. Trends did not differ significantly by diabetes status. Women with diabetes had significantly lower rates of AMI (IRR 0.46 [95% CI 0.40–0.53]) and stroke (0.73 [0.63–0.84]) compared with men with diabetes. However, gender differences in admission rates for AMI attenuated in diabetes compared with the non-diabetic group. While diabetes tripled admission rates for AMI in men (IRR 3.15 [95% CI 2.72–3.64]), it increased it by over fourfold among women (4.27 [3.78–4.93]). Furthermore, while the presence of diabetes was associated with a threefold increased rates for PCI and fivefold increased rates for CABG (IRR 3.14 [2.83–3.48] and 5.01 [4.59–5.05], respectively) in men, among women diabetes was associated with a 4.4-fold increased admission rates for PCI and 6.2-fold increased rates for CABG (4.37 [3.93–4.85] and 6.24 [5.66–6.88], respectively). Proportional changes in rates were similar in men and women for all study outcomes, leaving the relative risk of admissions unchanged.

Conclusions

Diabetes still confers a greater increase in risk of hospital admission for AMI in women relative to men. However, the absolute risk remains higher in men. These results call for intensified CVD risk factor management among people with diabetes, consideration of gender-specific treatment targets and treatment intensity to be aligned with levels of CVD risk.