Men, Women, and Diabetes: Same Disease, Different Clinical Course

Type 2 diabetes (T2DM) occurs at roughly the same prevalence in men and women. Despite the similar prevalence in the sexes, women who develop diabetes feel the effect of its complications disproportionately. They are less likely to reach HbA1c goals than men, and they die of diabetes-related causes more often. Diabetes predisposes both sexes to cardiovascular disease, but healthcare interventions have reaped improved outcomes in men recently. In women, there’s been no change. Researchers have been unable to pinpoint differences in physiology, treatment response, or psychology that might be responsible for the differences. Guidelines, with no evidence to tailor care, present recommendations without regard to sex.

The journal Diabetes, Metabolic Syndrome and Obesity: Targets and Therapy includes a review of sex differences in T2DM in its September 2014 issue. In it, reviewers from Karolinska Institutet, in Stockholm, Sweden, discuss existing literature on sex differences in diabetes and known hormonal pathophysiology that may affect diabetes presentation and prognosis.

Several of their findings are of general significance:

• When screening women, clinicians may miss T2DM if they rely on fasting plasma glucose rather than fasting plasma glucose augmented with an oral glucose tolerance test.
• Men with T2DM develop more microvascular complications, but women have higher cardiovascular morbidity and mortality.
• Women suffer psycho­logically to a greater degree than men, reporting more depression, anxiety and fatigue.
• The impact of various risk factors for complications may differ by sex. For example, elevated triglycerides and/or low high density lipoprotein may be stronger risk factors in women. Women may also have different (and yet unidentified) risk factors altogether.
• Preliminary findings suggest women may benefit more from treatment with longer-acting insulins because they are at increased risk of hypoglycemia. Studies are needed to address this question.
• Efficacy and side effects of some glucose-lowering drugs differ between men and women. One meta-analysis found that insulin, oral antidiabetic drugs, and dietary interventions reduced HbA1c less in women compared to men.

Clearly, study designs need to address sex differences in T2DM. The reviewers note that as we gather better information, different treatment guidelines may need to be developed for men and women.