Over the past two decades, diabetes has become one of the major medical challenges in the world. It is a chronic disease that is divided into two main types: Type 1 diabetes (T1D) and Type 2 diabetes (T2D).
In Israel, the rate of diabetes among the adult population (over the age of 21) stands at about 10%, with about 700,000 Israelis coping with the disease. The prevalence of the disease increases with age and is slightly higher among men. Nevertheless, women with diabetes, especially Type 2 diabetes, are at particularly high risk for coronary heart disease, which is caused by narrowing or blockage of the arteries that supply blood to the heart muscle and may impair heart function, as well as heart attack (myocardial infarction) or stroke. Studies show that women with diabetes are three times more likely to die from coronary heart disease compared to women without diabetes, emphasizing the importance of early diagnosis, monitoring, and treatment.
What causes this?
● Women often present a greater burden of risk factors such as obesity and psychosocial stress at diagnosis.
● Hormonal changes throughout life, including pregnancy, gestational diabetes, and menopause, further increase the risk.
● Women tend to receive fewer treatments that reduce the risk of cardiovascular diseases and are recommended according to clinical guidelines, which worsens outcomes.
● Diabetes essentially cancels the protective effect of the female sex against cardiovascular diseases, making the impact of diabetes on vascular complications more pronounced in women.
The common complications of diabetes unique to women include: Irregular menstrual cycles, late onset of menstruation, infertility, polycystic ovary syndrome (PCOS), and early menopause. These complications are caused by both Type 1 and Type 2 diabetes, with insulin resistance and excess insulin playing a central role in the development of polycystic ovary syndrome.
Women with diabetes also experience pregnancy-specific complications. Women with pregestational or gestational diabetes are at significantly increased risk for adverse pregnancy outcomes, including preeclampsia, preterm birth, cesarean section, stillbirth, and neonatal complications such as hypoglycemia and respiratory distress syndrome. The risk of these outcomes is significantly higher in women with Type 2 diabetes compared to those with gestational or no diabetes.
What are the factors that impair the quality of care in women with diabetes?
● Women with diabetes actually receive fewer treatments to reduce cardiovascular risk (the risk of developing heart and vascular diseases, such as heart attack and stroke), which are recommended by guidelines, including lipid-lowering and antihypertensive medications.
● Underrepresentation of women in clinical trials of diabetes medications (usually 28–36% of participants).
● A high rate of obesity among women, especially in lower socioeconomic status.
● The mistaken perception that women are more protected from heart disease even after menopause and in the presence of diabetes.
Addressing gaps in prescriptions, representation in trials, and management of risk factors, and adopting gender-specific and personalized approaches are essential for improving cardiovascular outcomes in women with diabetes, as emphasized by the American Heart Association and the American Diabetes Association.
The good news is that intensive lifestyle interventions, including dietary changes, increased physical activity, and weight loss, improve blood sugar control and reduce cardiovascular risk factors in women with diabetes. However, women may need more frequent and intense physical activity than men to achieve a similar reduction in cardiovascular risk, and adherence may sometimes be lower due to social and behavioral factors.
In addition, there are many medications proven to reduce heart disease in women with diabetes, including statin drugs for lipid disorders, antihypertensive medications, and other drugs.
Diabetes in women has an even greater potential for harm than in men, but there is definitely something that can be done. Diagnosis and treatment of risk factors, lifestyle modification, and a wide range of medications available in the health basket provide tools for coping and help save lives. At the same time, the healthcare system must invest in reducing gender gaps in this field as well, so that every woman receives appropriate and effective treatment.
Dr. Orit Bernholtz is an expert in obstetrics, gynecology, and endocrinology and head of the diabetes field at Meuhedet, Jerusalem District.