Diabetes mellitus - a priority health care issue for women. (includes related article)

In recognition that diabetes mellitus is a major health problem for women, The American Dietetic Association's (ADA) Nutrition & Health Campaign for Women has added diabetes as a priority health issue. Diabetes is a major cause of morbidity and premature mortality in the United States. Diabetes is the most frequent cause of blindness among working-age adults and is the major cause of end-stage renal disease and nontraumatic lower-extremity amputation. It is a major cause of congenital malformations and perinatal mortality (1). In 1992, diabetes cost an estimated $92 billion in direct (medical care) and indirect (lost productivity) costs (2). Diabetes disproportionately affects women, older Americans, and minorities. Other priority health issues recognized by the Nutrition & Health Campaign for Women include heart disease, breast cancer, osteoporosis, and weight management. Two of these priority issues are directly linked to diabetes -- heart disease and weight management. Diabetes is a risk factor for development of ischemic heart disease (3) and overweight or obesity are risk factors for development of diabetes (4). Diet and nutrition issues are lined to the prevention and treatment of diabetes, heart disease, and obesity.

This review highlights aspects of diabetes related to women. Background data on prevalence and incidence of diabetes are provided to establish the magnitude of this health issue for women. Comorbidity, risk factor, and public health impact data are presented to underscore the health risk and costs that diabetes confer on individuals and society. Life cycle and social support issues are covered with emphasis on aspects of diabetes unique to women. For instance, diet, the cornerstone of diabetes management, and nutrition will be discussed in relation to women. The article concludes with a look toward future goals and research efforts.

The discussion focuses on the increasing scope of women's health. The field is expanding and refraining itself beyond reproductive issues, which were synonymous with women's health until the 1990s. Thus, this article covers reproductive issues, such as pregnancy for women with type I diabetes mellitus (insulin-dependent diabetes mellitus [IDDM]) and gestational diabetes mellitus (GDM), within the context of risk prevention and risk association. Pregnancy fo women with IDDM is discussed within the context of preconceptual counseling. GD is covered within the context of the risk for developing type II diabetes mellitus (non-insulin-dependent diabetes mellitus [NIDDM]). A number of publications are available on reproductive issues for women with GDM (5-10) and IDDM or NIDDM (11-13) as well as on contraception for women with diabetes (14).

PREVALENCE AND INCIDENCE

At least 13 million persons in the United States, or 5% of the population, have diabetes mellitus (1), although it is estimated that diabetes is undiagnosed in half of these persons. More than half a million persons were diagnosed with diabetes in 1990. The vast majority of persons over 20 years of age with diabetes (98%) have NIDDM. IDDM occurs in only 2% of persons with diabetes. GDM occurrences may be as high as 4% of all pregnancies (15).

Sex-Specific Associations

Incidence of diabetes is higher in women than in men -- 60% of new cases are diagnosed in women. In 1989, diabetes contributed to the mortality of more than 80,000 women either directly (underlying cause of death) or indirectly (contributing to any cause of death) (1). This number is nearly twice as high a the number of women who died from breast cancer during 1989 (16). However, the percentage of women with breast cancer who die annually of breast cancer is similar to the percentage of women with diabetes who die annually of diabetes. This is because the incidence of diabetes in US women is twice that of breast cancer. Approximately 365,000 women developed diabetes in 1989 (1), and approximately 182,000 women developed breast cancer (16).

Race and Ethnicity

Race and ethnicity are important determinants when assessing a person's risk of developing diabetes. In 1990, black women had the highest age-adjusted prevalence of diabetes compared with, in descending order, black men, white women, and white men (1). These statistics (1), compiled by the Centers for Disease Control and Prevention, use data from the National Health Interview Survey, which defines "white" as all ethnicities that are not "black." Thus, no specific data subsets for Native Americans or Hispanics are described in this publication (1,17).

Prevalence of diabetes in Native Americans, blacks, or Hispanics is higher than in non-Hispanic whites (18). Pima Indian women between the ages of 20 and 39 years have the highest incidence of diabetes worldwide at an age-adjusted prevalence rate of 22.5 (18). Navajo Indians (men and women) have a 2.5 times higher prevalence of diabetes than the general US population and the prevalence is higher in women than in men (19). Prevalence of diabetes in women aged 20 through 39 years, is 2.4% in blacks, 2.2% in Hispanics, and 1.8% in non-Hispani whites. Figure 3 displays the prevalence of diabetes in women aged 20 through 3 years from several ethnicities (18). Black women aged 65 through 74 have a 21% prevalence of diabetes, which is the highest incidence of diabetes of all white and blacks (male and female) in all age categories (1). Prevalence of diabetes increases with advancing age in all racial and ethnic groups; approximately hag of all cases are in people older than 55 (15).

COMORBIDITIES AND RISK FACTORS

Cardiovascular Disease

Cardiovascular disease is the greatest comorbidity and risk factor for women with diabetes. In 1989, cardiovascular disease was listed as the underlying cause of death in nearly hag the persons with diabetes (1). Investigators associated with the Nurses' Health Study (20), a prospective study with a cohor of 120,000 predominantly white female nurses, found that the increased risk of heart disease observed with diabetes was exacerbated by the simultaneous presence of additional risk factors including smoking, hypertension, and obesit (21). These investigators showed that women with IDDM and NIDDM are at higher risk for developing cardiovascular disease than are women who do not have diabetes.

Diabetes and age over 55 are independent risk factors for developing coronary heart disease in women. Women over the age of 55 years who have diabetes are at high risk for developing coronary heart disease (22). Women with diabetes appea to lose the protective effect of their gender against heart disease (23). Diabetes independently confers a 16-fold higher relative risk of mortality due to heart disease in women under the age of 55 years than is observed in women without, diabetes (24). As a point of reference, men with diabetes under the ag of 45 years have only an eightfold increased relative risk of mortality compare with men without diabetes of the same age.

Women with diabetes had a threefold greater mortality rate from ischemic heart disease than women without diabetes in the Rancho Bernardo Study (25). The investigators concluded that this increased mortality rate was attributable to high survival rates in women without diabetes rather than a mortality-linked association between ischemic heart disease and diabetes. Still, the mortality rate for cardiovascular disease and ischemic heart disease is higher in men wit diabetes than in women with diabetes (1). Similar results were found for men an women for myocardial infarction in a Mexican-American population (26) and in a low-income minority population in Chicago, Ill (27).

Ethnicity and gender inject an interactive profile to the risk of coronary hear disease in diabetes. The mortality rate for coronary heart disease remains higher in white males than in white females with diabetes and in black males than in black females, although whites with diabetes have an overall greater mortality rate than blacks with diabetes (1).

Several related factors contribute to the risk of cardiovascular disease in women with diabetes. These factors, often occurring together, include hyperlipidemia, hypertension, overweight, and obesity -- particularly upper-bod obesity.

Hyperlipidemia

Women with diabetes usually have one of the lipid profiles consistent with a high risk of cardiovascular disease -- low levels of high-density lipoprotein cholesterol (HDL-C), small low-density lipoprotein (LDL) particle size, or high levels of triglyceride (28, 29). The higher cardiovascular mortality rate in women who have diabetes than in women who do not have diabetes is consistent with the presence of a high-risk blood lipid profile …