Gender Disparities in the Control of Cardiovascular Risk Factors in People With Diabetes

Although diabetes markedly increases the risk of cardiovascular disease (CVD) in both men and women, it has a much stronger effect on the risk of coronary heart disease (CHD) in women compared with men. ¹ Women with diabetes have up to a 10‐fold increase in CHD mortality compared with women without diabetes. ¹ , ² Women with hypertension and diabetes are at even greater risk.

More disturbing is that women with diabetes have not experienced the decline in CHD mortality that has been observed over the past three decades in diabetic men ³ and in both men and women without diabetes. In fact, over the past three decades, mortality from CHD has actually increased in women with diabetes. ³ The decline in CHD mortality in the US population has generally been attributed to a reduction in cardiovascular risk factors and improvement in the treatment of heart disease.

While the exact pathophysiologic mechanisms underlying gender disparity in CVD risk associated with diabetes are not well identified, the larger impact of diabetes on CHD risk is explained, in part, by the heavier burden of both traditional and nontraditional CVD risk factors; a greater effect of atherogenic dyslipidemia and hypertension has been observed in women with diabetes. ¹ These facts highlight the need for a more aggressive approach to the treatment of CVD risk factors in women with diabetes, a particularly vulnerable group. Two recent reports, ⁴ , ⁵ including one by our group of a large cohort of 3678 patients with diabetes followed at seven medical centers, indicate that women with diabetes have been treated less aggressively compared with diabetic men. ⁴ For example, women in our cohort had a higher glycosylated hemoglobin, low‐density lipoprotein cholesterol (LDL‐C), and systolic blood pressure than men. An LDL‐C goal of <100 mg/dL was achieved in a lower percentage of women compared with men. ⁴ Furthermore, women with diabetes were more likely to have stage 3 hypertension and less likely to be referred for a dilated eye exam or to be screened for microalbuminuria. Interestingly, women were much less likely to be cigarette smokers compared with men. ⁴

These results are consistent with recent data from cross‐sectional analyses of a diabetic cohort from a large academic center. ⁵ In this study, women also had higher glycosylated hemoglobin, LDL‐C, and systolic blood pressure. Furthermore, women treated for dyslipidemia or hypertension were less likely to achieve a goal LDL‐C of <100 mg/dL or a blood pressure of <130/80 mm Hg. ⁵ Women were also less likely to be prescribed aspirin, ⁵ a finding that is consistent with a previous report. ⁶

Elderly women constitute the fastest‐growing segment of our society. ² Therefore, it is not surprising that there is increased public awareness ⁷ and professional advocacy for addressing heart disease in women, ⁸ including women with diabetes. However, despite increased public awarenessof CVD, a significant gap between perceived and actual risk of CVD in women remains, ⁷ especially among minority and younger women. Better educational strategies directed to these groups are necessary. One‐on‐one follow‐up programs have been shown to significantly change behavior and decrease women's risk for CVD. ⁹

In 2004, the American Heart Association developed the first set of evidence‐based guidelines for the prevention of CVD in adult women with a broad range of cardiovascular risk factors, including diabetes (Table). ⁸ A scoring sheet to calculate absolute 10‐year CHD risk in women was provided for use in clinical practice with these guidelines. ⁸ Translation of these guidelines to clinical practice remains to be seen, particularly with the overall poor control of CVD risk factors in the diabetic population.