Research finds decreased death rates in diabetic men, but not in diabetic women: why not?

A new research report (Mortality Trends in Men and Women with Diabetes, 1971–2000) suggests that a decrease in mortality has occurred in the U.S. from 1971 to 2000 in the general population, and also in diabetic men, but a similar decrease was not observed in diabetic women. This report implies that somehow, diabetic women are being short-changed and are not sharing the improvements in medical care that diabetic men have apparently gained. And if the data are real, how can diabetic women share those benefits? Are they using less aspirin then men? Getting less antihypertensive or other therapy? Less aggressive medical management for heart disease? Or what?

The authors analyzed data from three consecutive studies (called the National Health and Nutrition Examination Surveys I, II, and III), looking to examine whether all-cause and cardiovascular disease mortality rates have declined among the U.S. population with and without diabetes. Apparently, finding that women weren’t having a decrease in mortality was a surprise to the researchers: the lead author was quoted by Reuters as saying "… the finding in women is concerning and means we may need to explore whether different approaches are needed to improve health outcomes for women with diabetes." And an accompanying editorial opined “Are women with CHD and diabetes less likely to receive appropriate care? The answer appears to be ‘yes.’ Sex disparities disadvantaging women with established CHD are also prominent, regardless of diabetic status. Women receive CHD diagnoses later in their illness, have fewer preventive interventions, and receive less guideline-based therapies at hospital admission and at discharge after an acute coronary event.”

But there are some problems with the NHANES data that make it difficult to interpret.

First, it should be pointed out that “diabetes” was self-reported in these surveys, and many persons with undetected hyperglycemia (or in denial!) would be misclassified into the nondiabetic group. (Would men or women be more likely to have undetected hyperglycemia – I have no idea!)

Second, among both men and women with diabetes, the proportion of nonwhite persons roughly doubled across the survey years, implying that different socioeconomic groups were being surveyed in different years – and it is well-known (but not commented upon in this report) that several non-white populations (Latinos and African-Americans, Pacific Islanders) have higher rates of diabetes than whites. That’s a real problem in delivery of medical care, as these groups may not share the wealth of resources that Anglos can tap into. But again, are non-white women different from non-white men in accessing medical care? Obviously, further research will be needed to tease out why these results were obtained.

In the meantime, whether man or woman, white or non-white, it’s important for physicians and other care-givers to provide aggressive care to all people with diabetes: it’s been clear since the DCCT was published in 1983 that aggressive diabetes care can prevent or ameliorate diabetes complications that cause major morbidity and mortality in patients with diabetes.