Diabetes in Women

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Focus on Diabetes in women... On the eve of World Diabetes Day...

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WOMEN AND DIABETES DR.JALAJA RAMESH (SENIOR CONSULTANT DIABETOLOGIST):

WOMEN AND DIABETES DR . JALAJA RAMESH (SENIOR CONSULTANT DIABETOLOGIST)

INTRODUCTION:

INTRODUCTION Diabetes is a chronic, metabolic, vascular, endocrine progressive, endothelial disorder characterized by elevated sugars in the blood due to beta cell dysfunction – - Insulin secretary defect - Insulin resistance Common types of diabetes - - Type 1 DiabeteS - Type 2 Diabetes - Gestational diabeteS - Other types

EPIDEMIOLOGY:

EPIDEMIOLOGY India is second after china which is home to 92.3 million diabetics. By 2030 it is expected to cross 100 million. Diabetes is epidemic in India – in future India may become the diabetic capital of the world Especially there is an increase in the incidence of pregnancy diabetes (GDM) Increase in the obesity, lack of physical activity, excessive stress, lack of sleep and hormonal changes (PCOD) in youngsters making India presently home to young diabetics

WILL INDIA BECOME DIABETIC CAPITAL OF THE WORLD ????:

WILL INDIA BECOME DIABETIC CAPITAL OF THE WORLD ????

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International diabetic federation has estimated that over 389 million people have diabetes and approximately 50% of them are women (187 million) IDF estimated that 16.8% of live births are affected by some form of hyperglycemia and 6 million in India alone of which 90% are due to GDM The gap between the number of diabetic men and women in India is also diminishing 30 million men are diabetic and 29 million women are affected by diabetes

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Diabetes in women is on rise due to – Increased incidence of obesity Less physical activity Excessive stress Lack of adequate sleep Disordered eating habits ( skipping of breakfast and fasting) Increased prevalence of polycystic ovary Associated thyroid dysfunction Hormonal changes due to early menopause / surgical menopause

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Diabetes in women is on rise Diabetes in women is different Diabetes in women is neglected Diabetes affects – women more severely because of its unique – Biological Hormonal Cultural and socio-economic status

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Diabetes in women is significant and different. As the hormones, inflammation, anemia and excessive stress in women make the diagnosis and management difficult and different Especially changes in the hormone levels before, during and after, menstruation, pre – menopause and post – menopause makes diabetes management difficult

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Different stages of menstrual cycle (either follicular or lateral phase) may have different effect on the blood sugar level due to the level of oestrogen and progesterone Pre-menstrual period – increase in level of blood sugar can occur due to the temporary insulin resistance by the hormones like oestrogen and progesterone in some patients Blood sugar may reduce as menstruation begins. Peri-menopause due to the variation in hormone levels severe swings in the blood sugar can occur

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Diabetes in children – Type 1 DM Early onset of type 2 DM Diabetes in teen age – Delayed puberty Irregular periods Polycystic ovarian disease Sub-fertility Diabetes in reproductive age – Gestational diabetes

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Diabetes in middle age – Type 2 DM May be associated with hypertension May be associated with coronary heart disease Hypo-thyroidism Other thyroid dysfunction Depression Diabetes in old age – Late menopause Increased incidence of osteoporosis Coronary artery disease

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Diabetes may be harder in women Diabetes can cause various difficulties during pregnancy – Abortion (miscarriage) Congenital anomalies Still birth ( intrauterine death) Macrosomia ( big baby) Unplanned pregnancies can lead to increase the risk of abortion and congenital anomalies

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In DM women during pregnancy retinopathy can develop or any pre-existing mild retinopathy worsens In pre-gestational diabetic women may require higher dose of insulin during pregnancy Diabetes can also occur first time during pregnancy ( gestational diabetes) Though GDM generally disappears after delivery, women who had GDM have 50-80% risk to develop type 2 DM in another 5-10 yrs Pregnancy is window of opportunity to prevent future diabetes for two generations

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Diabetes is unique in women because the disease can affect both mother and her unborn children Women with diabetes are particularly vulnerable for more complications of diabetes especially coronary artery disease, retinopathy and nephropathy Women with diabetes experience more depression

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Diabetic kidney disease is more worse in women with diabetes than men with diabetes Diabetic kidney disease is more common in menopausal diabetic women Higher incidence of hypertension Habit of taking more salt Lack of physical activity Late diagnosis of disease increases increased incidence of diabetic kidney disease in female

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Diabetes is a powerful risk factor heart disease in women Heart disease in the leading cause of death in women with diabetes Women with diabetes are 2 times as likely to have second heart attack and 4 times more likely to have heart failure than women without diabetes Women with type 1 DM can develop heart disease when they are young

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Warning signs for heart attack is different in men than women. Many diabetic women may experience only nausea, jaw pain, shortness of breath, back pain or difficulty in upper abdomen instead of experiencing typical chest pain Diabetic women can have heart attacks without chest pain Diabetic women with coronary artery disease have lower survival rates than men Women experience higher mortality and morbidity from diabetic complication than male counter parts

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Women with diabetes lose their premenopausal protection from IHD Generally women have high HDL cholesterol when compared to men When a women become diabetes her HDL cholesterol reduces and protection against CAD lost

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Women are also at greater risk for blindness due to diabetes than men Adolescent girls have a higher risk of developing PDR (proliferative retinopathy) than age matched boys Diabetic retinopathy may develop or worsen in the pregnant women complicated with diabetes Diabetic retinopathy may develop or worsen in a pregnant women complicated with diabetes Women are at greater risk of blindness due to DM retinopathy than diabetic men

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Condition in which the bones becomes less dense and more likely to fracture The diabetes – osteoporosis link type 1 DM is linked to low bone density (low bone mass) Some people with type 1 DM have celiac disease which also associated with reduced bone mass Cytokines – substances produced by various cells in the body play a role in the development of both type 1 DM and osteoporosis

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Patients with diabetes mellitus have various skeletal disorder including osteoporosis or osteopenia Osteoporosis is one of most important metabolic bone disease in patients with diabetes mellitus Osteoporosis is an underestimated complication of DM 2 fold relative risk of hip fractures in patients with diabetes Women with type 1 diabetes had a 6.9-12 fold relative risk of hip fractures compared to women without diabetes 1,2 Study of osteoporotic fractures in women other than 65years with type 2 diabetes found an increased risk of hip and proximal humerus fractures despite a higher bone mineral density(BMD) in those patients 3

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Directly due to diabetes or its complication – Poor glycemic control Nephropathy Neuropathy Diabetic diarrhea Due to diseases associated with diabetes – Graves disease Celiac sprue Amenorrhea Delayed puberty Eating disorders Contd.......

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Risks for falls – Hypoglycemia Nocturia Poor vision Poor balance Orthostatic hypotension Impaired joint motility

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Diabetic patients have a higher prevalence of thyroid disorders compared with the normal population 30% female type 1 DM patients have thyroid disease The rate of post partum thyroiditis in diabetic patients is three times of that in normal women In type 2 DM – hypothyroidism is more common Thyroid disease in the general population – 6.6% where as thyroid disease in diabetes – 10.8%

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The presence of thyroid dysfunction may affect diabetes control Hyperthyroidism is typically associated in worsening of glycemic control and increased insulin requirements In case of unexplained worsening of hyperglycemia one should exclude hyperthyroidism

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Uncontrolled hypothyroidism can produce recurrent hypoglycemia Either hypothyroidism or subclinical hypothyroidism can worsen the Dyslipidemia As thyroid dysfunction is quite common in female diabetic when compared to male diabetic – if there is glycemic flucation or persistent neuropathy – one should asses thyroid dysfunction

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The rate of depression in people with diabetes is much higher than in the general population Women experience depression about twice as often as men The risk of depression increases in women with diabetes Post partum depression occurs within 4 weeks of child births (most new mothers suffer from some form of baby blue)

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This increased rate of depression in women is associated with – Menstrual cycle changes Pregnancy Miscarriage Post partum period Pre menopause Post menopause High serotonin concentrations in insulin resistant cases

STRESS:

STRESS Stress is an important cause equally important as family history in women STRESS Increased level of glucocorticoids Decreased insulin More insulin is utilized for metabolizing sugars Releases more glucose in the stream Insulin resistance Causing insulin to work less efficiently

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Uncontrolled diabetes in women is associated with recurrent UTI, bladder dysfunction, especially urinary incontinence, urge incontinence – affect the quality of life in DM women Recurrent UTI can cause life threatening pyelonepritis Decreased renal function, abscess formation and dangerous renal papillary necrosis Asymptomatic UTI is more common in DM women than non diabetic women

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DM women who have recurrent UTI can have recurrent fungal infection as increase in blood glucose level in blood, urine and vaginal secretion can trigger fungal and bacterial growth Women with diabetes experience more frequent bouts of vaginitis and fungus infection

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Where type 2 DM birth control oral contraceptive pills may rise blood sugar levels DM women with intrauterine contraceptive disease, uncontrolled blood sugar can increase pelvic inflammatory disease If one uses OC pills for a longer duration of time. The risk of developing DM complications like DM retinopathy and kidney disease can occur

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DM can affect fertility indirectly Increased androgen levels an ovulatory cycle Uncontrolled diabetes can lead to – Libido ( less sexual drive) Nerve damage Less blood flow to vagina and female genital organ causing dryness of vagina Recurrent vulvo-vaginitis All these can cause sub fertility

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Diabetic women have shorter life expectancy than women without diabetes Moreover the burden of diabetes in women is unique because the disease can affect two generation Diabetes can have many impacts on many aspects of women’s health especially in the reproductive age group Less physical activity, abdominal obesity, hormonal changes, abnormalities in blood vessel, less optimum functions control of blood pressure and Dyslipidemia all these push diabetic women high risk to develop coronary artery disease

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HEALTHY WOMEN HEALTHY INDIA

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THANK YOU

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