Focusing on diabetes management through prevention, diagnosis and treatment is one of the major keys to maintaining good health among the population. Diabetes is a major health issue of the modern era. As supported by scientific studies, the lifetime risk of diabetes is very high, but it is more different, distressing and difficult in women.
The prevalence of diabetes in young women is alarming. More women are developing PCOS, obesity, and infertility, all of which predispose diabetes. Women in at reproductive age (15-45 years) group with Type I or II diabetes are at a risk to develop pregnancy complications like pregnancy loss, preterm delivery and neonates with birth defects (glucotoxicity embryopathy). Sometimes maternal high glucose levels causes fetal toxicity, affects the growing embryo and embryopathy.
MedPiper Technologies and JournoMed in association with Sri Gokulam Foundation and IWN Tamil Nadu conducted an informative Webinar on 26th April 2022 where the speakers provided relevant information about diabetes in Indian women. More stress was put on creating awareness and educating the general population regarding women’s health and diabetes.
Ms Rajalaksmi Subramanyam, Co-Chairman, Indian Women Network (IWN) Tamil Nadu and Director Tree HR Solutions Pvt Ltd gave a brief introduction about Dr, Mohan T Shenoy and discussed his pivotal achievements in the field of healthcare. Dr Shenoy is Consultant Endocrinologist, at Sri Gokulam Medical College and Research Foundation, Venjaramoodu, Trivandrum. He spoke about the details of diabetes management in women and suggested ways to create mass awareness through different techniques.
Diabetes Mellitus (DM) is a group of metabolic disorders characterised by hyperglycemia resulting from defects in insulin secretion (Type I), insulin action (Type II) or both (Gestational Diabetes or GDM). Chronic hyperglycemia in diabetes causes long-term damage, dysfunction and failure of various vital organs like eyes, kidneys, heart, nerves and blood vessels.
Epidemiology of DM
The WHO states that the prevalence of the disease have increased exponentially from 4.7% to 8.5%. In women, 2 out of every 5 women suffers from diabetes in the reproductive age group, accounting for 60 million cases in women worldwide. GDM develops in 1 in 25 pregnancies worldwide. In India, 4 million women have GDM. Approximately 50% of women with GDM develop Type II diabetes within 5-10 years after delivery. So it is mandatory to always screen them annually every 3 years.
Complications of DM
During GDM, Type I diabetic pregnant women show more risk due to lower blood glucose levels. Glucose tolerance worsens during this time. The pregnant person must keep their the HbA1c levels in the controlled range below 6.5. This will prevent fetal damage and the risk of diabetes, obesity, and metabolic syndrome in the baby.
There are two types of complications associated with DM.
- Microvascular complications, like retinopathy (eye damage), nephropathy (kidney damage), and neuropathy (nerve damage).
- Macrovascular complications, like cerebrovascular disease like stroke, cardiovascular disease like heart attack, and peripherovascular disease like poor circulation to the limbs.
These complications are extremely preventable by proper screening, annual eye tests, quarterly glucose and creatinine testing and inducing self-empowerment towards DM.
Driving risk factors of high prevalence of DM in women
Factors like pregnancy, Poly Cystic Ovary Syndrome (PCOS), menopause, obesity, sedentary lifestyle, urbanization, globalization, stress, genetics, healthcare disparities, financial dependence, work stress, sleep deprivation, and stress of caregiving to the family all contribute to DM in women. Undoubtedly, female diabetics have to overcome gender-specific issues, as they take less care of their health.
Obesity in women is one of the risk factors for Type II diabetes as it negatively impacts their health, and increases the risk of coronary heart disease. Due to the obesity pandemic, Indian women of childbearing age (15-45 years) develop DM related health complications, overt diabetes, asymptomatic obesity and PCOS in the younger population.
The Barker hypothesis predicts that maternal undernutrition leads to retarded fetal growth, structural change within organs, poor childhood growth, metabolic and endocrine dysfunction, hypertension and diabetes later in life. There are three types of risk factors in the case of female diabetics:
- Sex-specific risk factor, causes premature menopause, gestational diabetes, pregnancy-induced hypertension, preterm delivery, PCOS, and autoimmune disorder.
- Non recognized risk factors like psychosocial factors include partner abuse, socioeconomic deprivation, poor health literacy, and environmental risk factors (air pollution).
- Well established risk factors are hypertension, dyslipidemia, obesity, diabetes, unhealthy diet, sedentary lifestyle, smoking or tobacco use.
PCOS and DM
Insulin resistance has several reproductive repercussions such as
- elevated levels of insulin in the blood,
- decreased Sex Hormone Binding Globulin level in the liver,
- increased ovarian androgen production,
- decreased release of LH/FSH due to a disorder of the hypothalamus,
- elevated level of male hormone in the blood,
- absent or irregular ovulation, leading to PCOS.
Risk factor for cardiovascular disease also increases due to these factors. However, DM and related PCOS can be easily detected using ultrasound methods.
Sexual dimorphism and body fat distribution in DM patients
Visceral adiposity is more in males and subcutaneous adiposity is more in females. Male diabetes includes increased skeletal mass, visceral adiposity, ectopic fat, increased glucose oxidation during exercise, increased nefa (non esterified fatty acids) during rest, and increased fasting blood glucose level. Female diabetes includes increased total fat mass, increased subcutaneous adiposity, increased insulin sensitivity, increased nefa during rest, increased nefa oxidation during exercise and increase in postprandial glucose level.
Diabetes care in women
GDM is associated with hyperglycemia, insulin resistance, metabolic syndrome and Type II diabetes risk. Insufficient insulin production or excessive peripheral insulin resistance decreases glucose uptake, and increases glucose levels in blood. Short-term consequences of hyperglycemia include preeclampsia and long-term consequences includes type 2 diabetes. In the presence of both hyperglycemia and hyperinsulinemia, short term consequences of macrosomia and fetal hypoglycemia and long-term complication of Type II diabetes and obesity can be seen.
Diagnosis and Medication
During GDM, focus should be on achieving glycemic targets regularly. The glycemic target of FBG less than 95mg/dl, postprandial blood glucose level (1 hr post-meal) level of less than 140 mg/dl and 2 hrs post level of less than 120 mg/dl should be of high priority. These targets can be achieved by giving insulin therapy. The speakers recommend Self-monitoring by checking blood sugar levels four times throughout the day i.e fasting, 1 & 2 hr post-meal and early morning. Patients should be advised to use easily available glucose monitoring devices.
While offering intrapartum glycemic control, earlier medicine should be stopped, adequate hydration should be suggested, 72-126 mg/dl blood glucose should be maintained. In case of insulin infusion to reach the target, intravenous dextrose along with insulin should be recommended to prevent hypoglycemia and starvation ketosis. To provide post-partum care in preexisting and overt diabetes women, antihyperglycemic therapy is a good route. Modifications in insulin requirement should be done and glycemic target of FBG (90-130mg/dl) and post-meal after 2 hours (less than 180 mg/dl should be maintained.
While taking care of GDM women, glucose-lowering therapy should be discontinued, FBG and PPG should be monitored for 24-72 hours and at 6-12 weeks postpartum. The 75-g Oral glucose tolerance test (OGTT) should be suggested. In the case of diabetic lactating women, metformin should be suggested with caution and under expert advice, especially while nursing newborns and premature infants. An infant’s blood glucose level should always be checked. Diagnosis of PCOS at a young age helps with proper intervention. Metformin is effective in PCOS by improving ovarian induction, reducing insulin levels and acts on androgen hormone by inhibiting ovarian gluconeogenesis.
Lifestyle advice (weight, diet control and exercise) and lifelong screening for diabetics and at least every 3 years in prediabetics should be done. A lot of social media DM related awareness is there, but most women do not consult specialists but consult their friends first. Lack of diabetes management in women leads to lack of awareness, skipping meals often, and irregular eating habits. Women are hesitant to adopt lifestyle and dietary changes. There is a low level of awareness of prediabetic terms also. A good mass awareness drive is required among women and their families.
Women should be educated about infections in diabetes, which include bladder and sexual dysfunction, UTI ( mostly E.coli), and kidney disease. They should also be told about diabetic mastopathy, a rare complication of long-lasting diabetes, fibroinflammatory disease of the breast, firm non-tender lump, and malignancy. Good care should be taken in menopausal women with diabetes. It can lead to early menarche and early menopause, depression and cardiovascular disease. Attention should be given to bone mineral density as the risk of osteoporosis and hip fracture increases with progressing DM.
Pre-pregnancy planning to avoid diabetes complications
DM should be controlled during preconception and while planning a pregnancy in prediabetic and preexisting DM cases. Counselling and comprehensive preconception care are a must. DM in preconception increases the risk of maternal and fetal complications like spontaneous abortion, preeclampsia, macrosomia, preterm labour, and congenital anomalies. Good nutritional care and continuous glucose monitoring should be done in infants’ immunisation. The speakers suggest 6 main tips to follow before conception:
- optimal glycemic control before 3-6 months of conception,
- replacing oral antidiabetic drugs,
- evaluating retinopathy and nephropathy,
- regular BP check,
- discontinuing statin
- including 5 mg folic acid in the diet
While planning dietary recommendations for DM, good care and detailed portion size should be of high priority. A customized balanced easy to follow diet, suitable meal time chart and foods to eat and avoid should be suggested. While selecting artificial sweeteners, suggestions should be taken from the expert. Diabetes-related hunger pangs can be reduced by suggesting, good willpower development, drinking adequate water and doing the right type of exercise.
Creating DM and GDM awareness among women
The developmental origin of the disease is altered throughout life. Chances of developing coronary heart disease are more in women associated with diabetes. The risk of developing complications is higher in women. Endometrial and breast cancer chances are more in women due to hormonal disbalance. The lifetime risk of complications is more in women.
Hence, the awareness of women’s health is crucial for a family. Educating the mother means educating the family. Endocrine disease-associated awareness initiatives should be taken. One in 7 births is affected by gestational diabetes. Mandatory screening should be done in women who overweight or obese, suffer from PCOS, have a history of CVD and hypertension, or have first degree relative with diabetes.
The right amount of awareness should be provided regarding sociocultural barriers to diabetes. Women mostly do not take good care of their health, as they feel obesity is not considered a priority. They give less value to physical exercise, follow rigid social and cultural norms and hesitate to change the whole family diet as per their disease-specific dietary recommendations.
Proper counselling should be done regarding psychosocial determinants, like childhood experiences, housing, education, social support, family income, employment, and access to health services. As per ADA, access to diabetes care for women is very important. Women should be motivated and educated to do self-assessments and follow healthy food and exercise regimens
The International Diabetes Federation (IDF) made 14th November as International Diabetes Day. The idea behind this is to create more awareness of DM and give them proper access to medicine and offer self diabetes management education. The target should be to prevent gender-specific challenges while managing DM in women. Awareness should be created among all age groups regarding risk factors for diabetes. Universal screening, good maternal and fetal glycemic control, long-term follow-up and lifestyle modifications of the mother and a baby should be done tirelessly.