CHICAGO - Medicine has made life-saving advances in treating and preventing heart disease, the major killer of people with diabetes, yet female diabetics are dying at higher rates than 30 years ago, researchers reported Monday.
"There's good news here; we are making progress," said Dr. Deborah Burnet, a diabetes expert at the University of Chicago. "The bad news is it appears to be limited to men."
The trend has ominous public-health consequences, experts note. Diabetes is growing ever more common in the United States as the population gets older and fatter, and elderly women are the fastest-growing segment of society.
The new study, published online in the Annals of Internal Medicine, found that in the year 2000 the mortality rate for female diabetics was 25.9 per 1,000 women per year, a rate significantly higher than in the 1980s and '90s. Meanwhile, the death rate for diabetic men decreased.
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In addition, while having diabetes more than doubled a man's risk of dying of cardiovascular disease, it more than quadrupled the risk for women. Female diabetics were dying of heart disease at the rate of 9.4 per 1,000, compared with 2.3 for women without diabetes.
"A diabetic woman is at the same risk for heart attack as a woman who has already had one," said Dr. Nanette Wenger of Emory University, who wrote an editorial accompanying the study.
The study was not designed to explain the differences. But Wenger suggested that women with diabetes and heart disease are less likely to get appropriate care, such as cholesterol-lowering drugs.
Dr. Larry Deeb, president of the American Diabetes Association, speculated that part of the explanation might lie in the persistent misconception that heart disease is a man's problem.
"We were aggressive in men," he said. "We made them take aspirin, we made them exercise, we checked their blood pressure and cholesterol - and it paid off. ... We have medicines that work. Maybe we haven't been giving them to women."
Deeb said women should insist on the very best control of known risk factors. "Don't accept that your blood sugar is 10 or 15 percent too high," he said. "Don't accept that your blood pressure is almost controlled. Don't accept that your cholesterol is almost low enough. You want your numbers to be as good as they can get."
Aggressive management of risk factors for cardiovascular disease, along with improved treatment of those with the disease, have reduced deaths and increased life expectancy in the U.S. over the past quarter-century. A team of researchers from the Centers for Disease Control and Prevention and other federal agencies set out to determine whether the excess deaths associated with diabetes had also declined.
The investigators, led by Edward Gregg of the CDC, analyzed data from the National Health and Nutrition Examination Survey for three groups: participants interviewed between 1971 and 1974 and followed through 1986, a second group surveyed between 1976 and 1980 and followed through 1992, and a third group from 1988 to 1994 who were followed through 2000. Nearly 100,000 people in all were studied.
Overall mortality rates decreased from 14.4 per 1,000 people in the first group to 9.5 in the last. But everyone did not share equally in the good fortune.
Death rates from all causes decreased by 43 percent among diabetic men, from 42.6 to 24.4 deaths per 1,000 persons per year. (The trend for cardiovascular deaths was similar, declining from 26.4 to 12.8.) Women without diabetes saw a smaller decline, from 10.1 to 7.7. But among diabetic women there was no improvement. On the contrary, the all-cause mortality rate increased 41 percent, from 18.4 to 25.9.
"This study adds to the evidence that there is a gender gap in health care ... and it has a bottom-line impact on mortality," said Sherry Marts of the Society for Women's Health Research.
Marts said scientists are trying to figure out why men and women with diabetes have such difference outcomes. "It could be there are differences in the underlying biology of men's and women's cardiovascular systems," she said.
But in the meantime, all the experts agreed, doctors must realize that diabetic women are at extremely high risk of developing heart disease and must work aggressively to manage their risk factors - not just their blood sugar but also their cholesterol, blood pressure, smoking, obesity and lack of exercise.
Health-care providers - and diabetic women themselves - might also consider more aggressive treatment when they develop cardiovascular disease, Marts said.
"We don't want all of them demanding cardiac catheterization," she said. "But diabetic women need to become their own advocates. (They should) make doctors look at their risk factors - especially family history, which is more significant for women than men - and if they have symptoms, ask for a referral to a (heart) specialist."
20 million Americans
The American Diabetes Association says more than 20 million Americans have the disease, including nearly 21 percent of people over 60.
But people are also being diagnosed with diabetes at ever-younger ages, especially among minority populations. This alarming trend spurred doctors at the University of Chicago to create an outreach program designed to combat obesity and reduce the risk of diabetes in blacks.
Althera Steenes, an instructor in the program, is at high risk for diabetes because three of her close relatives have it and because she is overweight. Since the program started earlier this year, she has lost 20 pounds. That could save her life, because getting diabetes would double her risk of a heart attack or stroke and worsen her chances of surviving such an event.
"People don't recognize that being overweight is something you can do something about," Steenes said. "That's the part we need to wake up on."