Diabetes is a common condition that affects more than 13 million women in the United States.1 It is a chief contributor to morbidity and mortality, with estimated annual costs of $327 billion in 2017.2 Women are disproportionately affected by diabetes, as they have a more complicated clinical course and worse morbidity once they contract the disease. By careful screening, promotion of effective preventive strategies, aggressive case finding, and diligent monitoring of treatment success, there is a great deal that obstetrician-gynecologists can do to help our patients with, or at risk for, diabetes. This review focuses on Type 2 diabetes mellitus (T2DM) because it is far more prevalent than Type 1 disease and accounts for 90% to 95% of all diabetes cases.
Approximately 9% of the US population aged 18 and older has diabetes.3 African-American, Hispanic, and Native Hawaiian/Pacific Islanders are all twice as likely to develop diabetes as are white women.1,3 About 16% of Native American and Alaskan Native adults have diabetes.3 Diabetes is more common in Asian-American than in white women and develops at a lower body weight compared to other racial groups.
Identification and treatment of diabetes in women is particularly important because it is their biggest single risk factor for heart disease, especially in the premenopausal years. Diabetes is also more likely to lead to blindness in women than in men and is associated with a higher risk for depression than it is for men.4
With the national epidemic of obesity that is afflicting the population, T2DM is being diagnosed more frequently in younger individuals, with racial/ethnic disparities in prevalence that are even more pronounced than they are in adults.5 Girls are also more likely than boys to develop T2DM in childhood or adolescence.5
About 7% of the female population has polycystic ovary syndrome (PCOS)6 and this condition constitutes one of the major risk pools for T2DM in premenopausal women. Fortunately, PCOS is often readily identifiable in the clinical ob/gyn setting. A second major risk group for development of T2DM are women who have had gestational diabetes mellitus (GDM), about 4.6% to 9.2% of pregnant women.7 Their relative risk of subsequent diabetes within 10 years of GDM is over 7-fold compared to women with normoglycemic pregnancies.8
Testing and screening
The US Preventive Services Task Force recommends diabetes screening as part of a cardiovascular risk assessment (Grace B) in asymptomatic adults who are overweight or obese and aged between 40 and 70.9 Individuals with a history of PCOS, GDM, and those of higher-risk racial and ethnic groups (such as African Americans, Native Americans, Alaskan Natives, Hawaiians, Pacific Islanders, Asian Americans and Hispanics) should be considered for screening at younger ages and lower body mass indexes (BMI).9 The American Diabetes Association (ADA) has similar recommendations and most recently recommended screening youth with a BMI higher than the 85th percentile.10Table 1 summarizes current screening recommendations.
Hemoglobin A1c (HbA1c), fasting plasma glucose and oral glucose tolerance testing (OGTT) can all be considered for screening (Table 2).9,10 All positive test results require confirmation before a definitive diagnosis can be made.
Because PCOS is associated with insulin resistance and is typically diagnosed in young women, beta cell reserve may be adequate to maintain normoglycemia under most conditions. Provoking insulin secretion with a glucose challenge is more efficient in eliciting glucose intolerance in the setting of insulin resistance, because chronically elevated insulin levels are more likely to keep fasting glucose normal. In general, younger women are also capable of a rapid, robust insulin response to a meal, and again will be able to maintain nearly normal glucose levels most of the time. Therefore, for younger women with a history of GDM and women with PCOS, an OGTT containing 75 g of glucose should be strongly considered, at least as initial testing, as it will strongly provoke maximal insulin output and elucidate whether true beta cell failure is present. HbA1c and fasting plasma glucose testing are inexpensive and relatively easy for patients, but practicality may favor one testing method over another. Individuals with impaired glucose tolerance and impaired fasting glucose have a very high rate of progression to diabetes (15%-20% will develop T2DM within 10 years) and should be tested annually.
There is strong, Level I evidence that onset of frank T2DM can be delayed or prevented with lifestyle modification and/or metformin treatment in both men and women.11 In a landmark randomized study by the Diabetes Prevention Program, lifestyle modification involved caloric restriction and increased activity, with the goal of 7% loss of body weight and 150 minutes per week of physical activity. Medical management consisted of metformin 850 mg bid. About 50% of the lifestyle group achieved a 7% weight loss and about three-quarters were able to achieve 150 minutes of physical activity per week. Adherence to the metformin arm was 72%. Lifestyle (58% reduction in progression to T2DM) was more effective overall than metformin (31% reduction in progression to T2DM) over the 3-year follow-up period. Both regimens were effective, however, and outcomes with them were more similar in participants aged 25 to 44. Both men and women had similar results, and the study sample included ample numbers of women from which to draw conclusions (67.7% of all 3234 participants were female).
The authors report no potential conflicts of interest with regard to this article.
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