The objective of this cross-sectional study was to assess differences in the control and treatment of modifiable cardiovascular risk factors (CVRF: HbA1c, blood pressure [BP], LDL-cholesterol, body mass index, and smoking habit) according to gender and the presence of cardiovascular disease (CVD) in patients with type 2 diabetes mellitus (T2DM) in Catalonia, Spain. The study included available data from electronic medical records for a total of 286,791 patients. After controlling for sex, age, diabetes duration, and treatment received, both men and women with prior CVD had worse cardiometabolic control than patients without previous CVD; women with prior CVD had worse overall control of CVRFs than men except for smoking; and women without prior CVD were only better than men at controlling smoking and BP, with no significant differences in glycemic control. Finally, although the proportion of women treated with lipid-lowering medications was similar to (with prior CVD) or even higher (without CVD) than men, LDL-cholesterol levels were remarkably uncontrolled in both women with and women without CVD. The results stress the need to implement measures to better prevent and treat CVRF in the subgroup of diabetic women, specifically with more intensive statin treatment in those with CVD.
The prevalence rates of diabetes mellitus (DM) have significantly increased during the last years, accompanied by a parallel rise in complications and deaths from the disease [
People with type 2 diabetes mellitus (T2DM) are at increased risk of cardiovascular complications such as coronary artery disease, stroke, or peripheral vascular disease [
Systematic reviews of the literature have reported that the excess relative risk of CVD attributable to diabetes is 2-fold in men and 3- to 4-fold in women [
Cross-sectional studies have reported that the control of cardiovascular risk factors (CVRF) is poorer among diabetic women relative to diabetic men of the same age [
On the other hand, studies derived from the analysis of large databases have proven to be useful for evaluating cardiometabolic control, associated risk factors, long-term complications, and other clinically relevant aspects of T2DM [
The aim of the present population-based study was to assess differences in the degree of control and treatment of modifiable CVRF according to gender and CVD in patients with T2DM in Catalonia, Spain.
This cross-sectional study includes all type 2 diabetes subjects visiting any of the 274 primary care centres pertaining to the Catalan Health Institute (ICS) in Catalonia, a northeastern region of Spain, which takes care of a population of about 5.8 million patients (80% of the total population for the region).
The data for the present study (eCONTROL) were extracted from SIDIAP (Information System for the Development of Research in Primary Care; SIDIAP) [
Data from patients attended before July 1, 2009, aging 31 to 90 years, and with a diagnosis of type 2 diabetes (ICD-10 codes E11 or E14) were extracted from the SIDIAP database [
Diagnostic criteria for CVRF were HbA1c > 7%; hypertension (blood pressure > 140/90 mmHg); hypercholesterolemia (total cholesterol > 250 mg/dL); hypertriglyceridemia (triglycerides > 150 mg/dL); obesity (BMI > 30 kg/m2); and current or former smoking habit. Treatment goals for patients with and without a history of CVD were based on local guidelines [
This study was approved by the Ethics Committee of the Primary Health Care University Research Institute (IDIAP) Jordi Gol.
Descriptive analyses were summarized by mean and standard deviation for continuous variables and percentages for categorical variables. Comparisons by gender and presence of CVD were performed with Pearson chi-square tests for categorical variables and analysis of variance (ANOVA) for continuous variables. We applied multilevel logistic regression models to identify the factors associated with good cardiometabolic control of CVRFs. Only those variables with a statistically significant effect (
The study included data from a total of 286,791 patients with T2DM (153,987 men and 132,804 women). Overall, 18.4% of the patients (
In the overall population, all studied variables showed significant differences between men and women; women were in average older than men, had a longer duration of the disease, and had slightly worse cardiometabolic control than men, with higher blood pressure levels (mean 137.5/76.2 mmHg versus 136.9/76.6 mmHg;
Demographic, clinical characteristics, and degree of cardiometabolic control by gender and presence of
All patients | CVD | No CVD | ||||
---|---|---|---|---|---|---|
Men | Women | Men | Women | Men | Women | |
|
|
|
|
|
|
|
CV risk factors | ||||||
Age, mean (SD), years | 66.4 (11.3) | 70.3 (11.1) | 70.9 (9.6) | 75.6 (8.7) | 65.1 (11.4) | 69.4 (11.2) |
Diabetes duration, mean (SD), years | 6.2 (4.8) | 6.9 (5.3) | 7.3 (5.5) | 8.3 (6.4) | 5.9 (4.5) | 6.7 (5.1) |
Hypertension, % | 58.6 | 69.7 | 69.5 | 81.5 | 55.4 | 67.8 |
Systolic BP, mean (SD), mmHg | 136.9 (13.6) | 137.5 (14) | 136.1 (14.3) | 138 (14.7) | 137.2 (13.4) | 137.5 (13.8) |
Diastolic BP, mean (SD), mmHg | 76.6 (8.5) | 76.2 (8.1) | 73.8 (8.4) | 73.6 (8.2) | 77.5 (8.3) | 76.6 (8) |
Diabetic retinopathy, % | 5.6 | 6.1 | 8.3 | 10.9 | 4.8 | 5.4 |
Diabetic nephropathy, % | 20.7 | 12.3 | 26.7 | 18.3 | 19 | 11.3 |
BMI, mean (SD), kg/m2 | 28.8 (4.3) | 30.5 (5.6) | 28.6 (4.1) | 30.1 (5.4) | 28.9 (4.3) | 30.6 (5.6) |
HbA1c, % | 7.2 (1.5) | 7.1 (1.4) | 7.1 (1.4) | 7.2 (1.4) | 7.2 (1.5) | 7.1 (1.4) |
Total cholesterol, mean (SD), mg/dL | 186.2 (38.2) | 198.4 (38) | 171.5 (36.9) | 185.6 (39.4) | 190.5 (37.5) | 200.4 (37.3) |
HDL-cholesterol, mean (SD), mg/dL | 46.2 (12.3) | 52.7 (13.4) | 44.4 (11.8) | 50.2 (12.9) | 46.7 (12.4) | 53.1 (13.4) |
LDL-cholesterol, mean (SD), mg/dL | 109.7 (32.2) | 115.6 (32.3) | 97.1 (30.7) | 104.4 (32.5) | 113.6 (31.6) | 117.4 (31.9) |
Triglycerides, mean (SD), mg/dL | 158.5 (117.3) | 153.5 (88.7) | 153.4 (106.8) | 156.3 (91.8) | 160 (120.3) | 153.1 (88.2) |
Smoking status, % | ||||||
Non smokers | 43.5 | 88 | 42.4 | 90.1 | 43.8 | 87.6 |
Current smokers | 23.9 | 6.2 | 18.1 | 3.8 | 25.6 | 6.6 |
Ex-smoker | 32.6 | 5.8 | 39.5 | 6.1 | 30.6 | 5.8 |
Degree of CVRF control | ||||||
|
55.8 | 56.5 | 55 | 54.6 | 56 | 56.8 |
|
61 | 47.3 | 62.5 | 49.7 | 60.6 | 46.9 |
|
63.9 | 63.1 | 65.5 | 62.1 | 63.5 | 63.2 |
|
75.2 | 69.4 | 86.3 | 80.2 | 71.8 | 67.7 |
|
41.3 | 34.2 | 58.8 | 49.2 | 35.9 | 31.7 |
|
28.5 | 25.6 | 33.1 | 28.9 | 27.0 | 25.1 |
|
15.7 | 12.4 | 22.8 | 17.7 | 13.5 | 11.5 |
The stratified analysis according to history of CVD showed that men with prior CVD had significantly better control of BP, weight, lipid profile, and smoking than men without a history of CVD (all variables
When considering the adequate treatment goals of CVRFs by gender, women showed worse overall control than men (
Percentage of patients with T2DM and good control of CVRF by gender and history of CVD (all variables showed significant differences between sexes (
After adjusting for gender (woman), age, diabetes duration, and treatment received, multivariate analysis showed that men in secondary prevention after CVD had better control of all risk parameters except for smoking. In the case of prevention of CVD, women still had better control over smoking than men, but also better control of their BP, whilst there were no clinically significant differences in glycemic control between genders (Table
Multivariate analysis on the degree of control of CVRFs stratified according to the presence of CVD.
CVD | No CVD | |||
---|---|---|---|---|
ORa (95% CI)* |
|
ORa (95% CI)* |
|
|
HbA1c ≤ 7% | 0.95 (0.91–1.00) | 0.041 | 1.01 (0.99–1.03) | 0.23 |
PA ≤ 140/90 mmHg | 0.879 (0.84–0.92) | <0.001 | 1.082 (1.06–1.13) | <0.001 |
LDL-cholesterol | ||||
≤130 mg/dL (CVD) | 0.67 (0.64–0.70) | <0.001 | 0.74 (0.72–0.76) | <0.001 |
≤100 mg/dL (no CVD) | ||||
BMI ≤ 30 Kg/m2 | 0.50 (0.48–0.52) | <0.001 | 0.53 (0.52–0.54) | <0.001 |
Nonsmoker | 4.20 (3.86–4.58) | <0.001 | 4.01 (3.39–4.13) | <0.001 |
BMI: body mass index; BP: blood pressure; CVD: cardiovascular disease; OR: odds ratio.
*ORa: odds ratio adjusted by age, diabetes duration, treatment received, and sex (women).
Study of the different macrovascular complications, specifically coronary heart disease (CHD), stroke, or peripheral arterial disease (PAD), showed that the proportion of women with good control of target CVRFs, namely, HbA1c ≤ 7%, BP ≤ 140/90 mmHg, and BMI ≤ 30 Kg/m2, and also lipid profiles in subjects with or without prior CVD was lower than men irrespective of the type of CVD (
Degree of CVRFs control (% and 95% CI) in different macrovascular complications according to sex.
CHD | Stroke | PAD | CHD + stroke | CHD + PAD | Stroke + PAD | CHD + stroke + PAD | ||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
|
|
|
|
|
|
|
||||||||
Men | Women | Men | Women | Men | Women | Men | Women | Men | Women | Men | Women | Men | Women | |
HbA1c ≤ 7% | 54.2 (53.4–54.9) | 52.8 (51.7–53.9) | 58.1 (57–59.1) | 57.2 (56.0–58.5) | 50.5 (49.1–51.9) | 48.3 (45.8–50.8) | 53.8 (51.5–56.0) | 52.0 (48.8–55.2) | 49.4 (46.8–52.0) | 44.5 (39.0–50.1) | 51.9 (48.5–55.4) | 43.5 (36.5–50.6) | 51.3 (45.3–57.4) | 46.8 (32.0–61.6) |
BP ≤ 140/90 mmHg | 67.3 (66.0–66.7) | 62.6 (61.7–63.6) | 64.2 (63.3–65.2) | 63.0 (61.9–64.2) | 61.0 (59.8–62.3) | 55.8 (53.5–58.1) | 65.8 (63.8–67.8) | 64.5 (61.1–67.4) | 65.0 (62.8–67.3) | 59.0 (53.9–64.0) | 63.2 (60.0–66.3) | 56.0 (49.5–62.5) | 65.0 (59.7–70.4) | 55.7 (42.9–68.6) |
Nonsmoker | 43.8 (43.1–44.4) | 90.5 (89.9–91.0) | 45.2 (44.2–46.2) | 90.8 (90.1–91.4) | 30.7 (29.6–31.9) | 85.7 (84.1–87.3) | 45.1 (43.1–47.2) | 91.8 (90.2–93.4) | 34.3 (32.1–36.5) | 89.3 (86.2–92.5) | 33.1 (30.1–36.1) | 87.6 (83.3–91.8) | 37.5 (32.2–42.9) | 88.5 (80.3–96.8) |
BMI ≤ 30 kg/m2 | 39.7 (38.9–40.5) | 52.4 (51.2–53.5) | 34.3 (33.3–35.4) | 47.8 (46.4–49.2) | 33.0 (31.7–34.4) | 47.7 (45.0–50.3) | 34.0 (31.8–36.2) | 50.8 (47.2–54.3) | 35.9 (33.4–38.4) | 47.3 (41.3–53.2) | 31.9 (28.6–35.3) | 44.0 (36.2–51.8) | 31.1 (25.4–36.8) | 53.5 (38.0–69.0) |
LDL ≤ 130 mg/dL | 89.1 (88.6–89.5) | 82.8 (82.0–83.7) | 84.9 (84.1–85.7) | 78.9 (77.8–79.9) | 82.2 (81.1–83.2) | 73.7 (71.4–75.9) | 90.9 (89.6–92.9) | 84.4 (82.0–86.8) | 89.8 (88.2–91.4) | 81.5 (76.9–86.0) | 86.1 (83.6–88.5) | 79.0 (73.0–85.0) | 88.0 (84.0–92.1) | 81.0 (68.6–93.3) |
LDL ≤ 100 mg/dL | 63.1 (62.3–63.8) | 53.2 (52.0–54.3) | 56.4 (55.3–57.5) | 46.8 (45.5–48.1) | 51.8 (50.4–53.2) | 42.2 (39.6–44.7) | 65.1 (62.9–67.3) | 54.7 (51.4–57.9) | 62.4 (59.8–65.0) | 58.4 (52.6–64.1) | 58.4 (54.9–62.0) | 48.6 (41.3–56.0) | 59.8 (53.7–65.9) | 54.8 (39.1–70.5) |
BMI: body mass index; BP: blood pressure; CHD: coronary heart disease; PAD: peripheral artery disease.
We further studied whether treatment for the different CVRFs differed between genders in the presence/absence of prior CVD (Table
Treatment (%) used to control the different CVRFs in patients with or without CVD by gender.
Treatment | All patients | CVD | No CVD | ||||||
---|---|---|---|---|---|---|---|---|---|
|
|
|
|||||||
Men | Women |
|
Men | Women |
|
Men | Women |
|
|
|
|
|
|
|
|
||||
Glucose-lowering | |||||||||
Lifestyle changes only | 24.6 | 24.1 | 0.003 | 17.8 | 18.2 | 0.021 | 26.6 | 25.1 | <0.001 |
Oral monotherapy | 36.3 | 34.5 | <0.001 | 33.8 | 29.2 | <0.001 | 37.0 | 35.4 | <0.001 |
Combination of OAD | 22.9 | 21.9 | <0.001 | 23.5 | 19.9 | <0.001 | 22.7 | 22.2 | 0.001 |
Insulin + OAD | 8.80 | 11.7 | <0.001 | 13.3 | 18.1 | <0.001 | 7.50 | 10.7 | <0.001 |
Insulin monotherapy | 7.37 | 7.80 | <0.001 | 11.7 | 14.7 | <0.001 | 6.10 | 6.70 | <0.001 |
Any pharmacological treatment |
|
|
|
|
|
|
|
|
|
Antihypertensive | |||||||||
No treatment | 34.2 | 26.8 | <0.001 | 13.6 | 11.6 | <0.001 | 40.1 | 29.2 | <0.001 |
ACE inhibitor/ARA2 | 16.3 | 14.9 | <0.001 | 12.3 | 11.4 | 0.004 | 17.5 | 15.5 | <0.001 |
Diuretic | 2.01 | 4.4 | <0.001 | 1.37 | 2.45 | <0.001 | 2.20 | 4.72 | <0.001 |
Beta-blocker | 2.59 | 1.91 | <0.001 | 5.60 | 3.37 | <0.001 | 1.73 | 1.68 | 0.04 |
Calcium-channel blocker | 2.19 | 2.15 | 0.43 | 3.82 | 3.28 | 0.001 | 1.73 | 1.97 | <0.001 |
Combination of 2 | 22.7 | 26.8 | <0.001 | 30.4 | 29.8 | 0.17 | 20.5 | 26.3 | <0.001 |
Combination of 3 or more | 19.5 | 22.8 | <0.001 | 32.6 | 37.9 | <0.001 | 15.7 | 20.3 | <0.001 |
Any pharmacological treatment |
|
|
|
|
|
|
|
|
|
Lipid-lowering | |||||||||
No treatment | 50.3 | 49.4 | <0.001 | 27.1 | 31.1 | <0.001 | 56.9 | 52.4 | <0.001 |
Statin | 40.5 | 43.3 | <0.001 | 60.2 | 58.9 | 0.003 | 34.8 | 40.8 | <0.001 |
Fibrate | 3.88 | 2.81 | <0.001 | 2.36 | 2.17 | 0.17 | 4.31 | 2.91 | <0.001 |
Statin + fibrate | 1.06 | 0.67 | <0.001 | 1.81 | 1.13 | <0.001 | 0.84 | 0.59 | <0.001 |
Any pharmacological treatment |
|
|
|
|
|
|
|
|
|
Antiplatelet | |||||||||
No treatment | 60.7 | 66.3 | <0.001 | 22.5 | 28.2 | <0.001 | 71.7 | 72.4 | <0.001 |
Aspirin | 31.4 | 28.8 | <0.001 | 52.2 | 51.2 | 0.02 | 25.4 | 25.2 | 0.19 |
Clopidogrel | 4.14 | 2.98 | <0.001 | 12.6 | 11.9 | 0.01 | 1.71 | 1.55 | 0.004 |
Any pharmacological treatment |
|
|
|
|
|
|
|
|
|
ACE: acetylcholinesterase; ARA2: angiotensin II receptor antagonist; BMI: body mass index; BP: blood pressure; CVD: cardiovascular disease; OAD: oral antidiabetic drugs.
Gender differences among the diabetic population include disparities in adherence to treatment [
The prevalence rates of T2DM and CVD in our study were higher among men, which is in line with previous population-based studies [
The results of the study showed that there were significant gender differences in the control of T2DM and CVD individual risk factors. Namely, compared with men, women were on average older and had a longer duration of disease, and apart from less frequently being smokers than men, they had poorer control of hypertension, LDL-cholesterol levels, and BMI. This profile of worse control of CVRFs has been consistently reported before in previous surveys conducted in Spain and in other countries [
There are few reports assessing the control of CVRFs in T2DM according to gender as well as for the presence of prior CVD, and the present study is the first one conducted in a Spanish population. Our analysis stratifying by presence of prior CVD showed that both men and women with CVD in general had poorer control of CVRFs than those without. As for the degree of control of modifiable CVRFs, multivariate analysis showed that women with prior CVD were less likely to achieve their therapeutic targets than men for all parameters except for smoking. Women without CVD achieved the recommended HbA1c target as optimally as men and were better at controlling BP and smoking but again more frequently did not achieve recommended therapeutic targets for obesity and LDL-cholesterol. Our results on patients with prior CVD are in agreement with a previous cross-sectional study conducted in Germany, which found that women were more likely to have uncontrolled systolic BP, LDL-cholesterol, and HbA1c levels [
There is compelling evidence in Spain and other countries that women receive less health care attention not only for the treatment of their T2DM [
When we assessed whether there were gender disparities in the management of modifiable CVRF in T2DM patients according to a history of CVD, we found that women were more likely to be treated with antihypertensive drugs and less likely to take antiplatelet drugs than men irrespective of having a history of CVD, while glucose- and lipid-lowering treatment varied according to the absence/presence of prior CVD: the proportion of women with CVD taking glucose and/or lipid-lowering medications was similar to men, but women without CVD took more glucose and/or lipid-lowering drugs than men. However, while the degree of achieved glycemic control was similar between women with and without previous CVD, lipid levels were remarkably uncontrolled in both cases and more pronounced in women with prior CVD. This is of concern if we take into account that a history of CVD is an independent factor associated with higher morbidity and mortality and that the 4-year survival rate of women with prior CVD is lower than in women without a history of CVD [
Strengths of the present study include the use of registries coming from primary care medical records, which allows the collection of a large volume of patients’ real-life clinical practice data. However, there are some limitations that should be acknowledged and considered when interpreting the results of this study. Firstly, inherent to any cross-sectional design, no causal associations or conclusion on trends in treatment can be drawn, and the retrospective design is subject to biases concerning the lack of data recording for some of the studied variables (e.g., 25% of patients did not have corresponding HbA1c values for the previous year). Secondly, the studied cohort is representative of a specific territory in Spain and may not necessarily reflect standards of care in other territories. Thirdly, information on treated (and the specific therapeutic agents prescribed) and untreated patients was based on drugs obtained at the pharmacy, and we were not able to assess medication adherence factors. Finally, we had no data to assess factors known to differ by gender in T2DM that may influence disease outcomes, such as diabetes knowledge, self-management practices, lifestyle related factors, socioeconomic status, education, or social support [
The results of the study confirm that Spanish women with T2DM have suboptimal control of CVRFs; they also show that compared with men women with CVD were less likely to achieve therapeutic goals for BMI, BP, LDH-cholesterol, and HbA1c and that those without a history of CVD were also less likely to achieve BMI and LDL-cholesterol recommended goals. Furthermore, although the proportion of women treated with lipid-lowering medications was similar to or even higher than men, LDL-cholesterol levels were remarkably uncontrolled in both women with and without CVD, and women with CVD still had uncontrolled BP relative to men in spite of being treated with antihypertensive drugs in a comparable proportion of cases. The observed differences have clinical implications that warrant further investigation through studies specifically designed to assess gender differences in the control of modifiable CVRF and further stress the need to implement measures to better prevent and treat this subgroup of diabetic women. Actions should include not only targeted awareness programs for health professionals, but also the implementation of specific educational programs aimed at improving self-awareness and self-care in women with T2DM.
The authors declare that there is no conflict of interests regarding the publication of this paper.
The Catalan Diabetes Association, the Catalan Health Department, and part of an unrestricted grant provided by Sanofi-aventis Spain supported this study, as well as the Network of Preventive Activities and Health Promotion in Primary Care (redIAPP) granted by the Instituto de Salud Carlos III (RD06/0018). The authors also acknowledge Mònica Gratacòs and Maren White for providing support in the paper preparation and editing.