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Managing the Multiple Symptoms of Benign Prostatic Hyperplasia — CME
Managing Type 2 Diabetes in Men
Meeting New Challenges with Antiplatelet Therapy in Primary Care
Dr. Aguilar has disclosed that he has ongoing relationships with the following companies: Amylin Pharmaceuticals; Eli Lilly; Janssen Pharmaceuticals, Inc; Novo Nordisk, Inc; and Takeda Pharmaceuticals USA, Inc.
SUPPORT
This program is sponsored by the PCEC and is supported by funding from Novo Nordisk, Inc.
The prevalence of type 2 diabetes mellitus (T2DM) is similar in men and women (11.8% vs 10.8%, respectively), however there are gender differences that should be considered when developing a treatment plan (eg, cardiovascular risk, psychosocial factors, coping strategies, and the perception of benefit from self-care) when managing those diagnosed with this disease and those at risk for developing it.1 This article describes these differences in the context of two patients—one at risk for T2DM being seen by his health care provider for a routine physical examination, and one who has been treated for several years for T2DM and is being seen for a follow-up office visit. For each patient, the implications for treatment are discussed.
Men at Risk for Type 2 Diabetes Mellitus
JW is a 48-year-old white male being seen for a routine physical examination; he last saw a physician 6 years ago, also for a routine physical. He has no complaints and is taking no medications. Having divorced 7 years ago, he lives alone in an apartment and eats many of his meals at fast food restaurants. JW drinks 2 to 3 beers a night several times a week and more when he socializes with his friends 2 to 3 evenings per week. He smokes socially. His father has a 12-year history of T2DM. His mother has a 4-year history of essential hypertension and a 9-year history of chronic obstructive pulmonary disease.
Physical examination shows that JW is 5’11” tall, weighs 207 pounds (body mass index (BMI), 29 kg/m2), and has a 41” waist circumference; his blood pressure (BP) is 138/86 mm Hg and respiratory rate is 17 breaths/min. The remainder of his physical examination, including eye and neurologic exams, is normal. Laboratory results, including a screening glycated homoglobin (A1C), are pending.
Key Risk Factors for Type 2 Diabetes Mellitus in Men
This case is not an uncommon presentation of a middle-aged male who has several risk factors for diabetes (see Case Study 1 continued ). JW also has key risk factors for T2DM in men. The Monitoring of Trends and Determinants in Cardiovascular Disease (MONICA) Augsburg surveys identified 128 men and 85 women with T2DM.2 Increasing age and BMI, positive parental history of T2DM, and a low high-density lipoprotein cholesterol (HDL-C) level were independent risk factors predicting the development of T2DM in both men and women. However, several other factors posed a higher risk in men relative to women, including systolic BP (hazard ratio [HR], 1.16 per 10-mm Hg increase), regular smoking (HR, 1.75), and alcohol intake ≥ 40 g/d (HR, 1.95). (Note: 1 fluid ounce 80 proof alcohol ≈ 11 g ethanol; 12 fluid ounces beer [~5% alcohol] ≈ 14 g ethanol). After adjusting for these factors, a separate analysis (4424 men, 4380 women) showed that men who lived alone were more likely to develop T2DM than either men or women who did not live alone (HR, 1.69 in men vs 0.85 in women; P = .006).3 While the number of people with T2DM in MONICA was small, the results suggest that measuring BP, particularly systolic BP, and taking a smoking and alcohol history may be especially important in men.
With respect to alcohol intake, epidemiologic and randomized clinical trials have generally demonstrated an inverse relationship between moderate alcohol consumption (20 to 30 g/d) and the long-term risk of T2DM.2,4-7 Differences among studies in how patients were grouped preclude determination of the daily alcohol consumption that confers the greatest risk benefit, although one recent study conducted over 4 years indicates that the greatest benefit in diabetes risk reduction may occur when men who previously consumed 8
Other nutrition and lifestyle patterns also seem to be particularly beneficial in reducing the risk of T2DM in men. Survey data involving 22,921 Japanese men and 29,759 Japanese women followed over 5 years showed that fish and seafood intake was significantly associated with a decreased risk of T2DM in men but not in women.9 The odds ratio of developing T2DM for the highest quartile versus the lowest quartile of fish and seafood intake was 0.73 (P = .04 for trend). Additional analysis did not identify any significant association with the fat content of fish.
Results of the Health Professionals Follow-up Study provide evidence of benefit in lowering the risk of T2DM in men who consume high amounts of low-fat dairy products, whole grains, and magnesium ( TABLE 1 ). With respect to dairy food consumption, after 12 years of follow-up involving 1243 incident cases of T2DM, the relative risk (RR) of developing T2DM in men in the top quintile of dairy intake was 0.77 compared with those in the lowest quintile (P = .003 for trend).10 Men in the highest quintile consumed 4.1 servings of dairy food per day compared with 0.5 servings per day in the lowest quintile. Each serving-per-day increase in total dairy intake was associated with a 9% lower risk for T2DM, with a lower risk seen with consumption of low-fat vs high-fat dairy food. With respect to whole-grain intake, the RR of developing T2DM was 0.58 in men in the upper vs lower quintiles (3.2 vs 0.4 servings/d), although the effect was attenuated with BMI (P = .0006 for trend).11 Similar observations were made with respect to magnesium consumption; a RR of 0.76 for T2DM was observed in men with a median magnesium consumption of 457 mg/d compared with those who consumed 270 mg/d.12
TABLE 1
Suggestions for Men Who Are at Risk of or Have Been Diagnosed with Type 2 Diabetes Mellitus (T2DM)*
For men who are at risk:
|
For men who have been diagnosed:
|
| BP, blood pressure; HDL-C, high-density lipoprotein cholesterol. *These suggestions are in addition to developing and fostering a collaborative, patient-centered approach. |
JW has the following risk factors for T2DM:
- Overweight with central adiposity
- Physical inactivity
- First-degree relative with T2DM
- Possible cardiovascular disease (CVD; hypertension, smoking)
- High daily alcohol intake (10 to 20 g alcohol/beer x 2-3 beers/d = 20 to 60 g alcohol/d)
- Poor nutrition
- Lives alone
Plan:
- Discuss above risk factors with JW
- Repeat BP measurement at next visit; implement treatment if BP >140/90 mm Hg (130/80 mm Hg if T2DM is diagnosed)
- Consider evaluation for alcohol/substance abuse
- Evaluate for smoking cessation program
- Nutrition referral for lifestyle and dietary management intervention
Working with men to avoid the development of T2DM is an important objective for family physicians. It is essential to identify men who are at increased risk, including those with prediabetes, provide education about the disease and its risk factors, and implement appropriate risk reduction strategies. Risk reduction strategies should focus on modifiable factors, such as body weight, physical activity, BP, blood lipids, blood glucose, and smoking. With JW, his motivation to “get back into shape” will help move the conversation toward achievable goals that can be set and modified over time. Other strategies that may be helpful in reducing the risk of developing T2DM in men include a moderate daily alcohol intake and a diet high in fish and seafood, low-fat dairy products, whole grains, and magnesium ( TABLE 1 ).
Once diagnosed with T2DM, there are risk management strategies that can be particularly helpful in men. These include strategies that target cardiovascular health, as well as those that consider the psychosocial and coping behaviors of men.
Risk of Complications in Men With Type 2 Diabetes Mellitus
Physical examination: BP, 126/78 mm Hg; body weight, 183 pounds (a 13 to 17 pound increase since the knee injury); waist circumference, 38” (BMI, 28 kg/m2); grade 1 retinopathy bilaterally; neurologic exam normal.
Laboratory: A1C, 7.8%; lipids normal except triglyceride level, 219 mg/dL; creatinine clearance (calculated), 69 mL/min; urine, 45 mg albumin/g creatinine.
MR’s self-measured fasting plasma glucose (FPG) has ranged from 121 to 143 mg/dL over the past month; isolated postprandial glucose (PPG) measurements show 194 to 258 mg/dL.
MR works as a vocational teacher at the local high school, and he teaches driver education after school. Review of his pharmacy records suggests his adherence over the past year has been: metformin (88%), hydrochlorothiazide (72%), and lisinopril (72%).
Assessment:
- A1C level of 7.8% indicates an estimated average glucose (eAG) of 177 mg/dL13
- –Mildly elevated FPG and PPG
- –Evidence of microvascular disease (retinopathy, nephropathy)
- –Creatinine clearance 69 mL/min and microalbuminuria indicate stage 2 chronic kidney disease14
In addition to referring MR for physical rehabilitation of his knee, you discuss with MR the need and options for intensifying his diabetes therapy.
Does the fact that MR is male affect your management plan?
In people diagnosed with T2DM, there are differences between men and women with respect to risk for cardiovascular and other comorbid diseases, as well as in their psychosocial well-being and coping strategies.
Risk for Cardiovascular Disease in Type 2 Diabetes Mellitus
A systematic literature review shows that men with T2DM generally fare better than women with T2DM regarding their risk for CVD. Men with T2DM have a 2- to 3-fold increase in the risk of developing coronary heart disease (CHD) compared with men without T2DM, whereas women with T2DM have a 4- to 6-fold increase in risk compared with women without T2DM.15 Compared with women with T2DM, men with T2DM also have a better prognosis after myocardial infarction (MI) and a lower risk of death overall from CVD. Possible reasons for these differences include a lower risk of hypertension, a less severe form of dyslipidemia, and a lower prevalence of obesity in men with T2DM compared with women with T2DM.15 These same reasons for observed differences between men and women were seen in a meta-analysis of 29 studies, where the RR of fatal MI in men with T2DM compared with women with T2DM was 0.68.16 Similar findings were seen in the Skaraborg Project, which involved 1116 Swedish patients with hypertension and/or T2DM.17 Compared with a healthy population, the age-adjusted HR for fatal MI was 1.9 for men with T2DM and 5.0 for women with T2DM over 8.1 years of follow-up (RR, 0.38 for men vs women). Analysis of the data indicated that these results were not explained by the more favorable survival rate in women without T2DM than in men without T2DM.17
Somewhat different results have been reported by the Italian Diabetes and Informatics Study Group in a slightly different T2DM population. This investigation involved men and women with T2DM (N = 11,644) who could have microvascular but not macrovascular disease.18 After 4 years of follow-up, the age-adjusted incident rates for first CHD event (composite of acute MI, coronary artery bypass grafting, percutaneous transluminal coronary angioplasty) were 28.8 per 1000 person-years in men and 23.3 per 1000 person-years in women. Incident rates (per 1000 person-years) of acute MI (10.3 vs 4.7), major CHD events (13.1 vs 5.8), and fatal CHD (2.6 vs 0.6) were all significantly more frequent in men than in women, respectively. Multivariate analysis showed that hypertension and A1C were additional risk factors for CHD in men; for each 20% increment above the A1C upper limit of normal, there was a 14% risk increase for CHD. The presence of microvascular complications increased risk by 20% in men and 35% in women. In this analysis, glycemic control and hypertension were found to be the predominant risk factors in men, while high triglyceride levels, low HDL-C levels, and microangiopathy were predominant in women.
Additional multivariate analyses provide greater insight into specific factors that affect the risk of CVD and outcomes in men with T2DM. One investigation compared men and women with T2DM who were normotensive without evidence of CVD but with microalbuminuria. After 4.7 years of follow-up, men were found to be at lower risk (RR, 0.12) for a composite of death, acute MI, unstable angina, coronary interventions, heart failure, cerebral ischemic stroke or transient ischemic attack, and peripheral artery disease.19 Other investigators have reported a lower risk of stroke, including fatal stroke, in men with T2DM compared with women with T2DM.20,21 For example, analysis of the General Practice Research Database identified 22,178 men and 19,621 women with T2DM between the ages of 35 and 89 years.20 The stroke rate per 1000 person-years across all ages was 10.82 (95% confidence interval (CI), 10.17-11.51) in men and 13.16 (95% CI, 12.40-13.97) in women. In men, the rate per 1000 person-years rose from 1.81 in the 35 to 44 year age group to 28.35 in men 85 years of age or older. Although the rate of stroke per 1000 person-years was lower in women than men in the 35 to 44 year age group (1.53 vs 1.81), the rate in women exceeded that of men in the 85 years of age or older group (32.20 vs 28.35).
Other Chronic Complications
Kidney disease is affected by blood lipids, specifically HDL-C, in men with T2DM. An investigation in men and women with T2DM with normoalbuminuria or microalbuminuria at baseline showed that a low HDL-C level was an independent predictor of progression to a more advanced stage of albuminuria over 4.3 years of follow-up (HR, 0.391 for men with normal HDL-C compared with men with low HDL-C). In women, no lipid parameters were associated with progression of albuminuria.22
While these investigations do not provide a clear picture of the differences regarding cardiovascular risk between men and women with T2DM, they suggest that men with T2DM have a lower risk of nonfatal and fatal CVD and stroke than do women with T2DM. However, the lower risk seen in men may be affected by the cardiovascular endpoints measured and the presence of microvascular disease. Possible independent risk factors for CVD in men with T2DM include hypertension, poor glycemic control, and low HDL-C.
Risk factors that place MR at greater risk for CVD compared with a woman with T2DM and therefore serve as key treatment targets include:
- Hypertension—although controlled (126/78 mm Hg) with hydrochlorothiazide and lisinopril
- Poor glycemic control—A1C, 7.8% (eAG, 177mg/dL)
- –Increase physical activity—refer for knee rehabilitation
- –Intensify glucose-lowering therapy by adding an additional glucose-lowering agent (eg, dipeptidyl peptidase-4 inhibitor, glucagon-like peptide-1 receptor agonist, thiazolidinedione, α-glucosidase inhibitor, sulfonylurea, glinide, or basal insulin)
- Microalbuminuria (45 mg urinary albumin/g creatinine)—encourage better adherence to lisinopril; monitor renal function
- Hypertriglyceridemia—initiate omega-3 fatty acid or extended-release niacin
Psychosocial Well-Being, Benefit of Self-Care, and Coping Strategies
Type 2 diabetes mellitus is a chronic disease with glycemic control largely determined by patient self-management, and the attitudes and beliefs of patients with T2DM are important factors to consider from diagnosis onward.23 There are important differences between men and women with T2DM regarding attitudes and beliefs. Published investigations provide some, although not entirely consistent, insight into these psychosocial differences between men and women with T2DM. These differences are summarized in TABLE 2 .24-32 Taking these differences into account when planning treatment and when communicating with and educating the patient is essential for improved patient self-management.
TABLE 2
Psychosocial and Coping Characteristics of Men with Type 2 Diabetes Mellitus (T2DM)24-32
Compared with women with T2DM, generally, men with T2DM:
|
Key interventions for MR:
- Maintain a dialogue and enhance collaboration with MR
- Establish shared goals that are customized to incorporate MR’s personal goals
- Problem solve with MR to identify ways he can better integrate the diabetes self-care objectives of dietary changes and blood glucose self-monitoring into his daily life
- Emphasize that enhanced or greater disease control can be achieved by good self-management, including better adherence to the management plan
- Remind MR that T2DM is a progressive disease that requires intermittent medication adjustments to keep pace with its progression
- Build upon the belief that T2DM can be controlled by reminding MR that the disease was well controlled before his knee injury
- –Focus on the importance of rehabilitating his knee
- –Develop a rehabilitation plan
- Provide informational support regarding options for intensifying diabetes therapy (eg, dipeptidyl peptidase-4 inhibitor, thiazolidinedione, glucagon-like peptide-1 receptor agonist, sulfonylurea, or insulin)
- –Discuss MR’s needs and concerns, as well as barriers for each treatment option, particularly hypoglycemia and weight gain
- –Provide instruction or educational materials regarding injection devices
- –Involve the healthcare team, as appropriate
- Keep the treatment regimen as simple as possible; consider pill combinations where appropriate
Summary
The growing epidemic of T2DM requires intervention to assist patients who have been diagnosed to better manage the disease, to reduce the risk of developing the disease in those who have not yet been diagnosed, and to manage the associated complications. In addition to individualizing interventions based on a patient’s needs, concerns, and capabilities, taking gender into account is necessary. In otherwise healthy people, several independent factors appear to pose a higher risk of T2DM in men relative to women, including systolic hypertension, regular smoking, and alcohol intake ≥ 40 g/d. At the same time, men achieve greater risk reduction from moderate daily alcohol intake and a diet high in fish and seafood, low-fat dairy products, whole grains, and magnesium.
Once diagnosed with T2DM, men generally fare better than women regarding the risk for CVD; they also have a better prognosis after MI and a lower risk of death overall from CVD. Possible independent risk factors for CVD in men with T2DM that are especially important may include hypertension, poor glycemic control, and low HDL-C levels. Psychosocial complications, such as depression, are less likely in men with T2DM. However, men expend less effort coping, are less likely to utilize healthcare services, and are less informed about treatment options. Although men have a lower expectation of the benefit of self-management, they find support from family and friends more helpful than do women, but they are fearful of losing control of their disease.
Taking these gender differences into account should prove helpful as family care physicians work with men to reduce their risk of developing T2DM and in helping men diagnosed with T2DM to better self-manage their disease.
1. Centers for Disease Control and Prevention. National diabetes fact sheet: national estimates and general information on diabetes and prediabetes in the United States, 2011. http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2011.pdf. Published 2011. Accessed May 2, 2011.
2. Meisinger C, Thorand B, Schneider A, Stieber J, Doring A, Lowel H. Sex differences in risk factors for incident type 2 diabetes mellitus: the MONICA Augsburg cohort study. Arch Intern Med. 2002;162(1):82-89.
3. Meisinger C, Kandler U, Ladwig KH. Living alone is associated with an increased risk of type 2 diabetes mellitus in men but not women from the general population: the MONICA/KORA Augsburg Cohort Study. Psychosom Med. 2009;71(7):784-788.
4. Baliunas DO, Taylor BJ, Irving H, et al. Alcohol as a risk factor for type 2 diabetes: a systematic review and meta-analysis. Diabetes Care. 2009;32(11):2123-2132.
5. Mozaffarian D, Kamineni A, Carnethon M, Djoussé L, Mukamal KJ, Siscovick D. Lifestyle risk factors and new-onset diabetes mellitus in older adults: the cardiovascular health study. Arch Intern Med. 2009;169(8):798-807.
6. Joosten MM, Grobbee DE, van der A DL, Verschuren WM, Hendriks HF, Beulens JW. Combined effect of alcohol consumption and lifestyle behaviors on risk of type 2 diabetes. Am J Clin Nutr. 2010;91(6):1777-1783.
7. Gigleux I, Gagnon J, St-Pierre A, et al. Moderate alcohol consumption is more cardioprotective in men with the metabolic syndrome. J Nutr. 2006;136(12):3027-3032.
8. Joosten MM, Chiuve SE, Mukamal KJ, Hu FB, Hendriks HF, Rimm EB. Changes in alcohol consumption and subsequent risk of type 2 diabetes in men. Diabetes. 2011;60(1):74-79.
9. Nanri A, Mizoue T, Noda M, et al. Fish intake and type 2 diabetes in Japanese men and women: the Japan Public Health Center-based Prospective Study. Am J Clin Nutr. 2011;94(3):884-891.
10. Choi HK, Willett WC, Stampfer MJ, Rimm E, Hu FB. Dairy consumption and risk of type 2 diabetes mellitus in men: a prospective study. Arch Intern Med. 2005;165(9):997-1003.
11. Fung TT, Hu FB, Pereira MA, et al. Whole-grain intake and the risk of type 2 diabetes: a prospective study in men. Am J Clin Nutr. 2002;76(3):535-540.
12. Lopez-Ridaura R, Willett WC, Rimm EB, et al. Magnesium intake and risk of type 2 diabetes in men and women. Diabetes Care. 2004;27(1):134-140.
13. Nathan DM, Kuenen J, Borg R, et al. Translating the A1C assay into estimated average glucose values. Diabetes Care. 2008;31(8):1473-1478.
14. Levey AS, Coresh J, Balk E, et al. National Kidney Foundation practice guidelines for chronic kidney disease: evaluation, classification, and stratification. Ann Intern Med. 2003;139(2):137-147.
15. Legato MJ, Gelzer A, Goland R, et al. Gender-specific care of the patient with diabetes: review and recommendations. Gend Med. 2006;3(2):131-158.
16. Huxley R, Barzi F, Woodward M. Excess risk of fatal coronary heart disease associated with diabetes in men and women: meta-analysis of 37 prospective cohort studies. BMJ. 2006;332(7533):73-78.
17. Larsson CA, Gullberg B, Merlo J, Rastam L, Lindblad U. Female advantage in AMI mortality is reversed in patients with type 2 diabetes in the Skaraborg Project. Diabetes Care. 2005;28(9):2246-2248.
18. Avogaro A, Giorda C, Maggini M, et al. Incidence of coronary heart disease in type 2 diabetic men and women: impact of microvascular complications, treatment, and geographic location. Diabetes Care. 2007;30(5):1241-1247.
19. Zandbergen AA, Sijbrands EJ, Lamberts SW, Bootsma AH. Normotensive women with type 2 diabetes and microalbuminuria are at high risk for macrovascular disease. Diabetes Care. 2006;29(8):1851-1855.
20. Mulnier HE, Seaman HE, Raleigh VS, et al. Risk of stroke in people with type 2 diabetes in the UK: a study using the General Practice Research Database. Diabetologia. 2006;49(12):2859-2865.
21. Tuomilehto J, Rastenyte D, Jousilahti P, Sarti C, Vartiainen E. Diabetes mellitus as a risk factor for death from stroke. Prospective study of the middle-aged Finnish population. Stroke. 1996;27(2):210-215.
22. Hanai K, Babazono T, Yoshida N, et al. Gender differences in the association between HDL cholesterol and the progression of diabetic kidney disease in type 2 diabetic patients. Nephrol Dial Transplant. 2012;27(3):1070-1075.
23. Tuerk PW, Mueller M, Egede LE. Estimating physician effects on glycemic control in the treatment of diabetes: methods, effects sizes, and implications for treatment policy. Diabetes Care. 2008;31(5):869-873.
24. Rubin RR, Peyrot M, Siminerio LM. Health care and patient-reported outcomes: results of the cross-national Diabetes Attitudes, Wishes and Needs (DAWN) study. Diabetes Care. 2006;29(6):1249-1255.
25. McCollum M, Hansen LB, Ghushchyan V, Sullivan PW. Inconsistent health perceptions for US women and men with diabetes. J Womens Health (Larchmt). 2007;16(10):1421-1428.
26. Gucciardi E, Wang SC, DeMelo M, Amaral L, Stewart DE. Characteristics of men and women with diabetes: observations during patients’ initial visit to a diabetes education centre. Can Fam Physician. 2008;54(2):219-227.
27. Chiu CJ, Wray LA. Physical disability trajectories in older Americans with and without diabetes: the role of age, gender, race or ethnicity, and education. Gerontologist. 2011;51(1):51-63.
28. Nielsen AB, de Fine Olivarius N, Gannik D, Hindsberger C, Hollnagel H. Structured personal diabetes care in primary health care affects only women’s HbA1c. Diabetes Care. 2006;29(5):963-969.
29. Shalev V, Chodick G, Heymann AD, Kokia E. Gender differences in healthcare utilization and medical indicators among patients with diabetes. Public Health. 2005;119(1):45-49.
30. Kacerovsky-Bielesz G, Lienhardt S, Hagenhofer M, et al. Sex-related psychological effects on metabolic control in type 2 diabetes mellitus. Diabetologia. 2009;52(5):781-788.
31. Brown SA, Harrist RB, Villagomez ET, Segura M, Barton SA, Hanis CL. Gender and treatment differences in knowledge, health beliefs, and metabolic control in Mexican Americans with type 2 diabetes. Diabetes Educ. 2000;26(3):425-438.
32. Liburd LC, Namageyo-Funa A, Jack L, Jr. Understanding “masculinity” and the challenges of managing type-2 diabetes among African-American men. J Natl Med Assoc. 2007;99(5):550-552, 554–558.
Managing the Multiple Symptoms of Benign Prostatic Hyperplasia — CME
Managing Type 2 Diabetes in Men
Meeting New Challenges with Antiplatelet Therapy in Primary Care
Dr. Aguilar has disclosed that he has ongoing relationships with the following companies: Amylin Pharmaceuticals; Eli Lilly; Janssen Pharmaceuticals, Inc; Novo Nordisk, Inc; and Takeda Pharmaceuticals USA, Inc.
SUPPORT
This program is sponsored by the PCEC and is supported by funding from Novo Nordisk, Inc.
The prevalence of type 2 diabetes mellitus (T2DM) is similar in men and women (11.8% vs 10.8%, respectively), however there are gender differences that should be considered when developing a treatment plan (eg, cardiovascular risk, psychosocial factors, coping strategies, and the perception of benefit from self-care) when managing those diagnosed with this disease and those at risk for developing it.1 This article describes these differences in the context of two patients—one at risk for T2DM being seen by his health care provider for a routine physical examination, and one who has been treated for several years for T2DM and is being seen for a follow-up office visit. For each patient, the implications for treatment are discussed.
Men at Risk for Type 2 Diabetes Mellitus
JW is a 48-year-old white male being seen for a routine physical examination; he last saw a physician 6 years ago, also for a routine physical. He has no complaints and is taking no medications. Having divorced 7 years ago, he lives alone in an apartment and eats many of his meals at fast food restaurants. JW drinks 2 to 3 beers a night several times a week and more when he socializes with his friends 2 to 3 evenings per week. He smokes socially. His father has a 12-year history of T2DM. His mother has a 4-year history of essential hypertension and a 9-year history of chronic obstructive pulmonary disease.
Physical examination shows that JW is 5’11” tall, weighs 207 pounds (body mass index (BMI), 29 kg/m2), and has a 41” waist circumference; his blood pressure (BP) is 138/86 mm Hg and respiratory rate is 17 breaths/min. The remainder of his physical examination, including eye and neurologic exams, is normal. Laboratory results, including a screening glycated homoglobin (A1C), are pending.
Key Risk Factors for Type 2 Diabetes Mellitus in Men
This case is not an uncommon presentation of a middle-aged male who has several risk factors for diabetes (see Case Study 1 continued ). JW also has key risk factors for T2DM in men. The Monitoring of Trends and Determinants in Cardiovascular Disease (MONICA) Augsburg surveys identified 128 men and 85 women with T2DM.2 Increasing age and BMI, positive parental history of T2DM, and a low high-density lipoprotein cholesterol (HDL-C) level were independent risk factors predicting the development of T2DM in both men and women. However, several other factors posed a higher risk in men relative to women, including systolic BP (hazard ratio [HR], 1.16 per 10-mm Hg increase), regular smoking (HR, 1.75), and alcohol intake ≥ 40 g/d (HR, 1.95). (Note: 1 fluid ounce 80 proof alcohol ≈ 11 g ethanol; 12 fluid ounces beer [~5% alcohol] ≈ 14 g ethanol). After adjusting for these factors, a separate analysis (4424 men, 4380 women) showed that men who lived alone were more likely to develop T2DM than either men or women who did not live alone (HR, 1.69 in men vs 0.85 in women; P = .006).3 While the number of people with T2DM in MONICA was small, the results suggest that measuring BP, particularly systolic BP, and taking a smoking and alcohol history may be especially important in men.
With respect to alcohol intake, epidemiologic and randomized clinical trials have generally demonstrated an inverse relationship between moderate alcohol consumption (20 to 30 g/d) and the long-term risk of T2DM.2,4-7 Differences among studies in how patients were grouped preclude determination of the daily alcohol consumption that confers the greatest risk benefit, although one recent study conducted over 4 years indicates that the greatest benefit in diabetes risk reduction may occur when men who previously consumed 8
Other nutrition and lifestyle patterns also seem to be particularly beneficial in reducing the risk of T2DM in men. Survey data involving 22,921 Japanese men and 29,759 Japanese women followed over 5 years showed that fish and seafood intake was significantly associated with a decreased risk of T2DM in men but not in women.9 The odds ratio of developing T2DM for the highest quartile versus the lowest quartile of fish and seafood intake was 0.73 (P = .04 for trend). Additional analysis did not identify any significant association with the fat content of fish.
Results of the Health Professionals Follow-up Study provide evidence of benefit in lowering the risk of T2DM in men who consume high amounts of low-fat dairy products, whole grains, and magnesium ( TABLE 1 ). With respect to dairy food consumption, after 12 years of follow-up involving 1243 incident cases of T2DM, the relative risk (RR) of developing T2DM in men in the top quintile of dairy intake was 0.77 compared with those in the lowest quintile (P = .003 for trend).10 Men in the highest quintile consumed 4.1 servings of dairy food per day compared with 0.5 servings per day in the lowest quintile. Each serving-per-day increase in total dairy intake was associated with a 9% lower risk for T2DM, with a lower risk seen with consumption of low-fat vs high-fat dairy food. With respect to whole-grain intake, the RR of developing T2DM was 0.58 in men in the upper vs lower quintiles (3.2 vs 0.4 servings/d), although the effect was attenuated with BMI (P = .0006 for trend).11 Similar observations were made with respect to magnesium consumption; a RR of 0.76 for T2DM was observed in men with a median magnesium consumption of 457 mg/d compared with those who consumed 270 mg/d.12
TABLE 1
Suggestions for Men Who Are at Risk of or Have Been Diagnosed with Type 2 Diabetes Mellitus (T2DM)*
For men who are at risk:
|
For men who have been diagnosed:
|
| BP, blood pressure; HDL-C, high-density lipoprotein cholesterol. *These suggestions are in addition to developing and fostering a collaborative, patient-centered approach. |
JW has the following risk factors for T2DM:
- Overweight with central adiposity
- Physical inactivity
- First-degree relative with T2DM
- Possible cardiovascular disease (CVD; hypertension, smoking)
- High daily alcohol intake (10 to 20 g alcohol/beer x 2-3 beers/d = 20 to 60 g alcohol/d)
- Poor nutrition
- Lives alone
Plan:
- Discuss above risk factors with JW
- Repeat BP measurement at next visit; implement treatment if BP >140/90 mm Hg (130/80 mm Hg if T2DM is diagnosed)
- Consider evaluation for alcohol/substance abuse
- Evaluate for smoking cessation program
- Nutrition referral for lifestyle and dietary management intervention
Working with men to avoid the development of T2DM is an important objective for family physicians. It is essential to identify men who are at increased risk, including those with prediabetes, provide education about the disease and its risk factors, and implement appropriate risk reduction strategies. Risk reduction strategies should focus on modifiable factors, such as body weight, physical activity, BP, blood lipids, blood glucose, and smoking. With JW, his motivation to “get back into shape” will help move the conversation toward achievable goals that can be set and modified over time. Other strategies that may be helpful in reducing the risk of developing T2DM in men include a moderate daily alcohol intake and a diet high in fish and seafood, low-fat dairy products, whole grains, and magnesium ( TABLE 1 ).
Once diagnosed with T2DM, there are risk management strategies that can be particularly helpful in men. These include strategies that target cardiovascular health, as well as those that consider the psychosocial and coping behaviors of men.
Risk of Complications in Men With Type 2 Diabetes Mellitus
Physical examination: BP, 126/78 mm Hg; body weight, 183 pounds (a 13 to 17 pound increase since the knee injury); waist circumference, 38” (BMI, 28 kg/m2); grade 1 retinopathy bilaterally; neurologic exam normal.
Laboratory: A1C, 7.8%; lipids normal except triglyceride level, 219 mg/dL; creatinine clearance (calculated), 69 mL/min; urine, 45 mg albumin/g creatinine.
MR’s self-measured fasting plasma glucose (FPG) has ranged from 121 to 143 mg/dL over the past month; isolated postprandial glucose (PPG) measurements show 194 to 258 mg/dL.
MR works as a vocational teacher at the local high school, and he teaches driver education after school. Review of his pharmacy records suggests his adherence over the past year has been: metformin (88%), hydrochlorothiazide (72%), and lisinopril (72%).
Assessment:
- A1C level of 7.8% indicates an estimated average glucose (eAG) of 177 mg/dL13
- –Mildly elevated FPG and PPG
- –Evidence of microvascular disease (retinopathy, nephropathy)
- –Creatinine clearance 69 mL/min and microalbuminuria indicate stage 2 chronic kidney disease14
In addition to referring MR for physical rehabilitation of his knee, you discuss with MR the need and options for intensifying his diabetes therapy.
Does the fact that MR is male affect your management plan?
In people diagnosed with T2DM, there are differences between men and women with respect to risk for cardiovascular and other comorbid diseases, as well as in their psychosocial well-being and coping strategies.
Risk for Cardiovascular Disease in Type 2 Diabetes Mellitus
A systematic literature review shows that men with T2DM generally fare better than women with T2DM regarding their risk for CVD. Men with T2DM have a 2- to 3-fold increase in the risk of developing coronary heart disease (CHD) compared with men without T2DM, whereas women with T2DM have a 4- to 6-fold increase in risk compared with women without T2DM.15 Compared with women with T2DM, men with T2DM also have a better prognosis after myocardial infarction (MI) and a lower risk of death overall from CVD. Possible reasons for these differences include a lower risk of hypertension, a less severe form of dyslipidemia, and a lower prevalence of obesity in men with T2DM compared with women with T2DM.15 These same reasons for observed differences between men and women were seen in a meta-analysis of 29 studies, where the RR of fatal MI in men with T2DM compared with women with T2DM was 0.68.16 Similar findings were seen in the Skaraborg Project, which involved 1116 Swedish patients with hypertension and/or T2DM.17 Compared with a healthy population, the age-adjusted HR for fatal MI was 1.9 for men with T2DM and 5.0 for women with T2DM over 8.1 years of follow-up (RR, 0.38 for men vs women). Analysis of the data indicated that these results were not explained by the more favorable survival rate in women without T2DM than in men without T2DM.17
Somewhat different results have been reported by the Italian Diabetes and Informatics Study Group in a slightly different T2DM population. This investigation involved men and women with T2DM (N = 11,644) who could have microvascular but not macrovascular disease.18 After 4 years of follow-up, the age-adjusted incident rates for first CHD event (composite of acute MI, coronary artery bypass grafting, percutaneous transluminal coronary angioplasty) were 28.8 per 1000 person-years in men and 23.3 per 1000 person-years in women. Incident rates (per 1000 person-years) of acute MI (10.3 vs 4.7), major CHD events (13.1 vs 5.8), and fatal CHD (2.6 vs 0.6) were all significantly more frequent in men than in women, respectively. Multivariate analysis showed that hypertension and A1C were additional risk factors for CHD in men; for each 20% increment above the A1C upper limit of normal, there was a 14% risk increase for CHD. The presence of microvascular complications increased risk by 20% in men and 35% in women. In this analysis, glycemic control and hypertension were found to be the predominant risk factors in men, while high triglyceride levels, low HDL-C levels, and microangiopathy were predominant in women.
Additional multivariate analyses provide greater insight into specific factors that affect the risk of CVD and outcomes in men with T2DM. One investigation compared men and women with T2DM who were normotensive without evidence of CVD but with microalbuminuria. After 4.7 years of follow-up, men were found to be at lower risk (RR, 0.12) for a composite of death, acute MI, unstable angina, coronary interventions, heart failure, cerebral ischemic stroke or transient ischemic attack, and peripheral artery disease.19 Other investigators have reported a lower risk of stroke, including fatal stroke, in men with T2DM compared with women with T2DM.20,21 For example, analysis of the General Practice Research Database identified 22,178 men and 19,621 women with T2DM between the ages of 35 and 89 years.20 The stroke rate per 1000 person-years across all ages was 10.82 (95% confidence interval (CI), 10.17-11.51) in men and 13.16 (95% CI, 12.40-13.97) in women. In men, the rate per 1000 person-years rose from 1.81 in the 35 to 44 year age group to 28.35 in men 85 years of age or older. Although the rate of stroke per 1000 person-years was lower in women than men in the 35 to 44 year age group (1.53 vs 1.81), the rate in women exceeded that of men in the 85 years of age or older group (32.20 vs 28.35).
Other Chronic Complications
Kidney disease is affected by blood lipids, specifically HDL-C, in men with T2DM. An investigation in men and women with T2DM with normoalbuminuria or microalbuminuria at baseline showed that a low HDL-C level was an independent predictor of progression to a more advanced stage of albuminuria over 4.3 years of follow-up (HR, 0.391 for men with normal HDL-C compared with men with low HDL-C). In women, no lipid parameters were associated with progression of albuminuria.22
While these investigations do not provide a clear picture of the differences regarding cardiovascular risk between men and women with T2DM, they suggest that men with T2DM have a lower risk of nonfatal and fatal CVD and stroke than do women with T2DM. However, the lower risk seen in men may be affected by the cardiovascular endpoints measured and the presence of microvascular disease. Possible independent risk factors for CVD in men with T2DM include hypertension, poor glycemic control, and low HDL-C.
Risk factors that place MR at greater risk for CVD compared with a woman with T2DM and therefore serve as key treatment targets include:
- Hypertension—although controlled (126/78 mm Hg) with hydrochlorothiazide and lisinopril
- Poor glycemic control—A1C, 7.8% (eAG, 177mg/dL)
- –Increase physical activity—refer for knee rehabilitation
- –Intensify glucose-lowering therapy by adding an additional glucose-lowering agent (eg, dipeptidyl peptidase-4 inhibitor, glucagon-like peptide-1 receptor agonist, thiazolidinedione, α-glucosidase inhibitor, sulfonylurea, glinide, or basal insulin)
- Microalbuminuria (45 mg urinary albumin/g creatinine)—encourage better adherence to lisinopril; monitor renal function
- Hypertriglyceridemia—initiate omega-3 fatty acid or extended-release niacin
Psychosocial Well-Being, Benefit of Self-Care, and Coping Strategies
Type 2 diabetes mellitus is a chronic disease with glycemic control largely determined by patient self-management, and the attitudes and beliefs of patients with T2DM are important factors to consider from diagnosis onward.23 There are important differences between men and women with T2DM regarding attitudes and beliefs. Published investigations provide some, although not entirely consistent, insight into these psychosocial differences between men and women with T2DM. These differences are summarized in TABLE 2 .24-32 Taking these differences into account when planning treatment and when communicating with and educating the patient is essential for improved patient self-management.
TABLE 2
Psychosocial and Coping Characteristics of Men with Type 2 Diabetes Mellitus (T2DM)24-32
Compared with women with T2DM, generally, men with T2DM:
|
Key interventions for MR:
- Maintain a dialogue and enhance collaboration with MR
- Establish shared goals that are customized to incorporate MR’s personal goals
- Problem solve with MR to identify ways he can better integrate the diabetes self-care objectives of dietary changes and blood glucose self-monitoring into his daily life
- Emphasize that enhanced or greater disease control can be achieved by good self-management, including better adherence to the management plan
- Remind MR that T2DM is a progressive disease that requires intermittent medication adjustments to keep pace with its progression
- Build upon the belief that T2DM can be controlled by reminding MR that the disease was well controlled before his knee injury
- –Focus on the importance of rehabilitating his knee
- –Develop a rehabilitation plan
- Provide informational support regarding options for intensifying diabetes therapy (eg, dipeptidyl peptidase-4 inhibitor, thiazolidinedione, glucagon-like peptide-1 receptor agonist, sulfonylurea, or insulin)
- –Discuss MR’s needs and concerns, as well as barriers for each treatment option, particularly hypoglycemia and weight gain
- –Provide instruction or educational materials regarding injection devices
- –Involve the healthcare team, as appropriate
- Keep the treatment regimen as simple as possible; consider pill combinations where appropriate
Summary
The growing epidemic of T2DM requires intervention to assist patients who have been diagnosed to better manage the disease, to reduce the risk of developing the disease in those who have not yet been diagnosed, and to manage the associated complications. In addition to individualizing interventions based on a patient’s needs, concerns, and capabilities, taking gender into account is necessary. In otherwise healthy people, several independent factors appear to pose a higher risk of T2DM in men relative to women, including systolic hypertension, regular smoking, and alcohol intake ≥ 40 g/d. At the same time, men achieve greater risk reduction from moderate daily alcohol intake and a diet high in fish and seafood, low-fat dairy products, whole grains, and magnesium.
Once diagnosed with T2DM, men generally fare better than women regarding the risk for CVD; they also have a better prognosis after MI and a lower risk of death overall from CVD. Possible independent risk factors for CVD in men with T2DM that are especially important may include hypertension, poor glycemic control, and low HDL-C levels. Psychosocial complications, such as depression, are less likely in men with T2DM. However, men expend less effort coping, are less likely to utilize healthcare services, and are less informed about treatment options. Although men have a lower expectation of the benefit of self-management, they find support from family and friends more helpful than do women, but they are fearful of losing control of their disease.
Taking these gender differences into account should prove helpful as family care physicians work with men to reduce their risk of developing T2DM and in helping men diagnosed with T2DM to better self-manage their disease.
Managing the Multiple Symptoms of Benign Prostatic Hyperplasia — CME
Managing Type 2 Diabetes in Men
Meeting New Challenges with Antiplatelet Therapy in Primary Care
Dr. Aguilar has disclosed that he has ongoing relationships with the following companies: Amylin Pharmaceuticals; Eli Lilly; Janssen Pharmaceuticals, Inc; Novo Nordisk, Inc; and Takeda Pharmaceuticals USA, Inc.
SUPPORT
This program is sponsored by the PCEC and is supported by funding from Novo Nordisk, Inc.
The prevalence of type 2 diabetes mellitus (T2DM) is similar in men and women (11.8% vs 10.8%, respectively), however there are gender differences that should be considered when developing a treatment plan (eg, cardiovascular risk, psychosocial factors, coping strategies, and the perception of benefit from self-care) when managing those diagnosed with this disease and those at risk for developing it.1 This article describes these differences in the context of two patients—one at risk for T2DM being seen by his health care provider for a routine physical examination, and one who has been treated for several years for T2DM and is being seen for a follow-up office visit. For each patient, the implications for treatment are discussed.
Men at Risk for Type 2 Diabetes Mellitus
JW is a 48-year-old white male being seen for a routine physical examination; he last saw a physician 6 years ago, also for a routine physical. He has no complaints and is taking no medications. Having divorced 7 years ago, he lives alone in an apartment and eats many of his meals at fast food restaurants. JW drinks 2 to 3 beers a night several times a week and more when he socializes with his friends 2 to 3 evenings per week. He smokes socially. His father has a 12-year history of T2DM. His mother has a 4-year history of essential hypertension and a 9-year history of chronic obstructive pulmonary disease.
Physical examination shows that JW is 5’11” tall, weighs 207 pounds (body mass index (BMI), 29 kg/m2), and has a 41” waist circumference; his blood pressure (BP) is 138/86 mm Hg and respiratory rate is 17 breaths/min. The remainder of his physical examination, including eye and neurologic exams, is normal. Laboratory results, including a screening glycated homoglobin (A1C), are pending.
Key Risk Factors for Type 2 Diabetes Mellitus in Men
This case is not an uncommon presentation of a middle-aged male who has several risk factors for diabetes (see Case Study 1 continued ). JW also has key risk factors for T2DM in men. The Monitoring of Trends and Determinants in Cardiovascular Disease (MONICA) Augsburg surveys identified 128 men and 85 women with T2DM.2 Increasing age and BMI, positive parental history of T2DM, and a low high-density lipoprotein cholesterol (HDL-C) level were independent risk factors predicting the development of T2DM in both men and women. However, several other factors posed a higher risk in men relative to women, including systolic BP (hazard ratio [HR], 1.16 per 10-mm Hg increase), regular smoking (HR, 1.75), and alcohol intake ≥ 40 g/d (HR, 1.95). (Note: 1 fluid ounce 80 proof alcohol ≈ 11 g ethanol; 12 fluid ounces beer [~5% alcohol] ≈ 14 g ethanol). After adjusting for these factors, a separate analysis (4424 men, 4380 women) showed that men who lived alone were more likely to develop T2DM than either men or women who did not live alone (HR, 1.69 in men vs 0.85 in women; P = .006).3 While the number of people with T2DM in MONICA was small, the results suggest that measuring BP, particularly systolic BP, and taking a smoking and alcohol history may be especially important in men.
With respect to alcohol intake, epidemiologic and randomized clinical trials have generally demonstrated an inverse relationship between moderate alcohol consumption (20 to 30 g/d) and the long-term risk of T2DM.2,4-7 Differences among studies in how patients were grouped preclude determination of the daily alcohol consumption that confers the greatest risk benefit, although one recent study conducted over 4 years indicates that the greatest benefit in diabetes risk reduction may occur when men who previously consumed 8
Other nutrition and lifestyle patterns also seem to be particularly beneficial in reducing the risk of T2DM in men. Survey data involving 22,921 Japanese men and 29,759 Japanese women followed over 5 years showed that fish and seafood intake was significantly associated with a decreased risk of T2DM in men but not in women.9 The odds ratio of developing T2DM for the highest quartile versus the lowest quartile of fish and seafood intake was 0.73 (P = .04 for trend). Additional analysis did not identify any significant association with the fat content of fish.
Results of the Health Professionals Follow-up Study provide evidence of benefit in lowering the risk of T2DM in men who consume high amounts of low-fat dairy products, whole grains, and magnesium ( TABLE 1 ). With respect to dairy food consumption, after 12 years of follow-up involving 1243 incident cases of T2DM, the relative risk (RR) of developing T2DM in men in the top quintile of dairy intake was 0.77 compared with those in the lowest quintile (P = .003 for trend).10 Men in the highest quintile consumed 4.1 servings of dairy food per day compared with 0.5 servings per day in the lowest quintile. Each serving-per-day increase in total dairy intake was associated with a 9% lower risk for T2DM, with a lower risk seen with consumption of low-fat vs high-fat dairy food. With respect to whole-grain intake, the RR of developing T2DM was 0.58 in men in the upper vs lower quintiles (3.2 vs 0.4 servings/d), although the effect was attenuated with BMI (P = .0006 for trend).11 Similar observations were made with respect to magnesium consumption; a RR of 0.76 for T2DM was observed in men with a median magnesium consumption of 457 mg/d compared with those who consumed 270 mg/d.12
TABLE 1
Suggestions for Men Who Are at Risk of or Have Been Diagnosed with Type 2 Diabetes Mellitus (T2DM)*
For men who are at risk:
|
For men who have been diagnosed:
|
| BP, blood pressure; HDL-C, high-density lipoprotein cholesterol. *These suggestions are in addition to developing and fostering a collaborative, patient-centered approach. |
JW has the following risk factors for T2DM:
- Overweight with central adiposity
- Physical inactivity
- First-degree relative with T2DM
- Possible cardiovascular disease (CVD; hypertension, smoking)
- High daily alcohol intake (10 to 20 g alcohol/beer x 2-3 beers/d = 20 to 60 g alcohol/d)
- Poor nutrition
- Lives alone
Plan:
- Discuss above risk factors with JW
- Repeat BP measurement at next visit; implement treatment if BP >140/90 mm Hg (130/80 mm Hg if T2DM is diagnosed)
- Consider evaluation for alcohol/substance abuse
- Evaluate for smoking cessation program
- Nutrition referral for lifestyle and dietary management intervention
Working with men to avoid the development of T2DM is an important objective for family physicians. It is essential to identify men who are at increased risk, including those with prediabetes, provide education about the disease and its risk factors, and implement appropriate risk reduction strategies. Risk reduction strategies should focus on modifiable factors, such as body weight, physical activity, BP, blood lipids, blood glucose, and smoking. With JW, his motivation to “get back into shape” will help move the conversation toward achievable goals that can be set and modified over time. Other strategies that may be helpful in reducing the risk of developing T2DM in men include a moderate daily alcohol intake and a diet high in fish and seafood, low-fat dairy products, whole grains, and magnesium ( TABLE 1 ).
Once diagnosed with T2DM, there are risk management strategies that can be particularly helpful in men. These include strategies that target cardiovascular health, as well as those that consider the psychosocial and coping behaviors of men.
Risk of Complications in Men With Type 2 Diabetes Mellitus
Physical examination: BP, 126/78 mm Hg; body weight, 183 pounds (a 13 to 17 pound increase since the knee injury); waist circumference, 38” (BMI, 28 kg/m2); grade 1 retinopathy bilaterally; neurologic exam normal.
Laboratory: A1C, 7.8%; lipids normal except triglyceride level, 219 mg/dL; creatinine clearance (calculated), 69 mL/min; urine, 45 mg albumin/g creatinine.
MR’s self-measured fasting plasma glucose (FPG) has ranged from 121 to 143 mg/dL over the past month; isolated postprandial glucose (PPG) measurements show 194 to 258 mg/dL.
MR works as a vocational teacher at the local high school, and he teaches driver education after school. Review of his pharmacy records suggests his adherence over the past year has been: metformin (88%), hydrochlorothiazide (72%), and lisinopril (72%).
Assessment:
- A1C level of 7.8% indicates an estimated average glucose (eAG) of 177 mg/dL13
- –Mildly elevated FPG and PPG
- –Evidence of microvascular disease (retinopathy, nephropathy)
- –Creatinine clearance 69 mL/min and microalbuminuria indicate stage 2 chronic kidney disease14
In addition to referring MR for physical rehabilitation of his knee, you discuss with MR the need and options for intensifying his diabetes therapy.
Does the fact that MR is male affect your management plan?
In people diagnosed with T2DM, there are differences between men and women with respect to risk for cardiovascular and other comorbid diseases, as well as in their psychosocial well-being and coping strategies.
Risk for Cardiovascular Disease in Type 2 Diabetes Mellitus
A systematic literature review shows that men with T2DM generally fare better than women with T2DM regarding their risk for CVD. Men with T2DM have a 2- to 3-fold increase in the risk of developing coronary heart disease (CHD) compared with men without T2DM, whereas women with T2DM have a 4- to 6-fold increase in risk compared with women without T2DM.15 Compared with women with T2DM, men with T2DM also have a better prognosis after myocardial infarction (MI) and a lower risk of death overall from CVD. Possible reasons for these differences include a lower risk of hypertension, a less severe form of dyslipidemia, and a lower prevalence of obesity in men with T2DM compared with women with T2DM.15 These same reasons for observed differences between men and women were seen in a meta-analysis of 29 studies, where the RR of fatal MI in men with T2DM compared with women with T2DM was 0.68.16 Similar findings were seen in the Skaraborg Project, which involved 1116 Swedish patients with hypertension and/or T2DM.17 Compared with a healthy population, the age-adjusted HR for fatal MI was 1.9 for men with T2DM and 5.0 for women with T2DM over 8.1 years of follow-up (RR, 0.38 for men vs women). Analysis of the data indicated that these results were not explained by the more favorable survival rate in women without T2DM than in men without T2DM.17
Somewhat different results have been reported by the Italian Diabetes and Informatics Study Group in a slightly different T2DM population. This investigation involved men and women with T2DM (N = 11,644) who could have microvascular but not macrovascular disease.18 After 4 years of follow-up, the age-adjusted incident rates for first CHD event (composite of acute MI, coronary artery bypass grafting, percutaneous transluminal coronary angioplasty) were 28.8 per 1000 person-years in men and 23.3 per 1000 person-years in women. Incident rates (per 1000 person-years) of acute MI (10.3 vs 4.7), major CHD events (13.1 vs 5.8), and fatal CHD (2.6 vs 0.6) were all significantly more frequent in men than in women, respectively. Multivariate analysis showed that hypertension and A1C were additional risk factors for CHD in men; for each 20% increment above the A1C upper limit of normal, there was a 14% risk increase for CHD. The presence of microvascular complications increased risk by 20% in men and 35% in women. In this analysis, glycemic control and hypertension were found to be the predominant risk factors in men, while high triglyceride levels, low HDL-C levels, and microangiopathy were predominant in women.
Additional multivariate analyses provide greater insight into specific factors that affect the risk of CVD and outcomes in men with T2DM. One investigation compared men and women with T2DM who were normotensive without evidence of CVD but with microalbuminuria. After 4.7 years of follow-up, men were found to be at lower risk (RR, 0.12) for a composite of death, acute MI, unstable angina, coronary interventions, heart failure, cerebral ischemic stroke or transient ischemic attack, and peripheral artery disease.19 Other investigators have reported a lower risk of stroke, including fatal stroke, in men with T2DM compared with women with T2DM.20,21 For example, analysis of the General Practice Research Database identified 22,178 men and 19,621 women with T2DM between the ages of 35 and 89 years.20 The stroke rate per 1000 person-years across all ages was 10.82 (95% confidence interval (CI), 10.17-11.51) in men and 13.16 (95% CI, 12.40-13.97) in women. In men, the rate per 1000 person-years rose from 1.81 in the 35 to 44 year age group to 28.35 in men 85 years of age or older. Although the rate of stroke per 1000 person-years was lower in women than men in the 35 to 44 year age group (1.53 vs 1.81), the rate in women exceeded that of men in the 85 years of age or older group (32.20 vs 28.35).
Other Chronic Complications
Kidney disease is affected by blood lipids, specifically HDL-C, in men with T2DM. An investigation in men and women with T2DM with normoalbuminuria or microalbuminuria at baseline showed that a low HDL-C level was an independent predictor of progression to a more advanced stage of albuminuria over 4.3 years of follow-up (HR, 0.391 for men with normal HDL-C compared with men with low HDL-C). In women, no lipid parameters were associated with progression of albuminuria.22
While these investigations do not provide a clear picture of the differences regarding cardiovascular risk between men and women with T2DM, they suggest that men with T2DM have a lower risk of nonfatal and fatal CVD and stroke than do women with T2DM. However, the lower risk seen in men may be affected by the cardiovascular endpoints measured and the presence of microvascular disease. Possible independent risk factors for CVD in men with T2DM include hypertension, poor glycemic control, and low HDL-C.
Risk factors that place MR at greater risk for CVD compared with a woman with T2DM and therefore serve as key treatment targets include:
- Hypertension—although controlled (126/78 mm Hg) with hydrochlorothiazide and lisinopril
- Poor glycemic control—A1C, 7.8% (eAG, 177mg/dL)
- –Increase physical activity—refer for knee rehabilitation
- –Intensify glucose-lowering therapy by adding an additional glucose-lowering agent (eg, dipeptidyl peptidase-4 inhibitor, glucagon-like peptide-1 receptor agonist, thiazolidinedione, α-glucosidase inhibitor, sulfonylurea, glinide, or basal insulin)
- Microalbuminuria (45 mg urinary albumin/g creatinine)—encourage better adherence to lisinopril; monitor renal function
- Hypertriglyceridemia—initiate omega-3 fatty acid or extended-release niacin
Psychosocial Well-Being, Benefit of Self-Care, and Coping Strategies
Type 2 diabetes mellitus is a chronic disease with glycemic control largely determined by patient self-management, and the attitudes and beliefs of patients with T2DM are important factors to consider from diagnosis onward.23 There are important differences between men and women with T2DM regarding attitudes and beliefs. Published investigations provide some, although not entirely consistent, insight into these psychosocial differences between men and women with T2DM. These differences are summarized in TABLE 2 .24-32 Taking these differences into account when planning treatment and when communicating with and educating the patient is essential for improved patient self-management.
TABLE 2
Psychosocial and Coping Characteristics of Men with Type 2 Diabetes Mellitus (T2DM)24-32
Compared with women with T2DM, generally, men with T2DM:
|
Key interventions for MR:
- Maintain a dialogue and enhance collaboration with MR
- Establish shared goals that are customized to incorporate MR’s personal goals
- Problem solve with MR to identify ways he can better integrate the diabetes self-care objectives of dietary changes and blood glucose self-monitoring into his daily life
- Emphasize that enhanced or greater disease control can be achieved by good self-management, including better adherence to the management plan
- Remind MR that T2DM is a progressive disease that requires intermittent medication adjustments to keep pace with its progression
- Build upon the belief that T2DM can be controlled by reminding MR that the disease was well controlled before his knee injury
- –Focus on the importance of rehabilitating his knee
- –Develop a rehabilitation plan
- Provide informational support regarding options for intensifying diabetes therapy (eg, dipeptidyl peptidase-4 inhibitor, thiazolidinedione, glucagon-like peptide-1 receptor agonist, sulfonylurea, or insulin)
- –Discuss MR’s needs and concerns, as well as barriers for each treatment option, particularly hypoglycemia and weight gain
- –Provide instruction or educational materials regarding injection devices
- –Involve the healthcare team, as appropriate
- Keep the treatment regimen as simple as possible; consider pill combinations where appropriate
Summary
The growing epidemic of T2DM requires intervention to assist patients who have been diagnosed to better manage the disease, to reduce the risk of developing the disease in those who have not yet been diagnosed, and to manage the associated complications. In addition to individualizing interventions based on a patient’s needs, concerns, and capabilities, taking gender into account is necessary. In otherwise healthy people, several independent factors appear to pose a higher risk of T2DM in men relative to women, including systolic hypertension, regular smoking, and alcohol intake ≥ 40 g/d. At the same time, men achieve greater risk reduction from moderate daily alcohol intake and a diet high in fish and seafood, low-fat dairy products, whole grains, and magnesium.
Once diagnosed with T2DM, men generally fare better than women regarding the risk for CVD; they also have a better prognosis after MI and a lower risk of death overall from CVD. Possible independent risk factors for CVD in men with T2DM that are especially important may include hypertension, poor glycemic control, and low HDL-C levels. Psychosocial complications, such as depression, are less likely in men with T2DM. However, men expend less effort coping, are less likely to utilize healthcare services, and are less informed about treatment options. Although men have a lower expectation of the benefit of self-management, they find support from family and friends more helpful than do women, but they are fearful of losing control of their disease.
Taking these gender differences into account should prove helpful as family care physicians work with men to reduce their risk of developing T2DM and in helping men diagnosed with T2DM to better self-manage their disease.
1. Centers for Disease Control and Prevention. National diabetes fact sheet: national estimates and general information on diabetes and prediabetes in the United States, 2011. http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2011.pdf. Published 2011. Accessed May 2, 2011.
2. Meisinger C, Thorand B, Schneider A, Stieber J, Doring A, Lowel H. Sex differences in risk factors for incident type 2 diabetes mellitus: the MONICA Augsburg cohort study. Arch Intern Med. 2002;162(1):82-89.
3. Meisinger C, Kandler U, Ladwig KH. Living alone is associated with an increased risk of type 2 diabetes mellitus in men but not women from the general population: the MONICA/KORA Augsburg Cohort Study. Psychosom Med. 2009;71(7):784-788.
4. Baliunas DO, Taylor BJ, Irving H, et al. Alcohol as a risk factor for type 2 diabetes: a systematic review and meta-analysis. Diabetes Care. 2009;32(11):2123-2132.
5. Mozaffarian D, Kamineni A, Carnethon M, Djoussé L, Mukamal KJ, Siscovick D. Lifestyle risk factors and new-onset diabetes mellitus in older adults: the cardiovascular health study. Arch Intern Med. 2009;169(8):798-807.
6. Joosten MM, Grobbee DE, van der A DL, Verschuren WM, Hendriks HF, Beulens JW. Combined effect of alcohol consumption and lifestyle behaviors on risk of type 2 diabetes. Am J Clin Nutr. 2010;91(6):1777-1783.
7. Gigleux I, Gagnon J, St-Pierre A, et al. Moderate alcohol consumption is more cardioprotective in men with the metabolic syndrome. J Nutr. 2006;136(12):3027-3032.
8. Joosten MM, Chiuve SE, Mukamal KJ, Hu FB, Hendriks HF, Rimm EB. Changes in alcohol consumption and subsequent risk of type 2 diabetes in men. Diabetes. 2011;60(1):74-79.
9. Nanri A, Mizoue T, Noda M, et al. Fish intake and type 2 diabetes in Japanese men and women: the Japan Public Health Center-based Prospective Study. Am J Clin Nutr. 2011;94(3):884-891.
10. Choi HK, Willett WC, Stampfer MJ, Rimm E, Hu FB. Dairy consumption and risk of type 2 diabetes mellitus in men: a prospective study. Arch Intern Med. 2005;165(9):997-1003.
11. Fung TT, Hu FB, Pereira MA, et al. Whole-grain intake and the risk of type 2 diabetes: a prospective study in men. Am J Clin Nutr. 2002;76(3):535-540.
12. Lopez-Ridaura R, Willett WC, Rimm EB, et al. Magnesium intake and risk of type 2 diabetes in men and women. Diabetes Care. 2004;27(1):134-140.
13. Nathan DM, Kuenen J, Borg R, et al. Translating the A1C assay into estimated average glucose values. Diabetes Care. 2008;31(8):1473-1478.
14. Levey AS, Coresh J, Balk E, et al. National Kidney Foundation practice guidelines for chronic kidney disease: evaluation, classification, and stratification. Ann Intern Med. 2003;139(2):137-147.
15. Legato MJ, Gelzer A, Goland R, et al. Gender-specific care of the patient with diabetes: review and recommendations. Gend Med. 2006;3(2):131-158.
16. Huxley R, Barzi F, Woodward M. Excess risk of fatal coronary heart disease associated with diabetes in men and women: meta-analysis of 37 prospective cohort studies. BMJ. 2006;332(7533):73-78.
17. Larsson CA, Gullberg B, Merlo J, Rastam L, Lindblad U. Female advantage in AMI mortality is reversed in patients with type 2 diabetes in the Skaraborg Project. Diabetes Care. 2005;28(9):2246-2248.
18. Avogaro A, Giorda C, Maggini M, et al. Incidence of coronary heart disease in type 2 diabetic men and women: impact of microvascular complications, treatment, and geographic location. Diabetes Care. 2007;30(5):1241-1247.
19. Zandbergen AA, Sijbrands EJ, Lamberts SW, Bootsma AH. Normotensive women with type 2 diabetes and microalbuminuria are at high risk for macrovascular disease. Diabetes Care. 2006;29(8):1851-1855.
20. Mulnier HE, Seaman HE, Raleigh VS, et al. Risk of stroke in people with type 2 diabetes in the UK: a study using the General Practice Research Database. Diabetologia. 2006;49(12):2859-2865.
21. Tuomilehto J, Rastenyte D, Jousilahti P, Sarti C, Vartiainen E. Diabetes mellitus as a risk factor for death from stroke. Prospective study of the middle-aged Finnish population. Stroke. 1996;27(2):210-215.
22. Hanai K, Babazono T, Yoshida N, et al. Gender differences in the association between HDL cholesterol and the progression of diabetic kidney disease in type 2 diabetic patients. Nephrol Dial Transplant. 2012;27(3):1070-1075.
23. Tuerk PW, Mueller M, Egede LE. Estimating physician effects on glycemic control in the treatment of diabetes: methods, effects sizes, and implications for treatment policy. Diabetes Care. 2008;31(5):869-873.
24. Rubin RR, Peyrot M, Siminerio LM. Health care and patient-reported outcomes: results of the cross-national Diabetes Attitudes, Wishes and Needs (DAWN) study. Diabetes Care. 2006;29(6):1249-1255.
25. McCollum M, Hansen LB, Ghushchyan V, Sullivan PW. Inconsistent health perceptions for US women and men with diabetes. J Womens Health (Larchmt). 2007;16(10):1421-1428.
26. Gucciardi E, Wang SC, DeMelo M, Amaral L, Stewart DE. Characteristics of men and women with diabetes: observations during patients’ initial visit to a diabetes education centre. Can Fam Physician. 2008;54(2):219-227.
27. Chiu CJ, Wray LA. Physical disability trajectories in older Americans with and without diabetes: the role of age, gender, race or ethnicity, and education. Gerontologist. 2011;51(1):51-63.
28. Nielsen AB, de Fine Olivarius N, Gannik D, Hindsberger C, Hollnagel H. Structured personal diabetes care in primary health care affects only women’s HbA1c. Diabetes Care. 2006;29(5):963-969.
29. Shalev V, Chodick G, Heymann AD, Kokia E. Gender differences in healthcare utilization and medical indicators among patients with diabetes. Public Health. 2005;119(1):45-49.
30. Kacerovsky-Bielesz G, Lienhardt S, Hagenhofer M, et al. Sex-related psychological effects on metabolic control in type 2 diabetes mellitus. Diabetologia. 2009;52(5):781-788.
31. Brown SA, Harrist RB, Villagomez ET, Segura M, Barton SA, Hanis CL. Gender and treatment differences in knowledge, health beliefs, and metabolic control in Mexican Americans with type 2 diabetes. Diabetes Educ. 2000;26(3):425-438.
32. Liburd LC, Namageyo-Funa A, Jack L, Jr. Understanding “masculinity” and the challenges of managing type-2 diabetes among African-American men. J Natl Med Assoc. 2007;99(5):550-552, 554–558.
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12. Lopez-Ridaura R, Willett WC, Rimm EB, et al. Magnesium intake and risk of type 2 diabetes in men and women. Diabetes Care. 2004;27(1):134-140.
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14. Levey AS, Coresh J, Balk E, et al. National Kidney Foundation practice guidelines for chronic kidney disease: evaluation, classification, and stratification. Ann Intern Med. 2003;139(2):137-147.
15. Legato MJ, Gelzer A, Goland R, et al. Gender-specific care of the patient with diabetes: review and recommendations. Gend Med. 2006;3(2):131-158.
16. Huxley R, Barzi F, Woodward M. Excess risk of fatal coronary heart disease associated with diabetes in men and women: meta-analysis of 37 prospective cohort studies. BMJ. 2006;332(7533):73-78.
17. Larsson CA, Gullberg B, Merlo J, Rastam L, Lindblad U. Female advantage in AMI mortality is reversed in patients with type 2 diabetes in the Skaraborg Project. Diabetes Care. 2005;28(9):2246-2248.
18. Avogaro A, Giorda C, Maggini M, et al. Incidence of coronary heart disease in type 2 diabetic men and women: impact of microvascular complications, treatment, and geographic location. Diabetes Care. 2007;30(5):1241-1247.
19. Zandbergen AA, Sijbrands EJ, Lamberts SW, Bootsma AH. Normotensive women with type 2 diabetes and microalbuminuria are at high risk for macrovascular disease. Diabetes Care. 2006;29(8):1851-1855.
20. Mulnier HE, Seaman HE, Raleigh VS, et al. Risk of stroke in people with type 2 diabetes in the UK: a study using the General Practice Research Database. Diabetologia. 2006;49(12):2859-2865.
21. Tuomilehto J, Rastenyte D, Jousilahti P, Sarti C, Vartiainen E. Diabetes mellitus as a risk factor for death from stroke. Prospective study of the middle-aged Finnish population. Stroke. 1996;27(2):210-215.
22. Hanai K, Babazono T, Yoshida N, et al. Gender differences in the association between HDL cholesterol and the progression of diabetic kidney disease in type 2 diabetic patients. Nephrol Dial Transplant. 2012;27(3):1070-1075.
23. Tuerk PW, Mueller M, Egede LE. Estimating physician effects on glycemic control in the treatment of diabetes: methods, effects sizes, and implications for treatment policy. Diabetes Care. 2008;31(5):869-873.
24. Rubin RR, Peyrot M, Siminerio LM. Health care and patient-reported outcomes: results of the cross-national Diabetes Attitudes, Wishes and Needs (DAWN) study. Diabetes Care. 2006;29(6):1249-1255.
25. McCollum M, Hansen LB, Ghushchyan V, Sullivan PW. Inconsistent health perceptions for US women and men with diabetes. J Womens Health (Larchmt). 2007;16(10):1421-1428.
26. Gucciardi E, Wang SC, DeMelo M, Amaral L, Stewart DE. Characteristics of men and women with diabetes: observations during patients’ initial visit to a diabetes education centre. Can Fam Physician. 2008;54(2):219-227.
27. Chiu CJ, Wray LA. Physical disability trajectories in older Americans with and without diabetes: the role of age, gender, race or ethnicity, and education. Gerontologist. 2011;51(1):51-63.
28. Nielsen AB, de Fine Olivarius N, Gannik D, Hindsberger C, Hollnagel H. Structured personal diabetes care in primary health care affects only women’s HbA1c. Diabetes Care. 2006;29(5):963-969.
29. Shalev V, Chodick G, Heymann AD, Kokia E. Gender differences in healthcare utilization and medical indicators among patients with diabetes. Public Health. 2005;119(1):45-49.
30. Kacerovsky-Bielesz G, Lienhardt S, Hagenhofer M, et al. Sex-related psychological effects on metabolic control in type 2 diabetes mellitus. Diabetologia. 2009;52(5):781-788.
31. Brown SA, Harrist RB, Villagomez ET, Segura M, Barton SA, Hanis CL. Gender and treatment differences in knowledge, health beliefs, and metabolic control in Mexican Americans with type 2 diabetes. Diabetes Educ. 2000;26(3):425-438.
32. Liburd LC, Namageyo-Funa A, Jack L, Jr. Understanding “masculinity” and the challenges of managing type-2 diabetes among African-American men. J Natl Med Assoc. 2007;99(5):550-552, 554–558.