According to the World Health Organization’s ‘Global Report on Diabetes’ 2016, diabetes is directly responsible for 1.5 million deaths around the world. This makes it the eighth leading cause of mortality. However, its impact is higher in women, for who diabetes is the fifth leading cause of death. At present, more than 200 million women are estimated to live with diabetes.
One reason for the problem of diabetes in women is the rise in the number of patients with the disease. The prevalence of diabetes, according to the WHO, has doubled since 1980. Moreover, it is no longer a disease that largely affects rich nations. Indeed, prevalence is now growing quickest in middle-income countries. More than half of the total number of women with diabetes today live in southeast Asia and the Western Pacific.
Another issue here is the the lack of healthcare. This means that the management of diabetes is inadequate, particularly for poorer people.

Debate dates to end of 1990s
The debate about gender and diabetes began to intensify at the end of the 1990s, as epidemiology improved, especially outside Western countries.
In January 2001, a report by University of Bristol researchers in ‘Diabetologia’ found geography and gender to be a major factor in Type I diabetes. The report found an excess of male patients in regions with the highest incidence of diabetes, above all in populations of European origin. These showed a roughly 3:2 ratio of males to females in the 15-40 age group. On the other side of the equation, lowest risk populations for Type I diabetes (principally non-European) typically showed a female bias.
The Bristol researchers also observed that Type II diabetes had shown an excess of females in the first half of the 20th century but had become equally prevalent among men and women in most populations, with some evidence of male preponderance in early middle age. Men seemed to also be more susceptible than women “to the consequences of indolence and obesity, possibly due to differences in insulin sensitivity and regional fat deposition.”  In addition, women were more likely to transmit Type II diabetes to their offspring.

Geography and gender
Recent figures from the WHO on mortality from high glucose confirm the dual impact of gender and geography. The data shows a fork in female mortality, from near equivalence to males in the Eastern Mediterranean, Africa and the Western Pacific, to  being about three fourths of male mortality in Europe, the Americas and South-East Asia.
Women may also be more prone to dying from diabetes due to physiological factors. Data show that women with diabetes are more likely than male patients to have poor blood glucose control and be overweight, along with high blood pressure and cholesterol levels. The latter impact directly on cardiac risk factors, and do so in seemingly different ways for men and women.
Male death rates fall, women’s stays unchanged
In 2007, a study in the ‘Annals of Internal Medicine’ revealed a disturbing fact – that women with diabetes fared far worse than men. The study found that in 1971-2000, death rates for diabetic men fell, while the rate for women hardly changed. Worse, while men with diabetes lived on average for 7.5 fewer years than those who did not have the disease, the difference for women was 8.2 years. This disparity is probably due to a combination of multiple factors, according to the study.

Physiological factors and standards of treatment
Most factors are physiological. However, it seems outcomes for women with diabetes may also be worse due to differences in standards of care and treatment. Some of these were highlighted in 2005 in ‘Diabetes Care’, or two years before the ‘Annals of Internal Medicine’ study mentioned above.
The ‘Diabetes Care’ article covered risk factors in coronary heart disease (CHD) and treatment for Type II diabetes. It found that women with diabetes “received less treatment for many modifiable CHD risk factors than diabetic men.” This included staple therapies such as medication for high LDL cholesterol. The authors concluded that “more aggressive treatment of CHD risk factors” in women offered “a specific target for improvement in diabetes care.”
In 2010, a study in ‘Diabetic Medicine’ found the picture to be similar for Type I diabetes. The study by another Massachusetts General Hospital team, led by M.E Clarkin, found women reported lower use than men of medications to reduce CHD risk. These included glycated hemoglobin, as well as aspirin, angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARBs) and statins.

The role of cardiac health
Key physiological differences do indeed concern cardiac health.
In the general population, women tend to live longer than men, mainly because of lower rates of heart disease. However, such an advantage becomes insignificant for diabetic women. Indeed, the risk of heart disease is reported to be six times higher for women with diabetes than those without, compared to an increase of just 2-3 times in men.
This impacts directly on mortality for several reasons. One of the most significant is that women can have heart attacks without its most notable symptom in males, namely chest pain. Indeed, women are more likely to experience only nausea, shortness of breath, and back or jaw pain during a heart attack. Many women and medical practitioners in poorer parts of the world do not recognize the latter as warning signs. This lowers the chance of recovery.
One study published in the ‘European Heart Journal’ in 2007 found a stronger association between diabetes and death by heart failure for women than men. A Finnish study also found that heart attacks are more often fatal for women with diabetes than they are for men.
Indeed, perception is linked to less effective health care for women with diabetes, and this is best typified by cardiac health. As women are less likely to have heart attacks than men, a woman may not raise the same alarm bells as a man, especially when she does not experience chest pain.

Renal disease
Women with diabetes face complications from renal disease, too. Men have a higher risk for kidney disease, but this disappears with the onset of diabetes. Women with diabetes are just as likely to get kidney disease as men. Moreover, such a likelihood is not dependent on age, although women tend to be unaffected by kidney disease until menopause, when a drop in oestrogen levels makes the female endocrine system more like a male’s. 
Some studies have found that lower oestrogen levels are associated with kidney disease, but the mechanisms of this association are not yet clear. One theory is that high testosterone, which kicks in as estrogen levels drop, is responsible. Should this be proven clinically, it may be possible for women with diabetes to use hormone therapy to restore the balance between estrogen and testosterone, and thereby improve their kidney health.

Mental health
Depression is about twice as common in women as men and is believed to worsen the outlook for women with diabetes. A study of women in the ‘Archives of Internal Medicine’ in 2010 suggests a two-way relationship between depression and diabetes risk, with each influencing the other. Indeed, some women-only studies have shown women with both conditions are twice as likely to die early as those who had neither. In 2006, a study in ‘Public Health’ extended the scope to men and found that diabetes and depression were not associated in men, unlike in women.

Polycystic ovary syndrome
Women with diabetes are also likely to have several conditions which are female-specific.
One of these is polycystic ovary syndrome (PCOS), a metabolic disorder caused by hormonal imbalance in the female body. PCOS causes irregular periods and can result in fertility problems. It is also associated with acne, darkening of facial skin and hair growth on the face, loss of hair on the head etc. Females with PCOS are at heightened risk of getting diabetes, and the above signs are thus potential indicators of impending diabetes.
The precise mechanism of PCOS is not known, but there is clinical evidence that women with PCOS develop high levels of resistance to insulin and this then leads to development of Type II diabetes.
What has however been confirmed is that women diagnosed with PCOS at an early age show a higher risk of diabetes and fatal heart conditions later in life.

Gestational diabetes mellitus
Women also face the risk of gestational diabetes mellitus (GDM). This is defined as blood glucose values above normal but below those of diabetes. GDM is diagnosed through screening, since several of its symptoms such as increased thirst and urination needs, dry mouth and fatigue are commonplace in pregnancy and are not necessarily a sign of a problem.
Although the true prevalence of GDM is unknown, it is estimated to affect 1-14% of pregnancies in the US, depending on the population studied and the diagnostic tests used. Recent research has focused on high-risk groups. A pan-European study of women with body mass index greater than 29 kg/m2  found prevalence of 24% in early pregnancy, with another 14% developing GDM at mid gestation (24-28 weeks) and 13% at late gestation (35-37 weeks). The study was published in the October 2017 issue of ‘Diabetologia’ and covered women at 11 centres across Europe.
GDM increases the risk of certain complications during pregnancy and delivery, both for the women in question and for their infants. One of these is pre-eclampsia, which causes high blood pressure during pregnancy. Others include the baby growing larger than usual and polyhydramnios, which is the presence of excess amniotic fluid.
Though GDM is a temporary condition, affected women have an over-sevenfold increase in the risk of developing Type II diabetes 5-10 years after delivery. Moreover, children born to mothers with GDM are also more likely to develop impaired glucose tolerance.
Early diagnosis of GDM through testing for blood sugar and modifications to lifestyle can be effective in preventing or delaying the condition and treating its consequences.

Anemia in pregnancy is one of the most common medical problems pregnant women encounter in both low and high income countries. It affects some 32 million pregnant women worldwide each year and is characterized by a lack of red blood cells. Women with severe anemia will have a blood count of less than 70 grams of hemoglobin per litre of blood. It is a dangerous condition and if not prevented or treated correctly can lead to maternal death.
Highlighting the danger, an international study published in May this year, shows that women with severe anemia during pregnancy or up to seven days after delivery have double the risk of dying compared to those who don’t suffer from the condition.
Previous studies had suggested that anemia was strongly associated with maternal death, but they were not clear due to the influence of other clinical factors. This study – the largest of its kind – is the first to control factors that can influence the development of anemia in pregnancy (such as blood loss or malaria infection) and which may have skewed the results of previous studies.

The researchers emphasize that clinicians, policy makers and healthcare professionals should now focus their attention on preventing anemia, using a multifaceted approach, and not just hope that iron tablets will solve the problem.
Although anemia is a readily treatable condition, the existing approaches have so far not been able to tackle the problem, say the researchers who published their study in the MAY/ JUNE 2018  issue of The Lancet Global Health.
For the study they looked at World Health Organization data on 312,281 pregnancies in 29 countries around the world. The study results show that, when all known contributing factors are controlled for, the odds of maternal death are doubled in mothers with severe anemia.
Importantly, the relationship between severe anemia and the increased risk of maternal death is seen in different geographical areas and, by using different statistical approaches, the researchers are able to show an independent relationship between severe anemia and maternal death does exist.
Prior to this research, the absence of robust data showing evidence of the relationship between severe anemia and maternal mortality has led to a relatively low prioritization of anemia as an important condition in its own right. This new research will hopefully motivate health policy makers to sharpen their focus on the prevention of anemia during pregnancy when they shape new policy on the condition.

Dr. Gianfranco Scaperrotta, the head of SS Senology Radiology at Fondazione IRCCS Istituto Nazionale dei Tumori (INT) in Milan, offers his perspective on what advisable investments healthcare executives should consider, pointing to inefficiencies in workflow and patient satisfaction in the stereotactic breast biopsy procedure to help illustrate his position.

by Dr. Gianfranco Scaperrotta

Healthcare executives – who are responsible for investment decisions – are constantly working to justify how a particular asset or purchase is beneficial to their facility. With multiple priorities to consider, from doctors’ and patients’ needs, to a facility’s financial goals and beyond – combined with budget limitations – the need to find and rationalize the right investment options can be particularly complex. This is largely caused by the demands being placed on facilities and doctors to work more quickly and efficiently. In an era marked by the concept of constantly doing more, faster and better, the search for the right investment essentially comes back to the same basic, and yet truly powerful idea: in the healthcare field, we are always on a quest for improvement.
 
One of the best ways to warrant an investment is to become immersed in the field’s overall functionality from a clinical, financial and patient perspective to unearth any weaknesses. There are certainly processes and procedures in each part of the healthcare industry that can and should be improved, and that, if effectively handled, could have a positive, widespread ripple effect across facilities. 
 
Breast biopsy procedure
The radiology sector, for example, is one of many in healthcare that has room for improvement. As the head of SS Senology Radiology at Fondazione IRCCS Istituto Nazionale dei Tumori (INT) in Milan, I feel this is particularly apparent when it comes to the current state of the stereotactic breast biopsy procedure. Throughout my 25-year career, I have performed many breast biopsy procedures, and although none of my experiences are exactly the same as one another, there are a few consistent aspects that are worth noting that help showcase a need for change. This is made evident when considering the overall procedural experience, from start to finish. 
 
More often than not, when patients come in for a breast biopsy, they’re already feeling anxious and uncertain about the procedure before they even enter the room. In addition to fearing a needle in the breast, they are likely contemplating the unsettling idea that they may be diagnosed with breast cancer. Their level of discomfort may grow while waiting for the clinicians to enter the room and begin to prepare for the procedure. To begin, the technologist will help the patient get into the appropriate position to ensure the biopsy needle is targeting the proper area of the breast, where the suspicious tissue was noted on the mammography exam. Depending on where the calcification is in the breast, in some cases, the patient must be placed in a particularly awkward position in order for the needle to reach the correct target area, and she must hold her body in that same position until the procedure is complete.  
 
At this point, the radiologist collects the tissue samples, which then require verification. This process varies depending on the facility. Whereas I have the resources to verify my patients’ samples in the same room where the biopsy is taking place, there are many cases in which the clinician must prepare the samples for transport, and then leave the procedure room to image and verify the samples on another piece of imaging equipment, which may already be in use for another patient and therefore cause scheduling delays. During this time the patient must remain in compression, which may increase her anxiety. In some cases, the clinician will determine the need to take more samples from the patient, making the procedure time lengthier than anticipated. After the tissues are verified, the breast biopsy procedure can conclude, yet the patient must first await her results, which will come later, after the samples have been sent to and evaluated by pathology. 
 
This one scenario in the radiology field demonstrates a few issues that must be tackled. First and foremost, patients are extremely anxious, and radiologists need to help ease their concerns. Perhaps they could be helped by enhancing the ambiance of the procedure room with more calming visuals or music to reduce tension. Additionally, positioning patients when their calcifications are in unusual areas can add to their discomfort. Similarly, lengthier procedure times  only add to patient apprehension, while also slowing radiologists down, which can affect their subsequent appointments. Lastly, patients must still wait for the samples to go through the pathology process before receiving a diagnosis.  

Patients satisfaction
It’s clear that today’s stereotactic breast biopsy could benefit from better workflow efficiency, yet this deep dive into the procedure also reveals a need for improved patient comfort. Together, time-savings and comfort contribute to overall patient satisfaction, and the fact that the stereotactic breast biopsy falls short in this area presents an opportunity for improvements to be made. For any doctor and facility, providing a positive patient experience and increasing satisfaction is crucial for success. Not only is it important to deliver high quality, swift care for patients for their health and happiness, but it’s also worth recognizing the business logistics associated with patient satisfaction – positive experiences can result in future referrals. Additionally, fast and efficient procedures mean that radiologists can get more work done in a day, furthering the overall productivity and financial success of a facility. 
 
In my opinion, when healthcare executives are thinking about their next investments, they should not only remember to consider a sector’s inefficiencies, but they should also take special note of those shortcomings that have the widest impact across the facility, like workflow and patient experience. Even beyond investments, it is human nature to constantly seek improvements. For example, I envision one day that radiologists will take an entirely new approach to the biopsy procedure, perhaps removing calcifications as a whole at once to start potential cancer treatment early, instead of taking smaller samples to first test the tissue. I encourage clinicians to similarly identify inefficiencies in their respective industries and search their minds for new, better ways. Let us challenge what we know and never tire from our quest to keep improving.