The impact of biological sex and social determinants of health (gender) on the prevalence of cardiovascular (CV) risk factors such as diabetes mellitus (DM) may vary by culture and health systems. In this study, we aimed to elucidate how sex and gender influence access to care and CV outcomes of individuals with DM across different countries.
METHODS AND RESULTS
Data from the Canadian Community Health Survey (2015-16) (N=109,659, 53.7% Females, 8.4% DM) and the European Health Interview Survey (N=316,333, 51.3% Females, 7.3% DM), were analyzed. A composite measure of socio-cultural gender was constructed (score range: 0-1; higher score identifying characteristics traditionally ascribed to women). The relationship between the gender score, antihyperglycemic care, complications and hospitalization of individuals with DM was assessed with a logistic regression model. European countries were stratified based on their Gender Inequality Index (GII); which quantifies gender disparity and inequity amongst various countries in the world, from low-GII (GII < 0.077), to medium (GII: 0.077-0.1635) and high (>=0.1635). Characteristics traditionally ascribe to women (i.e., higher gender score) included greater stress level, being widowed or divorced, larger household size, higher education, good sense of belonging to community, and lower income in Canadians; while being divorced or widowed, having greater household size, lower education and lower income were found in Europeans. Sex and gender significantly influenced the standard care of patients with diabetes including periodic glucose and HbA1C monitoring. Canadian diabetic females were more likely to check their HbA1c (OR: 1.29, 95%CI:1.03-1.6), while European counterparts were less likely to check their blood sugar (OR: 0.89, 95%CI:0.79-0.99). A higher gender score in both populations was associated with less frequent monitoring of HbA1C and blood glucose levels (Table 1). When stratifying by GII, DM patients in countries with medium and high GII were less likely to check their blood glucose levels compared to low GII countries (Table1). Additionally, higher gender scores independent of sex were associated with higher risk of heart disease, stroke and hospitalization in all countries albeit European countries with medium to high GII, conferred a higher risk of all complications and hospitalization rates (Table1).
Regardless of biological sex, diabetic individuals with characteristics typically ascribed to women and those living in countries with greater gender inequality, exhibited poorer antihyperglycemic care, greater risk of cardiovascular complications, and higher hospitalization rates. Country-specific gender related factors and gender disparity must be targeted for improving health status and access to care of patients with DM.
Khaled El Emam
Senior Scientist, CHEO Research Institute Professor, Faculty of Medicine, University of Ottawa