Women and Diabetes in the EU
Diabetes: The Basics
Diabetes is a complex metabolic disease which results from an inability to process or produce insulin[i]. The pancreas is responsible for producing insulin, a hormone which regulates blood glucose (sugar) levels. Some common symptoms of diabetes are increased thirst and/or hunger, frequent urination, and fatigue[ii] but if left untreated it can lead to complications such as stroke, heart attack[iii], kidney failure[iv], vision impairment[v] and nerve damage[vi]. In 2014, 422 million adults or 8.5% of the adult population were estimated to be living with diabetes, a proportion which has almost doubled since 1980[vii]. Globally, the disease ranks as the sixth leading cause of death[viii]. Diabetes can take multiple forms. Type 1 diabetes occurs when the pancreas does not produce enough insulin. Formerly called juvenile-onset diabetes, the disease can affect people of all ages but more commonly presents in children or young adults[ix]. Currently, what causes type 1 diabetes and how to prevent it are unknown. Type 2 diabetes accounts for approximately 90%of all cases of diabetes globally[x],[xi]. It occurs when the body does not use the insulin being produced by the pancreas effectively (insulin resistance). It usually results from excessive body weight and physical inactivity. Gestational diabetes occurs in women during pregnancy, usually presenting later in the pregnancy[xii]. It often goes away after delivery though women who have experienced it are at greater risk of developing type 2 diabetes in future[xiii]. This chronic condition is usually managed with a combination of lifestyle changes to diet and level of exercise, as well as medication administered orally or subcutaneously. Other interventions may sometimes be required.
Diabetes risk factors
- Physical inactivity
- Being overweight or obese
- Family history of diabetes
- High blood pressure
- Previously having suffered a heart attack or stroke
- Age (risk of developing diabetes increases with age)
- Race (being of South Asian, Black African, or Afro-Caribbean descent increases the likelihood of developing type 2 diabetes)
- Suffering from prediabetes
- Previously developing gestational diabetes
- Having polycystic ovary syndrome
Diabetes, sex and age
For both men and women, the proportion of people with diabetes increases with age[xviii]. However, incidence rates of type 1 diabetes among children (those under fifteen years-of-age) are increasing and are projected to rise in the future[xix],[xx]. Incidence of type 2 diabetes is also rising among children, with the growth largely due to increasing levels of childhood obesity[xxi],[xxii].
Globally, men are more likely to suffer from diabetes than women[xxiii] though the disease is still the tenth leading cause of death for women in high-come countries[xxiv] and there is evidence that women live with diabetes less effectively than men[xxv]. In 2015, 9.1% of the population of the European Union were estimated to be suffering from diabetes[xxvi]. Fig. 1 above presents the prevalence of diabetes across EU Member States by sex[xxvii]. In some Member States prevalence of the disease is higher among women (e.g. Czech Republic, Greece, Hungary, Malta), while in others the sex gap is very small (e.g. Belgium, Ireland, Lithuania, Luxembourg). Existing sex gaps may narrow in the future as women lead more sedentary lifestyles and experience increasing rates of obesity[xxviii] which puts them at greater risk of developing type 2 diabetes[xxix],[xxx].
Sex-specific differences in diabetes: the influence of hormones
Treatment of women of reproductive age who develop diabetes can represent a particular challenge[xxxi]. Fluctuations in hormone levels occur through the menstrual cycle. These fluctuations can affect blood sugar control in some women[xxxii], reducing it after ovulation takes place[xxxiii]. Effective treatment of diabetes for women experiencing such fluctuations as a result of their menstrual cycle requires close monitoring of their blood sugar levels and may necessitate adjustments in doses of any prescribed medication.
As many as one in five women of reproductive age suffer from polycystic ovary syndrome (PCOS), a hormonal disorder present in women with elevated levels of male hormones such as testosterone[xxxiv]. Women who suffer from this disorder can exhibit long or irregular menstrual cycles which have been found to carry an elevated risk of developing type 2 diabetes[xxxv]. The insulin resistance of between 50 to 70% of women with PCOS is estimated to be elevated or reduced, indicating an elevated risk of developing diabetes[xxxvi],[xxxvii]. The odds of women with PCOS developing type 2 diabetes is approximately four times that of women without PCOS[xxxviii]. For women who suffer from obesity as well as PCOS, the risk of developing type 2 diabetes can be as much as five times that of non-obese PCOS suffers[xxxix]. Women with PCOS are also at a higher risk of developing gestational diabetes[xl],[xli] (gestational diabetes is discussed in the next section).
For women with diabetes, undergoing the menopause can represent a particular challenge when managing that disease. Changes in the levels of oestrogen and progesterone can lead to fluctuations in blood glucose levels as well as weight gain, both of which can make it necessary to increase any medication being taken to manage the disease[xlii]. In addition, the combination of diabetes and menopause can lead to sleep problems as well as leaving women at greater risk of developing vaginal and urinary tract infections[xliii]. Early menopause (which takes place in women under the age of 45) is associated with increased risk of type 2 diabetes, though more research is necessary to clarify the nature of this relationship[xliv],[xlv]. Existing research on the impact of hormone replacement therapy (HRT) as treatment for the menopause indicates that it decreases insulin resistance in women[xlvi],[xlvii], though further research is needed before conclusions can be drawn about the impact of HRT on women with diabetes[xlviii].
Diabetes and pregnancy
Managing diabetes during pregnancy represents a particular challenge. It is difficult to control the blood glucose levels of expectant mothers suffering from either type 1 or 2 diabetes and this can have an impact on both the mother and the foetus. It is recommended that diabetics who are planning to become pregnant meet with their doctor in order to make a plan for pregnancy[xlix]. Doctors recommend that women try to bring their blood glucose levels close to their target range prior to becoming pregnant and may recommend that women who are overweight lose some weight as part of this plan to bring blood glucose levels under control[l]. Where a pregnancy is unplanned it is important for women who are diabetic to consult their doctor as soon as possible.
Pregnant women suffering from diabetes should maintain close contact with their doctor over the course of the pregnancy. Blood glucose levels will need to be monitored much more frequently and it may be necessary to make adjustments to any medication that is habitually taken to manage the disease[li].
Women with type 1 or type 2 diabetes who have uncontrolled or undiagnosed diabetes during pregnancy are at increased risk of complications which can affect the health of the mother and the foetus. Where diabetes is not well controlled, women are at risk of premature birth, miscarriage or stillbirth[lii], while babies are at greater risk of developing serious birth defects, in particular those affecting the heart, brain or spine[liii]. It is during the early months of the pregnancy when the organs of the foetus are being formed that these birth defects can develop where blood sugar is uncontrolled. Where pregnancy is unplanned this often occurs before the woman knows she is pregnant. Uncontrolled diabetes may also lead to the foetus growing excessively large, which can cause discomfort for the mother towards the end of the pregnancy. This can also lead to issues during delivery, making delivery by caesarean section more likely[liv]. Women with pre-existing diabetes are more likely to have high blood pressure and are therefore at greater risk of preeclampsia which can lead to stroke or seizure in expectant mothers.
Gestational diabetes mellitus (GDM) is a form of diabetes that occurs during pregnancy, usually developing during the second half of the pregnancy[lv]. It is estimated to occur in 3.8 to 7.8% of pregnancies in Europe[lvi]. While the exact number of women who suffer with GDM over the course of their pregnancy is unknown, it prevalence appears to be increasing[lvii]. Women in Southern Mediterranean countries appear to be at greater risk of developing GDM than they are in Northern EU countries. There is no consensus across EU Member States on testing, diagnostic procedures, and screening[lviii] so policy tackling GDM varies accordingly across states.
The complications that GDM can lead to for women and their foetuses are described in the section above. However, in addition to those, women and their infants have a greater risk of developing type 2 diabetes in the future. As much as half of all women who experienced GDM during their pregnancy will develop type 2 diabetes within 5 years of the birth[lix], with obesity representing an added risk factor in the emergence of this disease[lx].
Children born to women who suffered from GDM over the course of their pregnancy are six times more likely to develop type 2 diabetes than children born to mothers who did not develop GDM[lxi]. Children born to women with diabetes are also more to develop childhood obesity[lxii].
Diabetes and other diseases
Diabetes and cardiovascular disease
Diabetes is strongly associated with several other diseases. Diabetes is now seen as the biggest single risk factor for heart disease[lxiii]. High blood glucose levels which result from diabetes can lead over time to damage of blood vessels[lxiv]; damage which can be exacerbated in individuals with other risk factors such as high blood pressure, high cholesterol, and smoking. Those suffering from diabetes are approximately twice as likely to develop a range of cardiovascular diseases (CVD) as non-sufferers[lxv]. Those whose diabetes is undiagnosed or poorly controlled are most at risk of heart attack or stroke. The link between cardiovascular disease and diabetes is even stronger for women. The risk of women dying from coronary heart disease associated with type 2 diabetes is 50% greater than for men[lxvi]. Disparities in treatment that favour man may partially explain this higher coronary risk among diabetic women.
Diabetes and cancer
Both type 1 and type 2 diabetes are also linked to increased rates of certain types of cancers (e.g. liver, pancreatic, colorectal)[lxvii] for both men and women. Diabetic women see a substantial increase in their risk of developing endometrial and breast cancer[lxviii],[lxix]. Post-menopausal women with type 2 diabetes (but not type 1) see their risk of developing breast cancer rise by 27% on average compared with women without type 2 diabetes[lxx]. Diabetes can also affect cancer therapy and the use of screening in sufferers of breast cancer[lxxi]. Diabetic women with breast cancer have a greater risk of death than their non-diabetic counterparts[lxxii].
Diabetes and depression
Having diabetes roughly doubles the odds of having depression compared with the general population[lxxiii]. In Western countries, depression is approximately twice as prevalent among women as men[lxxiv]. This gender gap is replicated at EU-level, though the size of the gap varies across countries[lxxv]. Rates of depression among women with diabetes are almost twice that of men[lxxvi]. Depression affects quality of life, reduces the ability to self-manage diabetes[lxxvii] and increases the risk of complications, heart disease, and premature mortality[lxxviii]. The underlying mechanisms for the increased mortality risk associated with depression are not well understood and need to be studied further. Increased awareness of depression in women with diabetes by health professionals may lead to better management of both conditions and improve outcomes.
Diabetes and dementia
Individuals with type 2 diabetes have a risk of developing dementia (a range of symptoms associated with a decline in thinking skills and memory[lxxix]) that is as much as 60% greater than those without dementia[lxxx]. Among diabetics, women are more at risk than for men of vascular dementia (but not non-vascular dementia)[lxxxi]. Further research is required to understand which this gap emerges between men and women.
Diabetes and osteoporosis
Women are generally more likely than men to suffer from osteoporosis (a disease that causes weakness in the bones) than men in part due to the reduction in oestrogen, a hormone which protects bones, which occurs during the menopause[lxxxii]. Increasingly, there is evidence that osteoporosis and diabetes are related[lxxxiii]; individuals with type 1 diabetes have reduced bone mass and an increased risk of fragility fractures compared to those without it. Those with diabetes type 2 are particularly susceptible to low trauma fractures, especially hip fractures[lxxxiv]. Women with diabetes should therefore pay special attention to their bone health, already an important health consideration for older women.
Social factors and diabetes
Social factors (such as low educational level, income and occupation) are related to risk of obesity, an important risk factor for type 2 diabetes which accounts for the vast majority of cases of diabetes globally. This relationship appears to be stronger for women than it is for men[lxxxv]. Physical inactivity, high levels of consumption of sugar-sweetened beverages, moderate alcohol consumption, and smoking have all been found to be associated with increased risk of diabetes[lxxxvi]. Globally, women are estimated to smoke five times less than men[lxxxvii], however there is evidence that the gender-gap in alcohol consumption is closing, particularly among younger cohorts[lxxxviii]. Women in the European Union are less active than men, and have higher rates of obesity[lxxxix].
European and national strategies for diabetes prevention
Given the importance of obesity and physical activity as predictors of diabetes, policy in Europe aiming to tackle the disease focuses on these predictors. The WHO’s Action Plan for implementation of the European Strategy for the Prevention and Control of Noncommunicable Diseases 2012−2016 focused on making diets healthier and increasing physical activity[xc]. The European Union set up the European Diabetes Indicator Project (EUDIP) to gather information consistently about risk factors for diabetes across Member States with the aim of promoting “good diabetes health status and care in the different countries”[xci]. The EU’s Diabetes in Europe – Prevention using Lifestyle, Physical Activity and Nutritional Intervention project aims to implement a programme targeting lifestyle changes that will prevent type 2 diabetes from emerging in high-risk individuals[xcii]. At a national level, some Member States have introduced or will soon introduce sugar or fat taxes[xciii]. Policymakers hope that by targeting risk factors for obesity, they can reduce the prevalence of diseases like diabetes and tackle the associated costs of treating diabetes to their national health care systems which can range between 7.4 and 11.5% of total health expenditure[xciv].
In addition, the European Commission has called for increased cooperation to tackle prevention and care of chronic diseases within the European Union, and in response the European Joint Action on Chronic Diseases and Promoting Healthy Ageing across the Life Cycle (JA-CHRODIS) was launched in 2014. The aim is to use existing data to discern best practices across countries in combatting a range of chronic diseases, as well as to encourage coordination and cooperation among Member States. Diabetes was chosen as a case study, and JA-CHRODIS undertook the mapping of national diabetes plans (NDPs) in Europe[xcv].
Not all the countries included in the study are making strong progress with their NDPs; countries like Ireland and France do not have an NDP for example, and they are also lagging behind their European neighbours with respect to the preventative measures they are using and the extent to which they are raising awareness about the disease[xcvi]. Of the 13 (of 22) countries included in the case study, most of the NDPs had a general focus on the disease which covered types 1 and 2 diabetes, as well as gestational diabetes.
The report highlights the fact that most NDPs are developed by ministries of health, and that a lack of resources, skills, and influence can prevent these bodies from persuading key stakeholders (e.g. patients’ organisations, insurance companies) of the necessity of their involvement in developing an NDP.
Tackling climbing rates of diabetes in the European Union requires Member States to develop integrated plans that include stakeholders from across different sectors, put forward measures targeting individual-level as well as environmental risk factors, and, crucially, borrow from models of good practice in neighbouring states. The European Union has an important coordination role to play to ensure that Member States have the information and support that is necessary for developing strategies targeting chronic diseases available to them.
Steps for policy action
- Improve existing EU data collection on diabetes. Data should also be collected not only on death rates but also on the incidence and prevalence of diabetes, as well as its complications, disaggregating the data by gender and age in order to understand diabetes trends more fully.
- Examine the interaction between diabetes, gender, age, and other chronic diseases. As individuals live longer and the prevalence of chronic diseases increases, it is important to understand the role that gender, age, and the interaction with other chronic conditions that lead to multi-morbidity and an increase in the chronic disease burden. This would lead to better prevention and management of diabetes and other chronic diseases.
- Further study the impact of diabetes on other diseases affecting women in the Chronic Disease Joint Action. Diabetes in women has been linked to an increased risk of a range of diseases including cardiovascular disease, certain cancers, depression, and osteoporosis. The connection between diabetes and other conditions needs to be examined in more depth to gain a greater understanding of how diabetes impacts women’s health across the lifespan. Additionally, medical doctors need to be trained to recognise and manage the complex interaction of chronic diseases.
- Increase awareness of the connection between pregnancy and diabetes and improve detection and treatment of gestational diabetes. Women with pre-existing diabetes should be better informed about the risks of diabetes and pregnancy in order to help them prepare for and manage their condition better during pregnancy and thereby ensure good health for both mother and child. Gestational diabetes mellitus (GDM) increases the risk of type 2 diabetes in both mother and child. Efforts should be made to increase awareness and prevent the development of GDM. EU-wide screening and diagnostic guidelines need to be developed to improve better detection and treatment as well as the training of health professionals.
- Examine the effect of social determinants on diabetes for both women and men across the lifespan. Diabetes disproportionately affects lower socio-economic groups and older populations with women experiencing a greater disadvantage. In order to tackle health inequalities, it is essential for policymakers and healthcare professionals to understand the interplay between social, ageing and gender determinants to improve diabetes prevention and management across the lifespan and reduce the burden of chronic diseases.
- Continue to put forward policy tackling Europe’s obesity crisis. Targeting women in particular due to their role as family caregivers to ensure that they are health-literate and understand the role of diet and exercise in preventing diabetes. Type 2 diabetes is largely preventable. About nine out of ten cases could be avoided by taking a few simple steps: keeping weight down, exercising more, eating a healthy diet and not smoking.
[i] WHO. 2017. Diabetes. http://www.who.int/mediacentre/factsheets/fs312/en/
[iii] Emerging Risk Factors Collaboration. “Diabetes mellitus, fasting blood glucose concentration, and risk of vascular disease: a collaborative meta-analysis of 102 prospective studies.” The Lancet 375, no. 9733 (2010): 2215-2222.
[iv] Coresh, Josef, Elizabeth Selvin, Lesley A. Stevens, Jane Manzi, John W. Kusek, Paul Eggers, Frederick Van Lente, and Andrew S. Levey. “Prevalence of chronic kidney disease in the United States.” Jama 298, no. 17 (2007): 2038-2047.
[v] Bourne, Rupert RA, Gretchen A. Stevens, Richard A. White, Jennifer L. Smith, Seth R. Flaxman, Holly Price, Jost B. Jonas et al. “Causes of vision loss worldwide, 1990–2010: a systematic analysis.” The Lancet Global Health 1, no. 6 (2013): 339-349.
[vi] WHO. 2017. Diabetes. http://www.who.int/mediacentre/factsheets/fs312/en/
[vii] WHO. 2016. Global Report on Diabetes. http://apps.who.int/iris/bitstream/10665/204871/1/ 9789241565257_eng.pdf
[viii] WHO. 2016. Global Health Estimates 2015: Deaths by Cause, Age, Sex, by Country and by Region, 2000-2015. http://www.who.int/healthinfo/global_burden_disease/estimates/en/
[ix] International Diabetes Federation. About diabetes. https://www.idf.org/about-diabetes/what-is-diabetes.html
[x] WHO. 2017. Diabetes. http://www.who.int/mediacentre/factsheets/fs312/en/
[xi] Khoo, Cheen Leen, and Mahesh Perera. “Diabetes and the menopause.” British Menopause Society Journal 11, no. 1 (2005): 6-11.
[xii] NHS. 2016. Gestational diabetes. http://www.nhs.uk/Conditions/gestational-diabetes/
[xiii] CDC. 2017. Gestational Diabetes. https://www.cdc.gov/pregnancy/diabetes-gestational.html
[xiv] Mayo Clinic. 2017. Diabetes: risk factors. https://www.mayoclinic.org/diseases-conditions/diabetes/basics/risk-factors/con-20033091
[xv] Diabetes UK. 2017. Diabetes risk factors. https://www.diabetes.org.uk/preventing-type-2-diabetes/diabetes-risk-factors
[xvi] Diabetes Ireland. 2017. Diabetes risk factors. https://www.diabetes.ie/about-us/diabetes-risk-factors/
[xvii] CDC. 2017. Diabetes: who’s at risk? https://www.cdc.gov/diabetes/basics/risk-factors.html
[xviii] Narayan, KM Venkat, James P. Boyle, Theodore J. Thompson, Edward W. Gregg, and David F. Williamson. “Effect of BMI on lifetime risk for diabetes in the US.” Diabetes care 30, no. 6 (2007): 1562-1566.
[xix] Patterson, Christopher C., Gisela G. Dahlquist, Eva Gyürüs, Anders Green, Gyula Soltész, and EURODIAB Study Group. “Incidence trends for childhood type 1 diabetes in Europe during 1989–2003 and predicted new cases 2005–20: a multicentre prospective registration study.” The Lancet 373, no. 9680 (2009): 2027-2033.
[xx] Dabelea, Dana, Elizabeth J. Mayer-Davis, Sharon Saydah, Giuseppina Imperatore, Barbara Linder, Jasmin Divers, Ronny Bell et al. “Prevalence of type 1 and type 2 diabetes among children and adolescents from 2001 to 2009.” Jama 311, no. 17 (2014): 1778-1786.
[xxi] Dabelea, Dana, Elizabeth J. Mayer-Davis, Sharon Saydah, Giuseppina Imperatore, Barbara Linder, Jasmin Divers, Ronny Bell et al. “Prevalence of type 1 and type 2 diabetes among children and adolescents from 2001 to 2009.” Jama 311, no. 17 (2014): 1778-1786.
[xxii] Pulgaron, Elizabeth R., and Alan M. Delamater. “Obesity and type 2 diabetes in children: epidemiology and treatment.” Current diabetes reports 14, no. 8 (2014): 508.
[xxiii] Kautzky-Willer, Alexandra, Jürgen Harreiter, and Giovanni Pacini. “Sex and gender differences in risk, pathophysiology and complications of type 2 diabetes mellitus.” Endocrine reviews 37, no. 3 (2016): 278-316.
[xxiv] WHO. 2016. Global Health Estimates 2015: Deaths by Cause, Age, Sex, by Country and by Region, 2000-2015. http://www.who.int/healthinfo/global_burden_disease/estimates/en/
[xxv] Siddiqui, Muhammad A., Mannan F. Khan, and Thomas E. Carline. “Gender differences in living with diabetes mellitus.” Materia socio-medica 25, no. 2 (2013): 140.
[xxvi] International Diabetes Federation. 2015. 2015 Diabetes Global Atlas. http://www.diabetesatlas.org/resources/2015-atlas.html
[xxviii] OECD. 2017. OECD Obesity Update 2017. https://www.oecd.org/els/health-systems/Obesity-Update-2017.pdf
[xxix] Narayan, KM Venkat, James P. Boyle, Theodore J. Thompson, Edward W. Gregg, and David F. Williamson. “Effect of BMI on lifetime risk for diabetes in the US.” Diabetes care 30, no. 6 (2007): 1562-1566.
[xxx] Colditz, Graham A., Walter C. Willett, Andrea Rotnitzky, and JoAnn E. Manson. “Weight gain as a risk factor for clinical diabetes mellitus in women.” Annals of internal medicine 122, no. 7 (1995): 481-486.
[xxxi] Barata, Denise S., Luís F. Adan, Eduardo M. Netto, and Ana Claudia Ramalho. “The effect of the menstrual cycle on glucose control in women with type 1 diabetes evaluated using a continuous glucose monitoring system.” Diabetes care 36, no. 5 (2013): e70-e70.
[xxxii] Herranz, Lucrecia, Lourdes Saez-de-Ibarra, Natalia Hillman, Ruth Gaspar, and Luis Felipe Pallardo. “Glycemic changes during menstrual cycles in women with type 1 diabetes.” Medicina Clínica (English Edition) 146, no. 7 (2016): 287-291.
[xxxiii] Brown, Sue A., Boyi Jiang, Molly McElwee-Malloy, Christian Wakeman, and Marc D. Breton. “Fluctuations of hyperglycemia and insulin sensitivity are linked to menstrual cycle phases in women with T1D.” Journal of diabetes science and technology 9, no. 6 (2015): 1192-1199.
[xxxiv] Mayo Clinic. 2017. Polycystic ovary syndrome (PCOS). http://www.mayoclinic.org/diseases-conditions/pcos/symptoms-causes/syc-20353439?DSECTION=all
[xxxv] Solomon, Caren G., Frank B. Hu, Andrea Dunaif, Janet Rich-Edwards, Walter C. Willett, David J. Hunter, Graham A. Colditz, Frank E. Speizer, and JoAnn E. Manson. “Long or highly irregular menstrual cycles as a marker for risk of type 2 diabetes mellitus.” Jama 286, no. 19 (2001): 2421-2426.
[xxxvi] Ibricevic, Dzemal, and Zelija Velija Asimi. “Frequency of prediabetes in women with polycystic ovary syndrome.” Medical Archives 67, no. 4 (2013): 282.
[xxxvii] Legro, Richard S., Allen R. Kunselman, William C. Dodson, and Andrea Dunaif. “Prevalence and predictors of risk for type 2 diabetes mellitus and impaired glucose tolerance in polycystic ovary syndrome: a prospective, controlled study in 254 affected women.” The journal of clinical endocrinology & metabolism 84, no. 1 (1999): 165-169.
[xxxviii] Moran, Lisa J., Marie L. Misso, Robert A. Wild, and Robert J. Norman. “Impaired glucose tolerance, type 2 diabetes and metabolic syndrome in polycystic ovary syndrome: a systematic review and meta-analysis.” Human reproduction update 16, no. 4 (2010): 347-363.
[xxxix] Boudreaux, Monique Y., Evelyn O. Talbott, Kevin E. Kip, Maria M. Brooks, and Selma F. Witchel. “Risk of T2DM and impaired fasting glucose among PCOS subjects: results of an 8-year follow-up.” Current diabetes reports 6, no. 1 (2006): 77-83.
[xl] Boomsma, C. M., M. J. C. Eijkemans, E. G. Hughes, G. H. A. Visser, B. C. J. M. Fauser, and N. S. Macklon. “A meta-analysis of pregnancy outcomes in women with polycystic ovary syndrome.” Human reproduction update 12, no. 6 (2006): 673-683.
[xli] Kjerulff, Lucinda E., Luis Sanchez-Ramos, and Daniel Duffy. “Pregnancy outcomes in women with polycystic ovary syndrome: a metaanalysis.” American journal of obstetrics and gynecology204, no. 6 (2011): 558-e1.
[xlii] Mayo Clinic. 2017. Diabetes and menopause: a twin challenge. http://www.mayoclinic.org/diseases-conditions/diabetes/in-depth/diabetes/art-20044312?pg=1
[xliii] Mayo Clinic. 2017. Diabetes and menopause: a twin challenge. http://www.mayoclinic.org/diseases-conditions/diabetes/in-depth/diabetes/art-20044312?pg=1
[xliv] Monterrosa-Castro, A., J. E. Blümel, K. Portela-Buelvas, E. Mezones-Holguín, G. Barón, A. Bencosme, Z. Benítez et al. “Type II diabetes mellitus and menopause: a multinational study.” Climacteric 16, no. 6 (2013): 663-672.
[xlv] Brand, Judith S., Yvonne T. Van Der Schouw, N. Charlotte Onland-Moret, Stephen J. Sharp, Ken K. Ong, Kay-Tee Khaw, Eva Ardanaz et al. “Age at menopause, reproductive life span, and type 2 diabetes risk.” Diabetes care 36, no. 4 (2013): 1012-1019.
[xlvi] Salpeter, S. R., J. M. E. Walsh, T. M. Ormiston, E. Greyber, N. S. Buckley, and E. E. Salpeter. “Meta‐analysis: effect of hormone‐replacement therapy on components of the metabolic syndrome in postmenopausal women.” Diabetes, Obesity and Metabolism 8, no. 5 (2006): 538-554.
[xlvii] Ferrara, Assiamira, Andrew J. Karter, Lynn M. Ackerson, Jennifer Y. Liu, and Joseph V. Selby. “Hormone replacement therapy is associated with better glycemic control in women with type 2 diabetes.” Diabetes Care 24, no. 7 (2001): 1144-1150.
[xlviii] Bitoska, Iskra, Branka Krstevska, Tatjana Milenkovic, Slavica Subeska-Stratrova, Goran Petrovski, Sasha Jovanovska Mishevska, Irfan Ahmeti, and Biljana Todorova. “Effects of hormone replacement therapy on insulin resistance in postmenopausal diabetic women.” Open access Macedonian journal of medical sciences 4, no. 1 (2016): 83-88.
[l] National Institute of Diabetes and Digestive and Kidney Diseases. 2017. Pregnancy if You Have Diabetes. https://www.niddk.nih.gov/health-information/diabetes/diabetes-pregnancy
[liii] National Institute of Diabetes and Digestive and Kidney Diseases. 2017. Pregnancy if You Have Diabetes. https://www.niddk.nih.gov/health-information/diabetes/diabetes-pregnancy
[lv] Diabetes UK. 2015. Diabetes News. https://www.diabetes.org.uk/about_us/news/gestational-diabetes-and-children
[lvi] Eades, Claire E., Dawn M. Cameron, and Josie MM Evans. “Prevalence of gestational diabetes mellitus in Europe: A meta-analysis.” Diabetes Research and Clinical Practice 129 (2017): 173-181.
[lvii] Buckley, Brian S., Jürgen Harreiter, Peter Damm, Rosa Corcoy, Ana Chico, David Simmons, Akke Vellinga, and Fidelma Dunne. “Gestational diabetes mellitus in Europe: prevalence, current screening practice and barriers to screening. A review.” Diabetic medicine 29, no. 7 (2012): 844-854.
[lviii] Diabetes Ireland. 2017. Gestational Diabetes. https://www.diabetes.ie/living-with-diabetes/diabetes-pregnancy/gestational-diabetes/
[lix] National Institute for Health and Care Excellence. 2015. Diabetes in pregnancy: management from preconception to the postnatal period. https://www.nice.org.uk/guidance/ng3/chapter/2-research-recommendations#postnatal-treatment-for-women-diagnosed-with-gestational-diabetes
[lx] Kwak, Soo Heon, Sung Hee Choi, Hye Seung Jung, Young Min Cho, Soo Lim, Nam H. Cho, Seong Yeon Kim, Kyong Soo Park, and Hak C. Jang. “Clinical and genetic risk factors for type 2 diabetes at early or late post partum after gestational diabetes mellitus.” The Journal of Clinical Endocrinology & Metabolism 98, no. 4 (2013): e744-e752.
[lxi] Diabetes UK. 2015. Diabetes News. https://www.diabetes.org.uk/about_us/news/gestational-diabetes-and-children
[lxii] Hillier, Teresa A., Kathryn L. Pedula, Mark M. Schmidt, Judith A. Mullen, Marie-Aline Charles, and David J. Pettitt. “Childhood obesity and metabolic imprinting.” Diabetes care 30, no. 9 (2007): 2287-2292.
[lxiii] Joslin Diabetes Center. 2017. Diabetes and Heart Disease — An Intimate Connection. http://www.joslin.org/info/diabetes_and_heart_disease_an_intimate_connection.html
[lxiv] National Institute of Diabetes and Digestive and Kidney Diseases. 2017. Diabetes, Heart Disease, and Stroke. https://www.niddk.nih.gov/health-information/diabetes/overview/preventing-problems/heart-disease-stroke
[lxv] Emerging Risk Factors Collaboration. “Diabetes mellitus, fasting blood glucose concentration, and risk of vascular disease: a collaborative meta-analysis of 102 prospective studies.” The Lancet 375, no. 9733 (2010): 2215-2222.
[lxvi] Huxley, Rachel, Federica Barzi, and Mark Woodward. “Excess risk of fatal coronary heart disease associated with diabetes in men and women: meta-analysis of 37 prospective cohort studies.” Bmj332, no. 7533 (2006): 73-78.
[lxvii] Vigneri, Paolo, Francesco Frasca, Laura Sciacca, Giuseppe Pandini, and Riccardo Vigneri. “Diabetes and cancer.” Endocrine-related cancer 16, no. 4 (2009): 1103-1123.
[lxviii] Friberg, E., N. Orsini, C. S. Mantzoros, and A. Wolk. “Diabetes mellitus and risk of endometrial cancer: a meta-analysis.” (2007): 1365-1374.
[lxix] Weiderpass, Elisabete, Gloria Gridley, Ingemar Persson, Olof Nyrén, Anders Ekbom, and Hans-Olov Adami. “Risk of endometrial and breast cancer in patients with diabetes mellitus.” International journal of cancer 71, no. 3 (1997): 360-363.
[lxx] Boyle, Peter, Mathieu Boniol, A. Koechlin, Chris Robertson, Faustine Valentini, Kim Coppens, Laura-Louise Fairley et al. “Diabetes and breast cancer risk: a meta-analysis.” British journal of cancer 107, no. 9 (2012): 1608.
[lxxi] Wolf, Ido, Siegal Sadetzki, Raphael Catane, Avraham Karasik, and Bella Kaufman. “Diabetes mellitus and breast cancer.” The lancet oncology 6, no. 2 (2005): 103-111.
[lxxii] Peairs, Kimberly S., Bethany B. Barone, Claire F. Snyder, Hsin-Chieh Yeh, Kelly B. Stein, Rachel L. Derr, Frederick L. Brancati, and Antonio C. Wolff. “Diabetes mellitus and breast cancer outcomes: a systematic review and meta-analysis.” Journal of Clinical Oncology 29, no. 1 (2010): 40-46.
[lxxiii] Anderson, Ryan J., Kenneth E. Freedland, Ray E. Clouse, and Patrick J. Lustman. “The prevalence of comorbid depression in adults with diabetes.” Diabetes care 24, no. 6 (2001): 1069-1078.
[lxxiv] Piccinelli, Marco, and Greg Wilkinson. “Gender differences in depression.” The British Journal of Psychiatry 177, no. 6 (2000): 486-492.
[lxxv] Van de Velde, Sarah, Piet Bracke, and Katia Levecque. “Gender differences in depression in 23 European countries. Cross-national variation in the gender gap in depression.” Social science & medicine 71, no. 2 (2010): 305-313.
[lxxvi] Ali, S., M. A. Stone, J. L. Peters, M. J. Davies, and K. Khunti. “The prevalence of co‐morbid depression in adults with Type 2 diabetes: a systematic review and meta‐analysis.” Diabetic Medicine 23, no. 11 (2006): 1165-1173.
[lxxvii] Mayo Clinic. 2017. What’s the connection between diabetes and depression? http://www.mayoclinic.org/diseases-conditions/diabetes/expert-answers/diabetes-and-depression/faq-20057904
[lxxviii] Clouse, Ray E., Patrick J. Lustman, Kenneth E. Freedland, Linda S. Griffith, Janet B. McGill, and Robert M. Carney. “Depression and coronary heart disease in women with diabetes.” Psychosomatic medicine 65, no. 3 (2003): 376-383.
[lxxx] Chatterjee, Saion, Sanne AE Peters, Mark Woodward, Silvia Mejia Arango, G. David Batty, Nigel Beckett, Alexa Beiser et al. “Type 2 diabetes as a risk factor for dementia in women compared with men: a pooled analysis of 2.3 million people comprising more than 100,000 cases of dementia.” Diabetes Care 39, no. 2 (2016): 300-307.
[lxxxi] Chatterjee, Saion, Sanne AE Peters, Mark Woodward, Silvia Mejia Arango, G. David Batty, Nigel Beckett, Alexa Beiser et al. “Type 2 diabetes as a risk factor for dementia in women compared with men: a pooled analysis of 2.3 million people comprising more than 100,000 cases of dementia.” Diabetes Care 39, no. 2 (2016): 300-307.
[lxxxii] National Osteoporosis Foundation. 2017. What Women Need to Know. https://www.nof.org/preventing-fractures/general-facts/what-women-need-to-know/
[lxxxiii] Starup-Linde, Jakob, and Peter Vestergaard. “Management of endocrine disease: diabetes and osteoporosis: cause for concern?.” European Journal of Endocrinology 173, no. 3 (2015): r93-r99.
[lxxxiv] Adami, Silvano. “Bone health in diabetes: considerations for clinical management.” Current medical research and opinion 25, no. 5 (2009): 1057-1072.
[lxxxv] Kautzky-Willer, Alexandra, Jürgen Harreiter, and Giovanni Pacini. “Sex and gender differences in risk, pathophysiology and complications of type 2 diabetes mellitus.” Endocrine reviews 37, no. 3 (2016): 278-316.
[lxxxvi] Kautzky-Willer, Alexandra, Jürgen Harreiter, and Giovanni Pacini. “Sex and gender differences in risk, pathophysiology and complications of type 2 diabetes mellitus.” Endocrine reviews 37, no. 3 (2016): 278-316.
[lxxxvii] Hitchman, Sara C., and Geoffrey T. Fong. “Gender empowerment and female-to-male smoking prevalence ratios.” Bulletin of the World Health Organization 89, no. 3 (2011): 195-202.
[lxxxviii] Slade, Tim, Cath Chapman, Wendy Swift, Katherine Keyes, Zoe Tonks, and Maree Teesson. “Birth cohort trends in the global epidemiology of alcohol use and alcohol-related harms in men and women: systematic review and metaregression.” BMJ open 6, no. 10 (2016): e011827.
[lxxxix] WHO. 2017. Obesity: data and statistics. http://www.euro.who.int/en/health-topics/noncommunicable-diseases/obesity/data-and-statistics
[xc] WHO. 2012. Action Plan for implementation of the European Strategy for the Prevention and Control of Noncommunicable Diseases 2012−2016. http://www.euro.who.int/__data/assets/pdf_file/0019/170155/e96638.pdf?ua=1
[xci] European Commission. 2017. Responding to the need for EU comparable indicators for diabetes monitoring. https://ec.europa.eu/health/major_chronic_diseases/diseases/diabetes_en#fragment1
[xcii] European Commission. 2017. Responding to the need for EU intervention for diabetes prevention. https://ec.europa.eu/health/major_chronic_diseases/diseases/diabetes_en#fragment4
[xciii] The Economist. 2017. ‘Taxes to trim waistlines are spreading across Europe’. https://www.economist.com/news/europe/21723119-hungary-fattest-eu-member-leading-charge-taxes-trim-waistlines-are-spreading
[xciv] European Commission. 2017. The burden of diabetes: the economic costs. https://ec.europa.eu/health/major_chronic_diseases/diseases/diabetes_en#fragment7
[xcv] Richardson, Erica, Jelka Zaletel, and Ellen Nolte. “National Diabetes Plans in Europe.” (2016).
[xcvi] JA-CHRODIS. “Diabetes: a case study on strengthening health care for people with chronic diseases. Preface.” Annali dell’Istituto Superiore di Sanitā 51.3 (2015): 183-186.