Diabetes is a major public health problem that imposes a serious burden on individuals and on society. An estimated 15.7 million Americans have diabetes, and approximately one-third of these persons do not know they have the disease.

Even so, the number of persons with diagnosed diabetes increased fivefold between 1958 and 1993. In 1997, the cost of diabetes was estimated to be $98.2 billion, of which $44.1 billion was attributable to direct medical expenditures and $54.1 billion to indirect costs including absenteeism, disability, and premature death.

Despite this physical and financial toll, the public generally has not perceived diabetes as a serious disease.  As a result, many efficacious and cost-effective preventive practices that can reduce the burden of this disease are not widely used.

Diabetes as a Women’s Health Issue In general, American women live complicated and challenging lives. Women with diabetes face the same joys and problems, but with an added element: they battle a chronic disease with various social and personal challenges every hour of the day.

In 1983 the Assistant Secretary for Health established the Public Health Service Task Force on Women’s Health Issues. In 1985, this task force published a report that presented health issues across the life stages of women and listed recommendations that encouraged expanded research focusing on conditions and diseases unique to or more prevalent among women. The report also presented criteria for qualifying a health problem as a women’s issue. When these criteria are applied to diabetes, this condition can clearly be differentiated as a women’s issue. Diabetes in pregnancy is a serious condition that is unique to women because of its potential to affect the health of both the mother and her unborn child.

Approximately 2%–5% of all pregnancies in the United States are complicated by gestational diabetes, and this complication is most common among women of racial and ethnic groups at high risk for diabetes (blacks, Hispanics, American Indians, and Asian Americans). Moreover, the burden of diabetes falls disproportionately on women. More than half of all persons with diabetes are women.

In addition, among the 8.1 million women aged 20 years or older with diabetes, older women and minority women are disproportionately represented. The prevalence of diabetes is at least 2–4 times higher among black, Hispanic, American Indian, and Asian/Pacific Islander women than among white women. This excess of diabetes is even more profound for particular subgroups of women. Because of the increasing lifespan of women and the rapid growth of minority populations, the number of women in the United States at high risk for diabetes and its complications is increasing.

The risk for cardiovascular disease, the most common complication attributable to diabetes, is more serious among women than men. Notably, women with diabetes lose their premenopausal protection from ischemic heart disease and have risk for this condition as great as or greater than that of diabetic or nondiabetic men. Furthermore, among people with diabetes who develop ischemic heart disease, women have worse survival and quality of life measures. Women are also at greater risk for blindness due to diabetes than men.

Research has shown that many risk factors for diabetes (weight gain, obesity, lack of physical activity) are more common among women than men in all population subgroups. In addition, the natural history of these factors and their relationship to diabetes are quite different among some subgroups of American women. For example, black women retain more weight postpartum than white women with comparable gestational weight gain, increasing their risk for obesity and its sequelae in subsequent pregnancies and at older ages. Obesity is associated with the prevalence of type 2 diabetes and is a risk factor for the development of this disease.

Among women of minority racial or ethnic origin, there is earlier onset of obesity, and these groups experience disproportionately high levels of excess weight. This variation in risk profiles and cultural norms among the various populations of women with diabetes suggests that the interventions for mediating these risks should also vary accordingly. The results of the primary prevention trials now in progress should provide additional information that may benefit women at risk for type 2 diabetes mellitus.

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Diabetes and Women’s Health Across the Life Stages:
A Public Health Perspective

Editors: Gloria L.A. Beckles, MBBS, MSc, and Patricia E. Thompson-Reid, MAT, MPH

U.S. DEPARTMENT OF HEALTH
AND HUMAN SERVICES
CENTERS FOR DISEASE CONTROL AND PREVENTION

GLOSSARY:

acculturation — the process of adapting to the behaviors and norms of the majority culture. Degree of acculturation is often used to describe how much an immigrant has adopted the lifestyle of the majority culture.

acidosis — See diabetic ketoacidosis.

activities of daily living — scale developed by S. Katz and colleagues to measure personal selfmaintenance ability among older adults. The activities rated are eating, toileting, dressing, bathing, transferring (e.g., getting in and out of bed), and continence.

adherence — the extent to which patients follow health care provider recommendations for disease management, including health-promoting activities. For persons with diabetes, this includes taking medications, monitoring blood glucose, and following nutrition and physical activity guidelines. Also see compliance.

adiposity — excessive fat in the body; see obesity.

age-adjusted — describes rates that have been adjusted by an established procedure to minimize the effects of differences in age composition when comparing rates for different populations.

albuminuria — more than normal amounts of the protein albumin in the urine. Albuminuria may be a sign of kidney disease.

all-cause mortality rate — an estimate of the proportion of a population that dies during a specific period due to all those diseases, morbid conditions, or injuries that either resulted in or contributed to death and the circumstances of the accident or violence that produced any such injuries.

American Diabetes Association (ADA) — nonprofit national health organization that provides information, advocates policy change, and conducts research to prevent and cure diabetes and to improve the life of all people affected by diabetes. For more information, see http://www.diabetes.org.

angina — a condition in which the heart muscle does not receive enough blood, resulting in pain in the chest.

angiotensin converting enzyme (ACE) inhibitor — a type of drug used to lower blood pressure and to help prevent kidney disease in persons with diabetes.

anorexia — lack or loss of appetite for food.

anorexia nervosa — a serious eating disorder characterized by chronic decreased food intake that results in profound weight loss.

atherosclerosis/atherosclerotic disease — a disease in which fat builds up in the large and medium-sized arteries. This buildup of fat may slow down or stop blood flow.

atherosclerotic lesions/plaque — deposits in the arteries that result from the accumulation of cholesterol and lipids in the arteries. Persons with diabetes are at increased risk for atherosclerosis.

autonomic neuropathy — nerve damage affecting control of the internal organs, such as the bladder muscles, digestive tract, and genital organs. Autonomic neuropathy can develop as a complication of diabetes.

Behavioral Risk Factor Surveillance System (BRFSS) — an annual state-based telephone survey of the civilian, noninstitutionalized adult population conducted biannually by CDC and state health departments to assess lifestyle characteristics and risk and health-promoting behaviors. For more information, see http://www.cdc.gov/nccdphp/brfss.

beta cell- type of cell in the pancreas that makes and releases insulin.

body mass index (BMI) — a measure of body size that relates weight in kilograms to height in meters squared. Formula: weight in kilograms divided by height in meters squared (kg/m2). BMI correlates highly with body fat in most people.

bulemia — eating disorder characterized by binge eating and induced vomiting.

cardiovascular disease (CVD) — disease of the circulatory system, including the heart and blood vessels.

cataract — clouding of the lens of the eye. Cataracts can occur as a complication of diabetes.

central adiposity or obesity — fat deposits that form in the center of a person’s body, especially around the stomach area, often assessed by measuring waist-to-hip ratio. Central adiposity increases the risk for cardiovascular complications.

cerebrovascular disease — damage to the blood vessels in the brain that can result in a stroke. (See stroke.) Cerebrovascular disease can develop as a complication of diabetes.

cholesterol — a fat-like substance in the blood, muscle, liver, brain, and other tissues. Too much cholesterol may cause fat to build up in the artery walls and cause disease that slows or stops the flow of blood.

compliance — patients’ adherence to health care provider recommendations for disease management and health-promoting activities. (See adherence.)

comorbidity — the condition of having more than one illnesses at the same time (e.g., diabetes and depression, diabetes and heart disease).

continuous subcutaneous infusion of insulin (CSII) — or insulin pump, a device that delivers a continuous supply of insulin into the body. The insulin flows through the pump through a plastic tube that is connected to a needle inserted into the body and taped in place. Insulin is delivered at two rates: a low, steady rate (called basal rate) for continuous day-long coverage, and extra boosts of insulin (called bolus doses) to cover meals or when
extra insulin is needed.

coronary heart disease (CHD) — a disorder that affects the heart muscle and its blood vessels. The most serious danger of coronary heart disease is a heart attack, which occurs when the supply of blood to the heart is greatly reduced or stopped due to a blockage in a coronary artery. Persons with diabetes have an increased risk for CHD.

cortisol — one of several hormones made in the adrenal glands. The primary responsibility of cortisol is to activate the immune system; it also affects the metabolism of glucose.

dementia — loss of cognitive function; a condition of deteriorated mentality.

dentition — quality and quantity of teeth, including their number, kind, and arrangement.

diabetic ketoacidosis — acute complication of diabetes characterized by a high blood glucose in the presence of ketones in the urine and bloodstream. Diabetic ketoacidocis requires emergency treatment and is often caused by illness or taking too little insulin. Symptoms include nausea and vomiting, stomach pain, and deep, rapid breathing.

Diabetes Control and Complications Trial (DCCT) — clinical study funded by the National Institutes of Health to assess the effects of intensive therapy on the long-term complications of type 1 diabetes. The study showed that intensive blood glucose control slows the onset and progression of eye, kidney, and nerve disease caused by diabetes. For more information, see http://www.niddk.nih.gov/health/diabetes/pubs/dcct1/dcct.htm.

Diabetes Prevention Program (DPP) — clinical trial sponsored by the National Institutes of Health that compares the effectiveness of diet/exercise with that of metformin or a placebo in reducing the risk for type 2 in high-risk persons. For more information, see http://www.preventdiabetes.com/.

diabetogenic risk profile — a descriptive term for a person’s level of known risk factors for diabetes (e.g., body mass index, physical activity level, family history).

diabetogens — drugs or other factors that cause diabetes; some drugs cause blood glucose (sugar) to rise, resulting in diabetes.

dyslipidemia — abnormal excess of fat or lipids in the blood.

dyslipoproteinemia — abnormal concentrations of one or more lipoproteins, a combination of a lipid and a protein, used to transport cholesterol and other lipids through the bloodstream.

Early Treatment of Diabetic Retinopathy Study (ETDRS) — study that examined the effects of laser photocoagulation and aspirin on the progression of diabetic retinopathy in patients with diabetes. For more information, see http://www.nei.nih.gov/neitrials_static/study53.htm.

edentulous — describes the loss of teeth, especially in elderly people; toothless.

end-stage renal disease (ESRD) — the final phase of kidney disease, treated by dialysis or kidney transplantation. ESRD can be a complication of diabetes.

epinephrine — principal blood-pressure raising hormone secreted by the adrenal medulla.

estrogen replacement therapy (ERT) — refers to the use of estrogen as a prescription drug to replace the hormone estrogen that is no longer produced by the ovaries of women as a result of menopause.

excess mortality — increased rates or numbers of deaths in a specific population by age, sex, cause, and sometimes other variables.

fasting glucose — glucose concentration in a person who has not eaten recently; used to diagnose diabetes.

fatalism — a belief that events are predetermined and cannot be altered by human effort.

fibrinogen — a normal component of human plasma that functions in blood clotting.

functional impairment — damage that affects one’s ability to perform daily activities.

gangrene — death of body tissue due to poor circulation. Gangrene is a serious complication of diabetes and may lead to amputation.

gestational diabetes mellitus (GDM) — type of diabetes that can occur during pregnancy; in most cases, blood sugar levels return to normal after pregnancy.

glaucoma — eye disease associated with increased pressure within the eye that can damage the optic nerve and cause impaired vision and blindness. Persons with diabetes are at increased risk for glaucoma.

glomerular filtration rate — measure of the kidney’s ability to filter and remove waste products; used to diagnose kidney disease.

glucose tolerance test — test formerly used to diagnose diabetes. Blood glucose is measured before a patient has eaten that day. Blood is subsequently tested after the patient drinks a liquid containing glucose to see how the patient’s body metabolizes glucose over time.

glycated hemoglobin — see HbA1c.

glycemic control — maintenance of normal glucose levels.

glycosuria — high glucose in the urine, a sign of poor blood glucose control.

glycosylated hemoglobin test — see HbA1c.

health-related quality of life (HRQOL) — aspects of self-perceived well-being and ability to function affected by the presence or treatment of disease. A number of instruments have been developed to assess how health affects one’s functional ability.

hemoglobin A1c (HbA1c) — a blood test that measures a person’s average blood glucose level for the 2- to 3-month period before the test.

HDL cholesterol — high-density lipoprotein cholesterol, a transport form of cholesterol in the blood. Low concentrations of HDL cholesterol are a risk factor for CVD, especially in persons with diabetes.

Hispanic Health and Nutrition Examination Survey (HHANES) — a national survey conducted during 1982–84 of approximately 16,000 Hispanic persons aged 6 months–74 years. Hispanics were included in past health and nutrition examinations but not in sufficient numbers to produce estimates of the health of Hispanics in general nor specific data for Puerto Ricans, Mexican Americans, or Cuban Americans.

hormone replacement therapy (HRT) — refers to the use of hormones as prescription drugs to replace the hormones estrogen and progesterone that women’s ovaries stop producing during menopause.

hypercholesterolemia — excess of cholesterol in the blood.

hyperglycemia — too much glucose (sugar) in the blood, a sign that diabetes is out of control. Hyperglycemia can occur when the body does not have enough insulin or cannot use the insulin it does have to turn glucose into energy. Signs of hyperglycemia include a great thirst, a dry mouth, and a need to urinate often.

hyperglycemic conditions — conditions that cause an increase in the level of glucose in the blood.

hyperinsulinemia — too high a level of insulin in the blood.

hyperlipidemia — too high a level of fats (lipids) in the blood.

hyperosmolar coma — a coma related to high levels of glucose in the blood and requiring emergency treatment.

hypertension — high blood pressure, a condition that occurs when blood circulates through the arteries with too much force, increasing the risk for heart attack, stroke, and kidney problems.

hypertriglyceridemia — Too high a level of triglycerides, a type of blood fat. Triglycerides can increase when diabetes and weight are not under control.

hypoglycemia — a condition that occurs in persons with diabetes when their blood glucose levels are too low. Symptoms include feeling anxious or confused, numbness in the arms and hands, and shaking or feeling dizzy.

hypoglycemic agent — drug used to treat hyperglycemia in persons with diabetes.

impaired fasting glucose — When a person has a fasting glucose equal to or greater than 110 mg/dL and less than 126 mg/dL, they are said to have impaired fasting glucose. This result is considered a risk factor for future diabetes but, by itself, does not determine a diagnosis of diabetes.

impaired glucose tolerance (IGT) — condition diagnosed when a person is determined to have abnormal blood glucose levels, but not abnormal enough to be called diabetes. People with IGT are at increased risk of developing diabetes.

incidence — the number of new cases of a disease among a certain group of people during a certain period of time.

index pregnancy — the pregnancy in which a condition (e.g., diabetes) is first identified.

insulin — a hormone that controls the level of glucose (sugar) in the blood.

insulin resistance — abnormal metabolic pattern where body cells lose sensitivity to insulin. Insulin resistance is a risk factor for diabetes; it also increases risk for cardiovascular disease.

ischemic heart disease — See coronary heart disease. Juvenile Diabetes Research Foundation

International (JDRF) — major diabetes organization focused exclusively on diabetes research. JDRF focuses on type 1 diabetes. For more information, see http://www.jdf.org/.

ketoacidosis — see diabetic ketoacidosis.

LDL cholesterol — low-density lipoprotein cholesterol, a transport form of cholesterol in the blood. High concentrations of LDL cholesterol are a risk factor for cardiovascular disease, especially in persons with diabetes.

lipids — fats, including cholesterol, triglycerides, and phospolipids.

lipoprotein — component of system used to transport lipids (cholesterol, triglycerides) in the bloodstream. Major lipoproteins are LDL and HDL.

locus of control — a common measure of perceived ability to control events.

macroalbuminuria — high levels of urinary protein (albumin), a sign of kidney disease, especially in persons with diabetes.

macrovascular disease — disease of the large blood vessels caused by atherosclerosis. There are three types of macrovascular disease: coronary (heart) disease, cerebrovascular disease, and peripheral vascular disease.

metformin — a drug used to treat type 2 diabetes. mg/dL — milligrams per deciliter. Term used to describe how much of a substance is in a specific amount of liquid (e.g., the number of milligrams of glucose in 1 deciliter of blood).

microalbuminuria — refers to albumin excretion in the urine. Microalbuminuria is a risk factor for kidney disease.

microvascular disease — disease of the small blood vessels, especially of the kidney or the eye.

myocardial infarction — also called a heart attack, results from permanent damage to an area of the heart muscle, caused by narrowed or blocked blood vessels that interrupt the blood supply to the area. A serious complication of diabetes that can cause death.

National Cholesterol Education Program (NCEP) — program begun in 1985 by the National Institutes of Health. The goal is to reduce the percentage of Americans with high blood cholesterol through educational efforts to raise awareness and understanding about high blood cholesterol as a risk factor for coronary heart disease and the benefits of lowering cholesterol levels as a means of preventing coronary heart disease. For more information, see http://www.nhlbi.nih.gov/about/ncep/index.htm.

National Diabetes Education Program (NDEP) — federally sponsored initiative that involves public and private partners to improve the treatment and outcomes for persons with diabetes, to promote early diagnosis, and ultimately, to prevent the onset of diabetes. For more information, see http://www.cdc.gov/diabetes/projects/ndeps.htm.

National Health and Nutrition Examination Survey (NHANES) — refers to the periodic National Health and Nutrition Examination Surveys that use a household interview to ascertain diagnosed diabetes and an oral glucose tolerance test to measure undiagnosed diabetes. For more information, see http://www.cdc.gov/nchs/nhanes.htm.

National Health Interview Survey (NHIS) — data collection program of CDC’s National Center for Health Statistics that studies the health of the civilian noninstitutionalized population of the United States. Monitors trends in illness and disability and tracks progress toward national health objectives. For more information, see http://www.cdc.gov/nchs/nhis.htm.

nephropathy — kidney disease, a serious complication of diabetes.

neuroendocrine — pertaining to the interaction between the nervous and endocrine systems.

neuropathy — disease of the nervous system caused by damage to the nerves, a serious complication of diabetes.

oral glucose tolerance test (OGTT) — see glucose tolerance test.

parity — the state of having had children, or the number of children previously borne.

periodontal disease — disease of the gums; can be a complication of diabetes..

peripheral vascular disease (PVD) — disease of the large blood vessels of the arms, legs, and feet caused by blocking of major blood vessels.

person-years — or person-time, a measurement combining persons and time. It is the sum of individual units of time that the persons in a study population have been exposed to the condition of interest.

pharmacotherapy — the treatment of disease with medicines.

poverty — set of money income thresholds that take into account family size and composition used by the U.S. Bureau of the Census to define the official poverty level.

preeclampsia — condition characterized by high blood pressure and swelling that some women with diabetes have during the late stages of pregnancy.

prevalence — the number of people in a given group who are reported to have a disease at a certain point in time.

proliferative diabetic retinopathy (PDR) — growth of abnormal blood vessels and fibrous tissue from the optic nerve head or from the inner retinal surface elsewhere in persons with diabetes.

proteinuria — too much protein in the urine; may be a sign of kidney damage.

relative risk (RR) — the ratio of the risk of death or disease among those exposed to the risk among those unexposed.

renoprotective — describes a factor that preserves kidney function or prevents kidney disease.

reserpine — a drug used to treat hypertension. retinopathy — a disease of the small blood vessels in the retina of the eye.

San Antonio Heart Study — a population-based study of diabetes and cardiovascular disease in Mexican Americans and non-Hispanic whites.

secular trend — change over a long period of time, generally years or decades (e.g., the rise in prevalence of diabetes in the United States in the past 20 years).

self-efficacy — one’s personal judgment of one’s own ability to succeed in reaching a specific goal; belief in one’s ability to maintain behavioral change in the face of situational challenges.

self-management — a set of skilled behaviors that allow patients to manage their illness; for diabetes, this includes glucose management, patient education, and preventive care.

sequelae — results of a disease or injury or of complications. Sequelae of diabetes include its complications.

social network — a set of social ties that connects an individual with others.

social support — emotional or task-oriented assistance provided by the community, family, friends, or significant others.

socioeconomic status (SES) — a descriptive term for a person’s position in society, using criteria such as income, educational level attained, occupation, and value of dwelling place.

standardized rate ratio (SRR) — a rate ratio in which the numerator and the denominator have been standardized to the same (standard) population distribution.

stroke — disease caused by damage to blood vessels in the brain. Depending on the part of the brain affected, stoke can cause loss of muscle function, mental function, vision, sensation, or speech. Stroke can be a complication of diabetes.

sulfonylurea — a drug used to treat type 2 diabetes that lowers the level of glucose (sugar) in the blood.

thrombosis — the formation, development, or presence of a thrombus, or blood clot, in a blood vessel. Thrombosis can develop as a complication of atherosclerosis, especially in persons with diabetes.

triglycerides — type of blood fat.

United Kingdom Prospective Diabetes Study (UKPDS) — clinical study of newly diagnosed patients with type 2 diabetes. The UKPDS demonstrated that intensive glucose control prevents complications of diabetes.

vascular — relating to the body’s blood vessels (arteries, veins, capillaries). See cardiovascular disease.

vitreous hemorrhage — bleeding or leaking of the clear jelly (gel) that fills the center of the eye.

waist-to-hip ratio (WHR) — a measure of central obesity, which is related to insulin resistance and risk for diabetes. Formula: waist circumference divided by hip circumference.

Definitions for this glossary were compiled from the following sources:

National Institute of Diabetes and Digestive and Kidney Diseases. The Diabetes Dictionary. Bethesda, MD: U.S. Department of Health and Human Services, National Institutes of Health, NIDDK, 1994. (NIH Publication No. 98-3016)

American Heart Association. Heart and Stroke Facts. Dallas, Texas: American Heart Association, 1999. Last, John M., editor. A Dictionary of Epidemiology. Third Edition. New York: Oxford University Press, 1995.

Merriam-Webster’s Collegiate Dictionary. Tenth Edition. Springfiled, MA: Merriam-Webster, Inc.,
1993.

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