Author:  Patricia Nicholson

The latest report from the POWER study has some troubling data about women and diabetes in Ontario.

First, diabetes rates continue to rise in the province. Second, young women are now being diagnosed at unprecedented rates. And third, women with diabetes who become pregnant have increased risks for pregnancy complications as well as serious fetal complications.

The POWER (Project for an Ontario Women’s health Evidence-based Report) study is a multi-part, comprehensive report on Ontario women’s health. One of the lead authors of the diabetes report, Dr. Lorraine Lipscombe, a scientist at Women’s College Research Institute and endocrinologist at Women’s College Hospital, describes the POWER study as a report card on women’s health.

Incidence of diabetes has been rising dramatically: in the past 12 years, rates of diabetes have doubled in Ontario. It’s an alarming statistic, but it’s not only about the number of cases, but also who is being diagnosed. Diabetes has always been more common in men than in women, especially in younger age groups. The new POWER report found a shift in that trend.

‘Men still have higher rates of diabetes, but the landscape is changing in some age groups,’ Dr. Lipscombe says. ‘Older women still have lower rates of diabetes than older men, but younger women are now being diagnosed at the same rate as younger men.’

As more women are diagnosed with diabetes at a younger age, they are exposed to new current and future health risks.

‘The next cohort of women, as they enter older age, will have a higher burden of disease,’ Dr. Lipscombe explains.

Diabetes doubles the incidence of pregnancy complications

Diabetes also exposes women to pregnancy risks. Younger and younger women are getting diabetes, while many women are delaying pregnancy until they are older. The combination means a greater burden of diabetes in pregnancy.

The POWER report on diabetes represents the first solid information on pregnancy outcomes in women with diabetes in Ontario, Dr. Lipscombe says. The data suggest that more needs to be done to decrease the risks to diabetic women and their babies.

‘Women who had diabetes before pregnancy had increased pregnancy complications and fetal complications, including birth defects, stillbirths and perinatal mortality,’ Dr. Lipscombe said.

Fetal complications, stillbirth and perinatal mortality were twice as high in infants born to women who had diabetes before getting pregnant, compared to women without diabetes.

Dr. Lipscombe notes that the stillbirth and mortality rate remains low – 5.2 cases per 1,000 births.

‘However, it was double what we saw in women without diabetes,’ she says.

The research also showed that women with diabetes were significantly more likely than other women to deliver by caesarean section: 45 per cent of women who had diabetes before getting pregnant and 37 per cent of women with gestational diabetes had a C-section. The C-section rate in non-diabetic women was 27 per cent.

Dr. Lipscombe adds that the pregnancy findings are important, ‘because we know good counselling and tight diabetes control can lower the risks of pregnancy complications,’ she says. ‘We may not be doing a good enough job preparing women with diabetes for pregnancy.’

There is a need to educate physicians and health-care providers about the increased risks for pregnant women with diabetes, and also a need to counsel younger women with diabetes as they contemplate pregnancy, Dr. Lipscombe says.

Gender and income affect the course of diabetes

The POWER report also highlights the major differences in how diabetes affects men and women, not only in prevalence, but also in complications.

‘Men and women experience diabetes differently,’ Dr. Lipscombe says. In terms of complications related to diabetes, men have higher incidence of amputations and heart attacks. Women have higher incidence of disability and depression. They are also more likely to have other chronic diseases in addition to diabetes, and are more likely to rate their own health as poor or fair.

‘Women experience diabetes in a more troubling way, but men have more troubling outcomes,’ Dr. Lipscombe says.

Differences in income not only affected diabetes outcomes, but also affected men and women differently. Even in a universal health-care system in which everyone is supposed to have access, gaps were still evident.

In diabetes patients, men with low incomes were more likely to have complications, but women with low incomes were more likely to report depression, disability and poor health functioning.

Low-income women with diabetes were the largest group of women with poor self-rated health.

‘We know that people with diabetes are more likely to report fair or poor health, but we found a big difference in income,’ Dr. Lipscombe said. ‘Fifty per cent of women with diabetes who had low incomes reported fair or poor health, compared to 31 per cent of women with diabetes with high incomes.’

Among low-income people with diabetes, women had a greater disease burden: 63 per cent of low income women had two or more chronic conditions, compared to 51 per cent of men.

‘There is evidence that lower income populations need more frequent and intensive diabetes care or interventions to meet diabetes treatment goals,’ Dr. Lipscombe says. ‘We need to focus specifically on vulnerable populations to provide them with more frequent and intensive diabetes care.’

That care doesn’t necessarily have to come from doctors, she says. It can come via other health-care professionals, community resources, information and support.

‘It’s important to look at income-related disparities,’ Dr. Lipscombe says. ‘Lower income groups have less health advocacy, less health literacy. We need to provide greater outreach and opportunities for these groups.’

She adds that culturally appropriate diabetes care is required in diverse populations.

Half of Ontarians at risk

The POWER study results also highlight the fact that it’s not just about who is diagnosed with diabetes today. It’s also about who is at risk of diabetes in the future.

Currently, one in 10 adults in Ontario has diabetes. In people over 65, that number rises to one in four. But almost half of those who don’t have diabetes have at least one major risk factor: inactivity, not eating enough fruit and vegetables (a marker for poor nutrition) or being overweight or obese.

‘The fact that we’re seeing such huge increases means we need to increase preventive strategies,’ Dr. Lipscombe says. ‘Much of Type 2 diabetes can be prevented through weight loss, fitness and nutrition.’

The high prevalence of both diabetes and people at risk for it underscore the need for preventive strategies, public health initiatives and increased awareness.

The report notes the need to promote lifestyle changes in the general population: enabling people to live healthier lifestyles by promoting physical activity, and ensuring that people have access to healthy food and are able to live in safe neighbourhoods that promote walking.

An effective model for obesity prevention might be found in anti-smoking campaigns. Dr. Lipscombe notes that smoking rates are down to about 15 per cent in Canada. Long-term anti-smoking strategies have combined public awareness, social change and policy change. Tackling the epidemic of obesity and diabetes might take a similar approach in promoting physical activity and healthy eating.

The POWER study is funded by ECHO: Improving Women’s Health in Ontario, an agency of the Ministry of Health & Long-Term Care. The POWER reports are available at www.powerstudy.ca.