Sex-specific relevance of diabetes to occlusive vascular and other mortality: a collaborative meta-analysis of individual data from 980 793 adults from 68 prospective studies

Abstract

SummaryBackgroundSeveral studies have shown that diabetes confers a higher relative risk of vascular mortality among women than among men, but whether this increased relative risk in women exists across age groups and within defined levels of other risk factors is uncertain. We aimed to determine whether differences in established risk factors, such as blood pressure, BMI, smoking, and cholesterol, explain the higher relative risks of vascular mortality among women than among men.MethodsIn our meta-analysis, we obtained individual participant-level data from studies included in the Prospective Studies Collaboration and the Asia Pacific Cohort Studies Collaboration that had obtained baseline information on age, sex, diabetes, total cholesterol, blood pressure, tobacco use, height, and weight. Data on causes of death were obtained from medical death certificates. We used Cox regression models to assess the relevance of diabetes (any type) to occlusive vascular mortality (ischaemic heart disease, ischaemic stroke, or other atherosclerotic deaths) by age, sex, and other major vascular risk factors, and to assess whether the associations of blood pressure, total cholesterol, and body-mass index (BMI) to occlusive vascular mortality are modified by diabetes.ResultsIndividual participant-level data were analysed from 980 793 adults. During 9·8 million person-years of follow-up, among participants aged between 35 and 89 years, 19 686 (25·6%) of 76 965 deaths were attributed to occlusive vascular disease. After controlling for major vascular risk factors, diabetes roughly doubled occlusive vascular mortality risk among men (death rate ratio [RR] 2·10, 95% CI 1·97–2·24) and tripled risk among women (3·00, 2·71–3·33; χ2 test for heterogeneity p<0·0001). For both sexes combined, the occlusive vascular death RRs were higher in younger individuals (aged 35–59 years: 2·60, 2·30–2·94) than in older individuals (aged 70–89 years: 2·01, 1·85–2·19; p=0·0001 for trend across age groups), and, across age groups, the death RRs were higher among women than among men. Therefore, women aged 35–59 years had the highest death RR across all age and sex groups (5·55, 4·15–7·44). However, since underlying confounder-adjusted occlusive vascular mortality rates at any age were higher in men than in women, the adjusted absolute excess occlusive vascular mortality associated with diabetes was similar for men and women. At ages 35–59 years, the excess absolute risk was 0·05% (95% CI 0·03–0·07) per year in women compared with 0·08% (0·05–0·10) per year in men; the corresponding excess at ages 70–89 years was 1·08% (0·84–1·32) per year in women and 0·91% (0·77–1·05) per year in men. Total cholesterol, blood pressure, and BMI each showed continuous log-linear associations with occlusive vascular mortality that were similar among individuals with and without diabetes across both sexes.InterpretationIndependent of other major vascular risk factors, diabetes substantially increased vascular risk in both men and women. Lifestyle changes to reduce smoking...

Procoagulant activity in children and adolescents on intensive insulin therapy

“…Several reports have demonstrated increased relative risk of vascular mortality in women with diabetes compared with men, although the precise mechanism is not known . Our data, with lower levels of TFPI accompanied by increased F1+2 in females with type 1 diabetes, support a prothrombotic milieu, which might lead to vascular disease.…”

Sex differences in the burden of type 2 diabetes and cardiovascular risk across the life course

“…Sex differences in CVD outcomes for adults with type 2 diabetes across the life span Type 2 diabetes is a significant risk factor for CVD for both women and men. Findings from large-scale consortia of cohort studies have shown that the presence of diabetes doubles the risk of having a myocardial infarction or stroke [14,15,72]. However, as with other major vascular risk factors, such as blood pressure and BMI, the strength of the association between diabetes and vascular outcomes diminishes with age, partly because of the lower baseline risk for CVD in younger as compared with older adults [72,73].…”

“…Findings from large-scale consortia of cohort studies have shown that the presence of diabetes doubles the risk of having a myocardial infarction or stroke [14,15,72]. However, as with other major vascular risk factors, such as blood pressure and BMI, the strength of the association between diabetes and vascular outcomes diminishes with age, partly because of the lower baseline risk for CVD in younger as compared with older adults [72,73]. For example, in the largest meta-analysis to date, the rate ratio (RR) of occlusive vascular death was found to be greatest in men and women aged 35 ; p = 0.0001 for trend across age groups) [72].…”

Update on peripheral artery disease: Epidemiology and evidence-based facts

“…A recent meta-analysis evaluating the role of diabetes in PAD has shown that diabetes, independently from other major vascular risk factors, substantially increases vascular risk in both men and women [2]. However, lifestyle changes to reduce smoking and obesity and use of cost-effective drugs that target major vascular risks (including statins and antihypertensive drugs) – while remaining important in both men and women with diabetes – might not reduce the relative excess risk of occlusive vascular disease in women with diabetes [2].…”

“…However, lifestyle changes to reduce smoking and obesity and use of cost-effective drugs that target major vascular risks (including statins and antihypertensive drugs) – while remaining important in both men and women with diabetes – might not reduce the relative excess risk of occlusive vascular disease in women with diabetes [2]. Hence, in such a controversial field, gender-related differences could play a fundamental role [13].…”