Diabetes Women’s Health &

Across the Life

Stages

A

Public

Health

Perspective

U.S. DEPARTMENT OF HEALTH

AND HUMAN SERVICES

CENTERS FOR DISEASE CONTROL AND PREVENTION

Diabetes & Women’s Health Across the Life Stages Beckles & Thompson-Reid

Diabetes

Women’s Health

&

Across the Life

Stages

A

Public

Health

Perspective

U.S. DEPARTMENT OF HEALTH

AND HUMAN SERVICES

CENTERS FOR DISEASE CONTROL AND PREVENTION

Gloria L.A. Beckles, MBBS, MSc, and

Patricia E. Thompson-Reid, MAT, MPH

Editors
For more information, contact

CDC Division of Diabetes Translation

P. O. Box 8728

Silver Spring, MD 20910

Phone: Toll-free 1-877-CDC-DIAB (232-3422)

Fax: (301) 562-1050

E-Mail: diabetes@cdc.gov

Internet: http://www.cdc.gov/diabetes

Suggested citation:

Beckles GLA, Thompson-Reid PE, editors. Diabetes and Women’s Health Across the Life Stages: A

Public Health Perspective. Atlanta: U.S. Department of Health and Human Services, Centers for Disease

Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Division

of Diabetes Translation, 2001.
Message from Frank Vinicor, MD, MPH

Director, CDC Diabetes Program

Writing this monograph has been important for the diabetes program at the

Centers for Disease Control and Prevention (CDC). The monograph has

become much more than a “report” by CDC. It has become a model of

thought, interaction, and commitment to make a difference in the lives of 

people—women or men—facing the daily challenges of diabetes. 

We have come to better understand the impact of greater societal forces and

policies on the lives of people with diabetes, though individuals and health care

providers make their own essential contributions. Many cultural, social, organizational, and environmental forces do and will facilitate or limit the impact of

our individual decisions, and the need to always coordinate science and clinical

medicine with programs and policies has become much more obvious to us.

We (at CDC), along with many partners, have the opportunity to convert the

ideas in this monograph into concrete action to assure that efforts to augment

programs directed to both the prevention of diabetes and the care of those with

the disease will occur. These efforts will synergistically blend clinical and public

health strategies. In the next 12 months, CDC and its primary cosponsors, the

American Diabetes Association, the Association of State and Territorial Health

Officials, and the American Public Health Association, will convene a national

call-to-action meeting to develop and then implement the National Public

Health Action Plan for Diabetes and Women. Much more effort is required, but

with this monograph, the process has begun.

Our clinical care systems have benefited many Americans. Now, with the blending of public health and medical approaches to the prevention of the disease

burden associated with diabetes—in this case in women—many more people

who face the daily challenges of diabetes can maintain hope.

iii

Foreword

Diabetes has been a serious public health problem for many years. Currently an

estimated 16 million Americans have diabetes, more than half of them women.

Why, then, has so little progress been made in reducing the burden of this disabling

disease? This provocative question is explored by the authors of Diabetes and

Women’s Health Across the Life Stages: A Public Health Perspective. Throughout its

pages, editors Gloria L.A. Beckles and Patricia E. Thompson-Reid and their collaborators introduce us to some eye-opening issues and some serious, sobering implications for the health of women.

There is no better time for this in-depth look at diabetes as a women’s health issue

than now, as we begin a technologically advanced new century. Old or young, onethird of American women are overweight, and more than one-fourth do not participate in any leisure-time physical activity, according to the Third National Health

and Nutrition Examination Survey (NHANES III 1988–1994). As a group,

American women are aging and growing more obese and less physically active; each

of these factors increases their risk for type 2 diabetes. Currently, about 20 million

are over age 65. By the year 2030, that number is expected to double to 40 million,

or roughly 1 in 4 American women. Astonishingly, more than 7 million women

will be past the age of 85, compared with 4 million men.

The face of the American population is also changing: by the year 2050, 1 in 4

American women will be of Hispanic heritage, 1 in 8 African American, 1 in 11

Asian American, and 1 in 100 American Indian. Non-Hispanic whites will represent barely half of the population of women. Currently, the prevalence of diabetes is

at least 2–4 times higher among women of color, and if this trend continues, the

burden of diabetes could reach unimaginable dimensions.

As the authors point out, the number of persons diagnosed with diabetes increased

fivefold between 1958 and 1997, at a direct cost of over $40 billion and an indirect

cost of another $50 billion annually from absenteeism, disability, and premature

death. These facts carry frustrating, even poignant overtones, because much of the

burden of diabetes associated with complications is potentially preventable.

Although we are well aware of the clinical risks and outcomes of diabetes, this

monograph adds a new and important public health dimension to diabetes research

by looking at the socioeconomic environment that has contributed to the increase

of this disease and the challenges we face as we seek to effectively educate women
iv

about the behavioral changes necessary for prevention. As this document points

out, efforts to reach women with prevention messages will not work if their social

environment does not support the messages. The authors conclude that the same

social bias that resulted in women’s health historically being viewed primarily in the

context of their reproductive organs may still influence women’s health priorities.

The document’s uniqueness also lies in its visionary understanding of the changing

issues that affect women’s health through their life span. Because of this awareness,

the document is structured to reflect the different manifestations of diabetes at different stages of a woman’s life, including the threat of type 1 and the emergence of

type 2 diabetes in youth, gestational diabetes (seen in up to 5% of pregnancies)

among women of childbearing age, and type 2 diabetes as a disease of middle-aged

and older women.

The authors make a powerful argument that more information is needed on how

behavioral and social factors interact with biological factors to affect the health of

women, particularly those with diabetes or other chronic illnesses. Until such

research gives us a clearer picture of how diabetes develops over time, health care

systems should consider custom-designed prevention and control programs tailored

for women and based on local and regional attitudes about health care, differing

cultural health beliefs, and available social supports. Through the National Diabetes

Control Program, the Centers for Disease Control and Prevention collaborates with

all 50 states, the District of Columbia, and U.S. territories and jurisdictions to provide a mechanism for implementing such programs.

In the 21st century, the government cannot take on this health care burden

alone; diabetes will not receive the concerted effort it deserves without action

from both the public and private sectors. This monograph is lush with data and

easy to read and reference. It should quickly become a useful tool for health care

professionals, advocates, and educators seeking a leadership role in the fight

against diabetes.

Wanda K. Jones, DrPH

Deputy Assistant Secretary for Health (Women’s Health)

Director, U.S. Department of Health and Human Services

Office on Women’s Health
v

Contributing Authors

Chapters

Gloria L.A. Beckles, MBBS, MSc, Medical

Epidemiologist/Senior Service Fellow, Division of

Diabetes Translation, National Center for Chronic

Disease Prevention and Health Promotion, Centers

for Disease Control and Prevention, Atlanta,

Georgia.

Cynthia Berg, MD, MPH, Medical Officer,

Division of Reproductive Health, National Center

for Chronic Disease Prevention and Health

Promotion, Centers for Disease Control and

Prevention, Atlanta, Georgia.

Isabella Danel, MD, MPH, Epidemiologist,

Division of Reproductive Health, National Center

for Chronic Disease Prevention and Health

Promotion, Centers for Disease Control and

Prevention, Atlanta, Georgia.

Kellie-Ann Ffrench, MA, Department of

Psychology, University of Georgia, Athens, Georgia.

Catherine Hennessey, DrPh, Epidemiologist,

Division of Adult and Community Health,

National Center for Chronic Disease Prevention

and Health Promotion, Centers for Disease

Control and Prevention, Atlanta, Georgia.

Deanna Hill, MPH, Epidemiologist, Henry Ford

Health System, Department of Biostatistics and

Research Epidemiology, Detroit, Michigan.

Georgeanna J. Klingensmith, MD, University of

Colorado Health Sciences Center, The Barbara

Davis Center for Childhood Diabetes, Denver,

Colorado.

This report was prepared by the Centers for

Disease Control and Prevention, National Center

for Chronic Disease Prevention and Health

Promotion, Division of Diabetes Translation.

Jeffrey P. Koplan, MD, MPH, Director, Centers

for Disease Control and Prevention, Atlanta,

Georgia.

James S. Marks, MD, MPH, Director, National

Center for Chronic Disease Prevention and Health

Promotion, Centers for Disease Control and

Prevention, Atlanta, Georgia.

Frank Vinicor, MD, MPH, Director, Division of

Diabetes Translation, National Center for Chronic

Disease Prevention and Health Promotion, Centers

for Disease Control and Prevention, Atlanta,

Georgia.

Kathy Rufo, MPH, Deputy Director, Division of

Diabetes Translation, National Center for Chronic

Disease Prevention and Health Promotion, Centers

for Disease Control and Prevention, Atlanta,

Georgia.

Editors

Gloria L.A. Beckles, MBBS, MSc, Scientific

Editor, Medical Epidemiologist/Senior Service

Fellow, Division of Diabetes Translation, National

Center for Chronic Disease Prevention and Health

Promotion, Centers for Disease Control and

Prevention, Atlanta, Georgia.

Patricia E. Thompson-Reid, MPH, MAT,

Managing Editor, Program Development

Consultant, Division of Diabetes Translation,

National Center for Chronic Disease Prevention

and Health Promotion, Centers for Disease

Control and Prevention, Atlanta, Georgia.

Acknowledgments
vi

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

JoAnn E. Manson, MD, DrPH, Associate

Professor, Department of Epidemiology, Harvard

School of Public Health, Harvard University,

Boston, Massachusetts.

Lily D. McNair, PhD, Assistant Professor,

Department of Psychology, University of Georgia,

Athens, Georgia.

Jill M. Norris, MPH, PhD, Assistant Professor,

Department of Preventive Medicine and

Biometrics, University of Colorado School of

Medicine, Denver, Colorado.

Diane Rowley, MD, MPH, Associate Director for

Science, National Center for Chronic Disease

Prevention and Health Promotion, Centers for

Disease Control and Prevention, Atlanta, Georgia.

Mary Sabolsi, MD, MPH, Brigham and Women’s

Hospital, Harvard University, Boston,

Massachusetts.

Patricia E. Thompson-Reid, MPH, MAT, Program

Development Consultant, Division of Diabetes

Translation, National Center for Chronic Disease

Prevention and Health Promotion, Centers for

Disease Control and Prevention, Atlanta, Georgia.

Frank Vinicor, MD, MPH, Director, Division of

Diabetes Translation, National Center for Chronic

Disease Prevention and Health Promotion, Centers

for Disease Control and Prevention, Atlanta,

Georgia.

Case Studies

Ann Albright, PhD, RD, Director, California

Diabetes Control Program, California Department

of Health, Sacramento, California.

Ann Kollmeyer, RD, MPH, Chief, Office of Policy

and Program Information, Wolf Project, Minnesota

Department of Health, Minneapolis, Minnesota.

Dawn L. Satterfield, RN, MSN, Health Education

Specialist, Division of Diabetes Translation,

National Center for Chronic Disease Prevention

and Health Promotion, Centers for Disease Control

and Prevention, Atlanta, Georgia.

Angela Green-Phillips, MPA, Chief, Office of

Policy and Program Information, Division of

Diabetes Translation, National Center for Chronic

Disease Prevention and Health Promotion, Centers

for Disease Control and Prevention, Atlanta,

Georgia.

Senior Reviewers

Barbara A. Bowman, PhD, Associate Director for

Policy Studies, Division of Diabetes Translation,

National Center for Chronic Disease Prevention

and Health Promotion, Centers for Disease Control

and Prevention, Atlanta, Georgia.

Carl Caspersen, PhD, Associate Director for

Science, Division of Diabetes Translation, National

Center for Chronic Disease Prevention and Health

Promotion, Centers for Disease Control and

Prevention, Atlanta, Georgia.

Michael M. Engelgau, MD, Chief, Epidemiology

and Statistics Branch, Division of Diabetes

Translation, National Center for Chronic Disease

Prevention and Health Promotion, Centers for

Disease Control and Prevention, Atlanta, Georgia.

Anne Fagot-Campagna, MD, PhD, Visiting

Scientist, Division of Diabetes Translation, National

Center for Chronic Disease Prevention and Health

Promotion, Centers or Disease Control and

Prevention, Atlanta, Georgia.

H. Wayne Giles, MD, PhD, Associate Director for

Science, Division of Adult and Community Health,

National Center for Chronic Disease Prevention

and Health Promotion, Centers for Disease Control

and Prevention, Atlanta, Georgia.
Acknowledgments

vii

Nora L. Keenan, PhD, Epidemiologist, Division of

Adult and Community Health, National Center for

Chronic Disease Prevention and Health Promotion,

Centers for Disease Control and Prevention,

Atlanta, Georgia.

Juliette Kendrick, MD, Acting Associate Director

for Science, Division of Reproductive Health,

National Center for Chronic Disease Prevention

and Health Promotion, Centers for Disease Control

and Prevention, Atlanta, Georgia.

Rodolfo Valdez, PhD, Epidemiologist, Division of

Diabetes Translation, National Center for Chronic

Disease Prevention and Health Promotion, Centers

for Disease Control and Prevention, Atlanta,

Georgia.

Other Contributors

Kelly J. Acton, MD, MPH, FACP, Director,

National Diabetes Control Program, Indian Health

Service, Albuquerque, New Mexico.

Ana Alfaro-Correa, ScD, MA, Program

Development Consultant, Division of Diabetes

Translation, National Center for Chronic Disease

Prevention and Health Promotion, Centers for

Disease Control and Prevention, Atlanta, Georgia.

Christopher Benjamin, JD, MPA, Program

Development Consultant, Division of Diabetes

Translation, National Center for Chronic Disease

Prevention and Health Promotion, Centers for

Disease Control and Prevention, Atlanta, Georgia.

Donald Betts, MPA, Public Health Analyst,

Division of Diabetes Translation, National Center

for Chronic Disease Prevention and Health

Promotion, Centers for Disease Control and

Prevention, Atlanta, Georgia.

Kristen L. Bleau, Research Assistant, Division of

Diabetes Translation, National Center for Chronic

Disease Prevention and Health Promotion, Centers

for Disease Control and Prevention, Atlanta,

Georgia.

Diann Braxton, Program Operations Assistant,

Division of Diabetes Translation, National Center

for Chronic Disease Prevention and Health

Promotion, Centers for Disease Control and

Prevention, Atlanta, Georgia.

Betty S. Burrier, Center for Beneficiary Services,

Centers for Medicare and Medicaid Services, U.S.

Department of Health and Human Services,

Baltimore, Maryland.

Cynthia K. Clark, MA, Program Development

Consultant, Division of Diabetes Translation,

National Center for Chronic Disease Prevention

and Health Promotion, Centers for Disease

Control and Prevention, Atlanta, Georgia

Rita Diaz-Kenney, MPH, Health Education

Specialist, Division of Diabetes Translation,

National Center for Chronic Disease Prevention

and Health Promotion, Centers for Disease

Control and Prevention, Atlanta, Georgia.

Van H. Dunn, MD, Senior Vice President, New

York City Health and Hospital Corporation, New

York, New York.

Linda G. Elsner, Writer-Editor, National Center for

Chronic Disease Prevention and Health Promotion,

Centers for Disease Control and Prevention,

Atlanta, Georgia.

Margaret Fowke, RD, LD, MPA, Presidential

Management Intern, Division of Diabetes

Translation, National Center for Chronic Disease

Prevention and Health Promotion, Centers for

Disease Control and Prevention, Atlanta, Georgia.

Christine S. Fralish, MLIS, Chief, Technical

Information and Editorial Services Branch,

National Center for Chronic Disease Prevention

and Health Promotion, Centers for Disease

Control and Prevention, Atlanta, Georgia.

Don L. Garcia, MD, Family Practitioner, Medica

Health System, Anaheim, California.
viii

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

Sanford Garfield, PhD, National Institute of

Diabetes and Digestive and Kidney Diseases,

National Institutes of Health, Bethesda, Maryland.

Julie A. Gothman, RD, South Dakota Department

of Health, Pierre, South Dakota.

Yvonne Green, RN, MSN, CNM, Associate

Director for Women’s Health, Office of the

Director, Centers for Disease Control and

Prevention, Atlanta, Georgia.

Regina Hardy, MS, Deputy Chief, Epidemiology

and Statistics Branch, Division of Diabetes

Translation, National Center for Chronic Disease

Prevention and Health Promotion, Centers for

Disease Control and Prevention, Atlanta, Georgia.

Sabrina M. Harper, MS, Public Health Advisor,

Division of Diabetes Translation, National Center

for Chronic Disease Prevention and Health

Promotion, Centers for Disease Control and

Prevention, Atlanta, Georgia.

Nancy Haynie-Mooney, Health Communications

Specialist, Division of Diabetes Translation,

National Center for Chronic Disease Prevention

and Health Promotion, Centers for Disease

Control and Prevention, Atlanta, Georgia.

Kathryn Herron, MPH, Presidential Management

Intern, Health Resources and Services

Administration, U.S. Department of Health and

Human Services, Washington, DC.

Rick L. Hull, PhD, Writer-Editor, National Center

for Chronic Disease Prevention and Health

Promotion, Centers for Disease Control and

Prevention, Atlanta, Georgia.

Leonard Jack, Jr. PhD, MS, Acting Chief,

Community Intervention Section, Program

Development Branch, Division of Diabetes

Translation, National Center for Chronic Disease

Prevention and Health Promotion, Centers for

Disease Control and Prevention, Atlanta, Georgia.

Valerie Johnson, Writer-Editor, National Center for

Chronic Disease Prevention and Health Promotion,

Centers for Disease Control and Prevention,

Atlanta, Georgia.

Wanda K. Jones, DrPH, Deputy Assistant

Secretary, Director, Office on Women’s Health,

U.S. Department of Health and Human Services,

Washington, DC.

Lisa M. Kemp, Budget Analyst, Division of

Diabetes Translation, National Center for Chronic

Disease Prevention and Health Promotion, Centers

for Disease Control and Prevention, Atlanta,

Georgia.

Carol Krause, MA, Director, Division of

Communications, Office on Women’s Health, U.S.

Department of Health and Human Services,

Washington, DC.

Roz D. Lasker, MD, Director, Division of Public

Health, The New York Academy of Medicine, New

York, New York.

Arlene Lester, DDS, MPH, Program Development

Consultant, Division of Diabetes Translation,

National Center for Chronic Disease Prevention

and Health Promotion, Centers for Disease Control

and Prevention, Atlanta, Georgia.

Norma Loner, Committee Management Specialist,

Division of Diabetes Translation, National Center

for Chronic Disease Prevention and Health

Promotion, Centers for Disease Control and

Prevention, Atlanta, Georgia.

Ivette A. Lopez, MPH, Health Communications

Specialist, Division of Diabetes Translation,

National Center for Chronic Disease Prevention

and Health Promotion, Centers for Disease Control

and Prevention, Atlanta, Georgia.

Mary E. Lowrey, Program Analyst, Division of

Diabetes Translation, National Center for Chronic

Disease Prevention and Health Promotion, Centers

for Disease Control and Prevention, Atlanta,

Georgia.
Acknowledgments

ix

David Marrero, PhD, Associate Professor of

Medicine, Indiana University, Indianapolis, Indiana.

Phyllis C. McGuire, Public Health Analyst,

Division of Diabetes Translation, National Center

for Chronic Disease Prevention and Health

Promotion, Centers for Disease Control and

Prevention, Atlanta, Georgia.

Phyllis L. Moir, MA, Writer-Editor, National

Center for Chronic Disease Prevention and Health

Promotion, Centers for Disease Control and

Prevention, Atlanta, Georgia.

Kathy Mulcahy, CDE, Liaison, American

Association of Diabetes Educators, Chicago, Illinois.

Dara L. Murphy, MPH, Chief, Program Services

Branch, Division of Diabetes Translation, National

Center for Chronic Disease Prevention and Health

Promotion, Centers for Disease Control and

Prevention, Atlanta, Georgia.

Venkat Narayan, MD, Chief, Epidemiology Section,

Division of Diabetes Translation, National Center

for Chronic Disease Prevention and Health

Promotion, Centers for Disease Control and

Prevention, Atlanta, Georgia.

Carolyn W. Perkins, Administrative Officer,

Division of Diabetes Translation, National Center

for Chronic Disease Prevention and Health

Promotion, Centers for Disease Control and

Prevention, Atlanta, Georgia.

Todd W. Pierce, Visual Information Specialist,

Division of Diabetes Translation, National Center

for Chronic Disease Prevention and Health

Promotion, Centers for Disease Control and

Prevention, Atlanta, Georgia.

Audrey L. Pinto, Writer-Editor, National Center for

Chronic Disease Prevention and Health Promotion,

Centers for Disease Control and Prevention,

Atlanta, Georgia.

Thomas L. Pitts, MD, Chicago, Illinois.

Robert Pollet, MD, Department of Veterans

Affairs, Washington, DC.

Teresa M. Ramsey, MA, Writer-Editor, National

Center for Chronic Disease Prevention and Health

Promotion, Centers for Disease Control and

Prevention, Atlanta, Georgia.

Richard R. Rubin, PhD, Assistant Professor, The

Johns Hopkins University School of Medicine,

Baltimore, Maryland.

Kathy Rufo, MPH, Deputy Director, Division of

Diabetes Translation, National Center for Chronic

Disease Prevention and Health Promotion, Centers

for Disease Control and Prevention, Atlanta,

Georgia.

Marc A. Safran, MD, FACPM, Chief Medical

Officer, Division of Diabetes Translation, National

Center for Chronic Disease Prevention and Health

Promotion, Centers for Disease Control and

Prevention, Atlanta, Georgia.

Kathy E. Shaw, RN, Manager, Market

Development, Patient Care, Boehringer Mannheim

Corporation, Indianapolis, Indiana.

Arlene Sherman, Management Infomation

Assistant, Division of Diabetes Translation,

National Center for Chronic Disease Prevention

and Health Promotion, Centers for Disease

Control and Prevention, Atlanta, Georgia.

Russell J. Sniegowski, MPH, Chief, Health Systems

Section, Division of Diabetes Translation, National

Center for Chronic Disease Prevention and Health

Promotion, Centers for Disease Control and

Prevention, Atlanta, Georgia.

Mary Kay Sones, Health Communications

Specialist, National Center for Chronic Disease

Prevention and Health Promotion, Centers for

Disease Control and Prevention, Atlanta, Georgia.
x

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

Herman L. Surles, Jr., Writer-Editor, National

Center for Chronic Disease Prevention and Health

Promotion, Centers for Disease Control and

Prevention, Atlanta, Georgia.

Darlene Thomas, Secretary, Division of Diabetes

Translation, National Center for Chronic Disease

Prevention and Health Promotion, Centers for

Disease Control and Prevention, Atlanta, Georgia.

Diana J. Toomer, Writer-Editor, National Center

for Chronic Disease Prevention and Health

Promotion, Centers for Disease Control and

Prevention, Atlanta, Georgia.

Galo R. Torres, DDS, Program Consultant for

Migrant and Oral Health, Health Resources and

Services Administration, U.S. Department of

Health and Human Services, Atlanta, Georgia.

Jennifer Tucker, MPA, Program Analyst, National

Center for Chronic Disease Prevention and Health

Promotion, Centers for Disease Control and

Prevention, Atlanta, Georgia.

Michele Whatley, Office Automation Clerk,

Division of Diabetes Translation, National Center

for Chronic Disease Prevention and Health

Promotion, Centers for Disease Control and

Prevention, Atlanta, Georgia.

Quion Wilkes, Office Automation Clerk, Division

of Diabetes Translation, National Center for

Chronic Disease Prevention and Health Promotion,

Centers for Disease Control and Prevention,

Atlanta, Georgia.

Violet Woo, MS, MPH, Health Policy Analyst,

Division of Policy and Data, Office of Minority

Health, U.S. Department of Health and Human

Services, Rockville, MD.

Publication support was provided by Palladian

Partners, Inc., under Contract No. 200-98-0415 for

the National Center for Chronic Disease Prevention

and Health Promotion, Centers for Disease Control

and Prevention, U.S. Department of Health and

Human Services.
xi

DIABETES AND WOMEN’S HEALTH ACROSS THE LIFE STAGES:

A PUBLIC HEALTH PERSPECTIVE

List of Tables and Figures..............................................................................................................................xvii

Chapter 1: Introduction....................................................................................................................................1

References ..........................................................................................................................................6

Chapter 2: A Profile of Women in the United States .......................................................................................9

2.1. Population Size and Growth........................................................................................................9

2.2. Population Composition .............................................................................................................9

Age and Sex ..............................................................................................................................9

Racial and Ethnic Diversity ....................................................................................................11

Geographic Characteristics .....................................................................................................14

Social and Economic Characteristics.......................................................................................15

Health-Related Behaviors........................................................................................................20

2.3. Psychosocial Determinants of Health Behaviors and Health Outcomes ....................................23

The Social Environment.........................................................................................................24

Interactions with the Health Care System...............................................................................26

Personality Characteristics.......................................................................................................30

2.4. Public Health Implications........................................................................................................31

Assessment..............................................................................................................................31

Policy Development................................................................................................................32

Assurance................................................................................................................................32

References ........................................................................................................................................34

Chapter 3: The Adolescent Years..............................................................................................................................43

3.1. Prevalence, Incidence, and Trends .............................................................................................43

Prevalence...............................................................................................................................43

Incidence ................................................................................................................................44

Trends.....................................................................................................................................44

3.2. Sociodemographic Characteristics .............................................................................................44

3.3. Impact of Diabetes on Health Status.........................................................................................45

Complications of Diabetes: Type 1 .........................................................................................45

Complications of Diabetes: Type 2 .........................................................................................46

Risk of Death .........................................................................................................................46

Hospitalizations ......................................................................................................................47

Disabilities..............................................................................................................................48
xii

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

3.4. Health-Related Behaviors ..........................................................................................................49

Environmental Exposures .......................................................................................................49

Smoking .................................................................................................................................49

Obesity ...................................................................................................................................50

Insufficient Physical Activity...................................................................................................51

Pregnancy ...............................................................................................................................51

Adherence to Diabetes Management Tasks .............................................................................52

Recurrent Episodes of Ketoacidosis.........................................................................................53

3.5. Psychosocial Determinants of Health Behaviors and Health Outcomes ....................................53

Social Environment ................................................................................................................53

Legal Environment .................................................................................................................54

Interactions with the Health Care System...............................................................................55

3.6. Concurrent Illness as a Determinant of Health Behaviors and Health Outcomes .....................55

Eating Disorders .....................................................................................................................55

Other Psychiatric Disorders Affecting Diabetes Management.................................................58

Community Norms and Acculturation...................................................................................58

3.7. Public Health Implications........................................................................................................58

Assessment..............................................................................................................................58

Policy Development................................................................................................................59

Assurance................................................................................................................................59

References ........................................................................................................................................60

Chapter 4: The Reproductive Years ..................................................................................................................69

4.1. Prevalence, Incidence, and Trends .............................................................................................70

Prevalence...............................................................................................................................70

Incidence ................................................................................................................................72

Trends.....................................................................................................................................72

Gestational Diabetes ...............................................................................................................73

4.2. Sociodemographic Characteristics .............................................................................................73

Age, Race, and Ethnicity.........................................................................................................73

Marital Status/Living Arrangements .......................................................................................73

Education/Income/Employment.............................................................................................74

4.3. Impact of Diabetes on Health Status.........................................................................................76

Death Rates ............................................................................................................................76

Complications ........................................................................................................................77

Intensive Therapy and Its Effects on Quality of Life...............................................................79

Hospitalizations ......................................................................................................................80

Hyperglycemia During Pregnancy ..........................................................................................81
Table of Contents

xiii

4.4. Health-Related Behaviors ..........................................................................................................82

Risk Behaviors and Risk Factors .............................................................................................82

Health-Promoting Behaviors...................................................................................................84

Adherence and Self-Management............................................................................................86

4.5. Psychosocial Determinants of Health Behaviors and Health Outcomes ....................................87

Social Environment ................................................................................................................87

Life Stress ...............................................................................................................................88

Personal Disposition ...............................................................................................................88

Interactions with the Health Care System...............................................................................88

4.6. Concurrent Illness as a Determinant of Health Behaviors and Health Outcomes .....................89

Eating Disorders .....................................................................................................................89

Depression..............................................................................................................................89

4.7. Public Health Implications........................................................................................................90

References ........................................................................................................................................92

Chapter 5: The Middle Years .........................................................................................................................105

5.1. Prevalence, Incidence, and Trends ...........................................................................................106

Prevalence.............................................................................................................................106

Incidence ..............................................................................................................................107

Trends...................................................................................................................................108

5.2. Sociodemographic Characteristics ...........................................................................................109

Age, Sex, Race/Ethnicity.......................................................................................................109

Marital Status/Living Arrangements .....................................................................................109

Education/Income/Employment...........................................................................................109

5.3. Impact of Diabetes on Health Status.......................................................................................111

Death Rates ..........................................................................................................................111

Hospitalizations ....................................................................................................................112

Disabilities............................................................................................................................113

Quality of Life ......................................................................................................................113

5.4. Health-Related Behaviors ........................................................................................................113

Risk Behaviors and Risk Factors ...........................................................................................113

Health-Promoting Behaviors.................................................................................................115

Adherence.............................................................................................................................116

5.5. Psychosocial Determinants of Health Behaviors and Health Outcomes ..................................116

Social Environment ..............................................................................................................116

Interactions with the Health Care System.............................................................................119

Personality Characteristics.....................................................................................................121

5.6. Concurrent Illnesses as Determinants of Health Behaviors and Health Outcomes..................123

Mental Health ......................................................................................................................123

Physical Disability and Complications..................................................................................124
xiv

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

5.7. Public Health Implications......................................................................................................131

Assessment............................................................................................................................131

Policy Development..............................................................................................................132

Assurance..............................................................................................................................133

References ......................................................................................................................................135

Chapter 6: The Older Years............................................................................................................................147

6.1. Prevalence, Incidence, and Trends ...........................................................................................147

Prevalence and Incidence ......................................................................................................147

Temporal Trends...................................................................................................................148

6.2. Sociodemographic Characteristics ...........................................................................................148

Age and Sex ..........................................................................................................................148

Race/Ethnicity ......................................................................................................................149

Marital Status/Living Arrangements .....................................................................................150

Education .............................................................................................................................150

Family Income......................................................................................................................150

6.3. Impact of Diabetes on Illness and Death.................................................................................150

Risk of Death .......................................................................................................................150

Hospitalizations ....................................................................................................................152

Diabetes-Related Illnesses .....................................................................................................152

Disabilities............................................................................................................................154

6.4. Health-Related Behaviors ........................................................................................................154

Physical Inactivity.................................................................................................................154

Obesity .................................................................................................................................154

Smoking ...............................................................................................................................155

Preventive Self-Care..............................................................................................................155

6.5. Psychosocial Determinants of Health Behaviors and Health Outcomes ..................................155

Social Environment ..............................................................................................................155

Interactions with the Health Care System.............................................................................156

Barriers to and Motivations for Practicing Preventive Self-Care ............................................158

Traditional Beliefs.................................................................................................................159

6.6. Concurrent Illnesses as Determinants of Health Behaviors and Health Outcomes..................160

6.7. Public Health Implications......................................................................................................161

Assessment............................................................................................................................161

Policy Development..............................................................................................................162

Assurance..............................................................................................................................162

References ......................................................................................................................................163
Table of Contents

Chapter 7: Major Findings, Public Health Implications, and Conclusions......................................................169

7.1. Major Findings........................................................................................................................169

Feminization of Old Age ......................................................................................................169

Risk of Poverty .....................................................................................................................169

Trends in Employment .........................................................................................................170

Inadequate Medical Insurance Coverage ...............................................................................170

Increasing Overweight and Lack of Physical Activity............................................................170

Specific Groups of Women ...................................................................................................170

7.2. Public Health Implications......................................................................................................170

Assessment............................................................................................................................171

Policy Development..............................................................................................................174

Assurance..............................................................................................................................175

References ......................................................................................................................................176

Epilogue.........................................................................................................................................................177

Appendix A Percentage of U.S. adult population with physician-diagnosed diabetes, by age, sex, 

and race/Hispanic origin—NHANES III, 1988–94 .................................................................179

Appendix B Percentage of U.S. adult population with undiagnosed diabetes, by age, sex, and race/ 

Hispanic origin—NHANES III, 1988–94, and the 1977 ADA Fasting Plasma 

Glucose Criterion .....................................................................................................................181

Appendix C Age-standardized prevalence of diagnosed diabetes per 100 adult female population, 

by state—United States, 1998–2000.........................................................................................183

Appendix D Age-standardized prevalence of diagnosed diabetes per 100 adult female population, 

by state—United States, 1994–96.............................................................................................185

Appendix E 2001 Quick Guide to the American Diabetes Association’s Standards of Care..........................187

List of Abbreviations ......................................................................................................................................189

Glossary .........................................................................................................................................................191

xv

xvii

LIST OF TABLES AND FIGURES

Chapter 2: A Profile of Women in the United States

Table 2-1. Expectation of life, by age and sex—United States, 1979–81, 1990, 1995 .................10

Table 2-2. Age-specific female-male ratios, by race/Hispanic origin—

United States, 1995 ....................................................................................................11

Table 2-3. Median annual income of persons aged 15 years or older, by age and sex—

United States, 1995 ....................................................................................................17

Table 2-4. Percentage of persons who lived below the poverty level, by age, sex, and race/

Hispanic origin—United States, 1995 ........................................................................19

Table 2-5. Percentage of adolescent females and women who were overweight 

in various national surveys, by age and race/Hispanic origin, 1988–96 ......................20

Table 2-6. Percentage of female high school and college students who participated 

in vigorous or moderate physical activity, were enrolled in a physical 

education class, and played on an intramural sports team, 

by age, race/Hispanic origin, and grade—United States, 1995 ...................................22

Table 2-7. Percentage of adolescent females and women who were overweight 

or do not exercise, by race/Hispanic origin, generation, and duration

of residence—United States, 1995..............................................................................23

Figure 2-1. Percentage of women who lived alone, by age—United States, 

1970, 1980, 1995.......................................................................................................11

Figure 2-2. Percentage distribution of female population, by race/Hispanic origin—

United States, 1995 and 2010 (projected) ..................................................................11

Figure 2-3. Projected percentage change in the number of females, by age and race/

Hispanic origin—United States, 1995–2010 ..............................................................12

Figure 2-4. Population age structures: minority and non-Hispanic white females—

United States, 1995 ....................................................................................................13

Figure 2-5. Percentage of females who lived in central cities, by age and race/

Hispanic origin—United States, 1995 ........................................................................15

Figure 2-6. Percentage of women completing high school and college, by race/

Hispanic origin—United States, 1970, 1985, 1995....................................................16

Figure 2-7. Median annual income of adults aged 25 years or older, by sex 

and educational attainment—United States, 1995......................................................18

Figure 2-8. Median annual earnings of women who worked full-time year round, 

by race/Hispanic origin—United States, 1970–95......................................................18

Figure 2-9. Percentage of females who lived below the federal poverty level, 

by age and race/Hispanic origin—United States, 1995...............................................19
xviii

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

Figure 2-10. Health insurance coverage among all females and poor females, 

by race/Hispanic origin—United States, 1996............................................................27

Figure 2-11. Type of health care insurance coverage among all females and poor females, 

by race/Hispanic origin—United States, 1996............................................................28

Chapter 4: The Reproductive Years

Table 4-1. Prevalence of diagnosed diabetes among reproductive-aged women, 

by race/Hispanic origin—United States, 1965–97......................................................73

Table 4-2. Crude and age-adjusted prevalence of diabetes during pregnancy, 

by race/Hispanic origin—United States, 1993–95......................................................76

Table 4-3. Prevalence of sociodemographic characteristics of women aged 18–44 years 

with and without type 2 diabetes, by race/Hispanic origin—

United States, 1989 ....................................................................................................77

Figure 4-1. Prevalence of diagnosed and undiagnosed diabetes among U.S. adults, 

by age and sex—NHANES III, 1988–94 ...................................................................72

Figure 4-2. Prevalence of diagnosed and undiagnosed diabetes among U.S. women, 

by age and race/Hispanic origin—NHANES III, 1988–94 ........................................72

Figure 4-3. All-cause mortality rates for U.S. adults aged 25–44 years, by diabetes status, 

sex, and race/Hispanic origin, 1971–93......................................................................78

Chapter 5: The Middle Years

Table 5-1. Prevalence of diagnosed and undiagnosed diabetes among adults 

aged 45–64 years, by race/Hispanic origin—1986–97..............................................110

Table 5-2. Prevalence of sociodemographic characteristics of women aged 45–64 years 

with and without type 2 diabetes, by race/Hispanic origin—

United States, 1989 ..................................................................................................112

Table 5-3. Prevalence of hypertension among adults aged 45–64 years with and without

type 2 diabetes, by sex and race/Hispanic origin—United States, 1976–84 ..............129

Figure 5-1. Prevalence of diagnosed and undiagnosed diabetes among U.S. adults,

by age and sex—NHANES III, 1988–94 .................................................................108

Figure 5-2. Prevalence of diagnosed and undiagnosed diabetes among U.S. women, 

by age and race/Hispanic origin—NHANES III, 1988–94 ......................................108

Figure 5-3. All-cause mortality rates for U.S. adults aged 45–64 years, by diabetes status, 

sex, and race/Hispanic origin—1971–93..................................................................113

Figure 5-4a. Survival of diabetic and nondiabetic U.S. adults aged 45–54 years, 

by years of follow-up, 1971–93 ................................................................................114

Figure 5-4b. Survival of diabetic and nondiabetic U.S. adults aged 55–64 years, 

by years of follow-up, 1971–93 ................................................................................114
List of Tables and Figures

xix

Chapter 6: The Older Years

Table 6-1. Prevalence of sociodemographic characteristics of women aged 65 years or 

older with and without type 2 diabetes, by race/Hispanic origin—

United States, 1989 ..................................................................................................155

Table 6-2. Percentage of beneficiaries with diabetes who received recommended 

preventive and monitoring services in fee-for-service Medicare, 

by sex—United States, 1994.....................................................................................161

Table 6-3. Age-associated factors affecting diabetes management in older women.....................164

Figure 6-1. Prevalence of diagnosed and undiagnosed diabetes among U.S. adults, 

by age and sex—NHANES III, 1988–94 .................................................................151

Figure 6-2. Number of new cases and incidence rate of diagnosed diabetes 

among women aged 65 years or older—NHIS, 1980–94 .........................................152

Figure 6-3. Prevalence of diagnosed and undiagnosed diabetes among U.S. women, 

by age and race/Hispanic origin—NHANES III, 1988–94 ......................................153

Figure 6-4. All-cause mortality rates for U.S. adults aged 65–74 years, by diabetes status, 

sex, and race/Hispanic origin, 1971–93....................................................................156

Appendix A Percentage of U.S. adult population with physician-diagnosed diabetes, by age, sex, and

race/Hispanic origin—NHANES III, 1988–94 ........................................................................183

Appendix B Percentage of U.S. adult population with undiagnosed diabetes, by age, sex, and race/

Hispanic origin—NHANES III, 1988–94 ...............................................................................185

Appendix C Age-standardized prevalence of diagnosed diabetes per 100 adult female population, 

by state—United States, 1998–2000.........................................................................................187

Appendix D Age-standardized prevalence of diagnosed diabetes per 100 adult female population, 

by state—United States, 1994–96.............................................................................................189

1

1

INTRODUCTION

P.E. Thompson-Reid, MAT, MPH, P.C. McGuire, G.L.A. Beckles, MBBS, MSc

Diabetes is a major public health problem that

imposes a serious burden on individuals and on

society.1 An estimated 15.7 million Americans have

diabetes, and approximately one-third of these persons do not know they have the disease.2 Even so,

the number of persons with diagnosed diabetes

increased fivefold between 1958 and 1993.3 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.4 Despite this physical and

financial toll, the public generally has not perceived

diabetes as a serious disease.5 As a result, many 

efficacious and cost-effective preventive practices

that can reduce the burden of this disease are not

widely used.6-11

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.12 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.12 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.13,14 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.2,15 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.16-19

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.20-27 Women are also at greater risk for

blindness due to diabetes than men.28
2

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

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.29 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,30 increasing their risk for obesity and its sequelae in subsequent pregnancies and at older ages.31,32 Obesity is

associated with the prevalence of type 2 diabetes29

and is a risk factor for the development of this disease.33 Among women of minority racial or ethnic

origin, there is earlier onset of obesity, and these

groups experience disproportionately high levels of

excess weight.18,32,34-36 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.

Challenges and Opportunities

Women have made many strides in promoting

equity in their social status; nevertheless, there are

entrenched values and structures in our society that

continue to negatively affect the health of women

in general. The results of the Diabetes Complications and Control Trial and the United Kingdom

Prospective Diabetes Study have indicated that

most of the complications of type 1 and type 2 diabetes are preventable.11,37 However, progress in

applying this knowledge to reduce the burden of

diabetes has been slow. These realities, coupled with

gender-related issues, may serve as barriers to the

use of this knowledge by health care providers and

women with diabetes. The Public Health Service

Task Force Report on women’s health states that

“societal attitudes toward females, the socialization

of girls and women, differing economic and occupational status between men and women and

among women, as well as changing attitudes toward

the family, sexual behavior, and living arrangements

all have implications for women’s health.”12 More

knowledge is required to inform the public health

community about how these behavioral and social

factors interact with biological factors to affect the

health of women, particularly when they are compounded by the existence of a chronic disease such

as diabetes.

Historically the concept of women and women’s

health was defined by the very nature of their biology and social status as compared with those of

men. From the times of the Greeks, men and

women were seen as having similar biological structures, but women were seen as imperfect because of

their differences.38,39 In addition, until the mid1900s, the maternal role was thought to require so

much energy that other activities such as physical

activity and intellectual pursuits were not promoted

for women. Implicit in this assumption was the

perception that women are inferior to men.40

This gender bias created a social environment

where women’s work and concerns were not taken

seriously. Moreover, this perception of women dictated that the primary focus of women’s health be

on their reproductive function, to the neglect of

many other aspects of their general health.39 Such

thinking was also reflected in the types of policies

that were directed to women worldwide. For example, many biomedical and public policy studies of

the past did not include women.39-42 As a result,

findings of studies on men have been extrapolated

to women. Even in conditions specific to women,

there are gaps in research and treatment protocols.

For example, for women with gestational diabetes,

the primary focus is on the clinical management of

the mother’s glycemic status for positive birth outcomes. After the birth of the child, systematic 

follow-up of the mother with gestational diabetes

has not been uniformly provided to maintain her

health and to reduce her risk of developing diabetes

immediately postpartum or for several years later.43

In 1998, the American Diabetes Association

Clinical Practice Recommendations for women

with gestational diabetes were updated to facilitate

a broad-based approach to the follow-up of these
Introduction

3

women.44 This has brought renewed attention to

the issue; however, there are major systemic and

policy barriers that impair the implementation of

adequate follow-up for women with gestational diabetes.45

As a result of social, political, and economic pressures, the focus of the delivery of services to women

is moving from an emphasis on reproductive health

and pregnancy to comprehensive services for

women throughout their lives.

Notable events have also helped this process along

at the federal level:

• Publication of Women’s Health: Report of the

Public Health Service Task Force on Women’s

Health Issues12 in 1985.

• Establishment of the Office of Research on

Women’s Health within the Office of the

National Institutes of Health (NIH) Director.

• The NIH Revitalization Act of 1993.

• Establishment of the U.S. Public Health

Service’s Office of Women’s Health in 1994.

• Establishment of the Office of Women’s Health

at the Centers for Disease Control and

Prevention (CDC) in 1994.

• Publication of the NIH Guidelines on the

Inclusion of Women and Minorities as Subjects in

Clinical Research in 1994.

Despite these recent efforts to improve the health

status of women, there is still opportunity to examine, modify, and expand this focus as we move forward. An assessment of the health status of women

with diabetes in the United States and an examination of the determinants of women’s health at the

population level, particularly those that cannot be

addressed with traditional clinical interventions,

could influence changes in policy and the delivery

of services and inform the development of appropriate interventions to improve the health of

women overall. Many social scientists believe that

the interaction of the social and economic environment on the psychological resources and coping

skills of an individual may influence health status

much more than was expected.46-48 It is also likely

that these determinants play a role in the health

disparities found among women and among racial

and ethnic groups at greater risk for diabetes and its

complications. As we search for these explanations,

we must include a rigorous examination of the economic, social, and environmental factors that affect

the health of women and the availability of appropriate curative and preventive services so that the

public health community response will be appropriate.

Women’s Health at CDC

As the nation’s prevention agency, the mission of

CDC is to promote health and quality of life by

preventing and controlling disease, injury, and disability. The vision of CDC is “Healthy People in a

Healthy World—Through Prevention.” This is

reflected in its 1993 operational priorities:

• To strengthen the core functions of public

health.

• To enrich its capacity to respond to urgent

threats to health.

• To develop nationwide prevention efforts.

• To promote women’s health.

In 1993, in keeping with CDC policy directives,

the National Center for Chronic Disease

Prevention and Health Promotion established a

Women’s Health Working Group with representatives from each division to monitor issues related to

women’s health and to oversee the distribution of

resources for activities in this area. As a result of

discussions in this broader group, the following

questions were presented to each division in the

Center:

• From a public health perspective, what are the

biggest problems affecting women?

• What is the disease burden for women? 

• Can we describe the population at risk?

• What is preventable and what are we doing

about it?
4

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

Discussions of these questions revealed the lack of a

public health perspective on diabetes and women’s

health issues and formed the seed from which this

monograph grew.

Purpose

The intent of this monograph is

• To describe the diversity within the population

of American women as a context for the discussion of women’s health issues.

• To present a situational analysis of the epidemiological, social, and environmental circumstances

in which American women develop and live

with diabetes.

• To synthesize and present in a single document

the health status of women with diabetes.

• To suggest ways in which public health agencies

can contribute to improved access and quality of

care for women with diabetes.

• To serve as a general reference document for

public health professionals, advocacy groups,

and all persons in the diabetes community.

• To increase awareness of the general population

that diabetes is a serious health problem.

Conceptual Framework

The monograph is structured to examine the

impact of diabetes through the life stages of the

woman. The age groups are constrained by standard

age structures used in population-based studies and

national surveys. In keeping with a public health

paradigm, we first examine the sociodemographic

characteristics of the population of women in the

United States and subsequently look at subgroups

of women with diabetes. Chapter 2 of the monograph presents a general profile of women in the

United States, looking at population size and

growth among various ethnic and racial groups, the

psychosocial determinants of health, and the public

health implications of these findings. Chapters 3

through 6 begin with case studies that provide a

glimpse into the lives of women with diabetes discussed in each specific life stage. In chapters 3

through 6, the authors examine the impact of diabetes on women’s health through the life stage of

the woman:

• The Adolescent Years. The adolescent years are

marked by major biological and psychosocial

changes that transform the adolescent into an

adult. Many adolescents with diabetes face

lifestyle choices that can affect their ability to

control the disease. Policies—or the lack of

appropriate policies—in the wider society may

influence the ability of women in this age group

and their families to make healthy lifestyle

choices.

• The Reproductive Years. For women with diabetes, successful passage through this time of

greatest personal growth and responsibility

(schooling, marriage, career development, and

raising children) is enhanced by their ability to

control their disease. The development of gestational diabetes during pregnancy puts both the

woman and the unborn child at risk for negative

health outcomes. For those with few personal

resources, this period could place them at higher

risk for negative health outcomes and future

economic hardship.

• The Middle Years. Marked by major physiologic events such as menopause, this is a time when

other chronic diseases or complications of diabetes most often first appear, along with many

other social and psychological changes (e.g.,

death, divorce, retirement, poverty).

• The Older Years. During this time, women

with diabetes become even more vulnerable to

other chronic illnesses, disability, poverty, and

loss of social support systems. The number of

women in this age group is growing exponentially as the American population ages.

Within each chapter, authors discuss the prevalence

of diabetes, the sociodemographic characteristics of

women with diabetes in the age group, the impact

of diabetes on women’s health status, health-related

behaviors, access to care, the psychosocial determinants of health-related behaviors and health outcomes, comorbid conditions as determinants of
Introduction

5

health behaviors and health outcomes, and the public health implications of pertinent findings for

each life stage described above. Chapter 7 summarizes the findings in chapters 3 through 6 and 

presents their public health implications.

Audience and Scope

This document is intended for public health professionals, policy makers, staff of community-based

organizations and voluntary organizations,

researchers, and advocates for women’s health, as

well as persons interested in issues related to

women and diabetes. In particular, this document

seeks to provide essential information for persons

charged with making decisions and setting policies

related to diabetes and women’s health.

In addition to the seven chapters, including four on

the different life stages of women, several tools have

been added to enhance the reader’s use of the

monograph and to provide additional comprehensive, yet concise, information on diabetes. Immediately following the table of contents is a list of

tables and figures with the title and page number

for each table and figure by chapter. There are five

appendixes, including tables of diabetes prevalence

in the United States (diagnosed and undiagnosed),

U.S. maps of diabetes prevalence for two time periods (1996–1998 and 1998–2000), and the

American Diabetes Association’s guide to standards

of care. A list of abbreviations of common diabetes

terms or related organizations and a glossary of

terms used in the monograph are located after the

appendixes. Glossary listings for the major diabetes

organizations and frequently cited diabetes studies

include a Web site address.

Following chapter 7 is an epilogue in which the

editors present personal comments on the insights

they gained from their experience with the project.

Terminology

The racial and ethnic categories used in this document are in keeping with those set forth in the

Office of Management and Budget’s Statistical

Policy Directive No. 15, Race and Ethnic Standards

for Federal Statistics and Administrative Reporting.

Hence, these names are used: American Indian or

Alaska Native, Asian/Pacific Islander, black not of

Hispanic origin, Hispanic, and white not of

Hispanic origin. However, because some authors

used different terminology for race and ethnicity,

data are presented here as reported in the publications cited.

Many diabetes terms or abbreviations used in this

publication may be found in the list of abbreviations or in the glossary in the back of the monograph.
6

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

References

1. Vinicor F. Is diabetes a public health disorder? Diabetes

Care 1994;17(Suppl 1):22–7.

2. Harris MI. Summary. In: National Diabetes Data

Group, editors. Diabetes in America. 2nd ed. Bethesda,

MD: National Institutes of Health, 1995:1–13. (NIH

Publication No. 95-1468)

3. Centers for Disease Control and Prevention. National

Diabetes Fact Sheet: National Estimates and General

Information on Diabetes in the United States. Atlanta:

U.S. Department of Health and Human Services,

Centers for Disease Control and Prevention, 1997.

4. American Diabetes Association. Economic consequences

of diabetes mellitus in the U.S. in 1997. Diabetes Care

1998;21(2):296–309.

5. Slovic P. Perception of risk. Science 1987;236(4799):

280–5.

6. Litzelman DK, Slemenda CW, Langefeld CD, et al.

Reduction of lower-extremity clinical abnormalities in

patients with non–insulin-dependent diabetes mellitus.

A randomized, controlled trial. Ann Intern Med

1993;119(1):36–41.

7. Ferris FL 3rd. How effective are treatments for diabetic

retinopathy? JAMA 1993;269(10):1290–1.

8. The Diabetes Control and Complications Trial Research

Group. The effect of intensive treatment of diabetes on

the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J

Med 1993;329(14):977–86.

9. Rost KM, Flavin KS, Schmidt LE, McGill JB. Self-care

predictors of metabolic control in type 1 patients.

Diabetes Care 1990;13(11):1111–13.

10. Brown SA. Studies of educational interventions and outcomes in diabetic adults: a meta-analysis revisited.

Patient Educ Couns 1990;16(3):189–215.

11. The Diabetes Control and Complications Trial Research

Group. Lifetime benefits and cost of intensive therapy as

practiced in the Diabetes Control and Complications

Trial. JAMA 1996;276(17):1409–15.

12. U.S. Public Health Service. Women’s Health: Report of the

Public Health Service Task Force on Women’s Health Issues.

Vol. 1. U.S. Department of Health and Human

Services, 1985.

13. Coustan DR. Gestational diabetes. In: National

Diabetes Data Group, editors. Diabetes in America. 2nd

ed. Bethesda, MD: National Institutes of Health,

1995:703–17. (NIH Publication No. 95-1468)

14. Buchanan TA. Pregnancy in preexisting diabetes. In:

National Diabetes Data Group, editors. Diabetes in

America. 2nd ed. Bethesda, MD: National Institutes of

Health, 1995:719–33. (NIH Publication No. 95-1468)

15. Kenny SJ, Aubert RE, Geiss LS. Prevalence and incidence of non–insulin-dependent diabetes. In: National

Diabetes Data Group, editors. Diabetes in America. 2nd

ed. Bethesda, MD: National Institutes of Health,

1995:47–67. (NIH Publication No. 95-1468)

16. Tull ES, Roseman JM. Diabetes in African Americans.

In: National Diabetes Data Group, editors. Diabetes in

America. 2nd ed. Bethesda, MD: National Institutes of

Health, 1995:613–30. (NIH Publication No. 95-1468)

17. Stern MP, Mitchell BD. Diabetes in Hispanic

Americans. In: National Diabetes Data Group, editors.

Diabetes in America. 2nd ed. Bethesda, MD: National

Institutes of Health, 1995:631–59. (NIH Publication

No. 95-1468)

18. Fujimoto WY. Diabetes in Asian and Pacific Islander

Americans. In: National Diabetes Data Group, editors.

Diabetes in America. 2nd ed. Bethesda, MD: National

Institutes of Health, 1995:661–81. (NIH Publication

No. 95-1468)

19. Gohdes D. Diabetes in North American Indians and

Alaska Natives. In: National Diabetes Data Group, editors. Diabetes in America. 2nd ed. Bethesda, MD:

National Institutes of Health, 1995:683–701. (NIH

Publication No. 95-1468)

20. Gu K, Cowie CC, Harris MI. Mortality in adults with

and without diabetes in a national cohort of the U.S.

population, 1971–1993. Diabetes Care 1998;21(7):

1138–45.
Introduction

7

21. Garcia MJ, McNamara PM, Gordon T, Kannel WB.

Morbidity and mortality in diabetics in the Framingham

population. Sixteen-year follow-up study. Diabetes

1974;23(2):105–11.

22. Barrett-Connor EL, Cohn BA, Wingard DL, Edelstein

SL. Why is diabetes mellitus a stronger risk factor for

fatal ischemic heart disease in women than in men? The

Ranch Bernardo Study. JAMA 1991;265(5):627–31.

23. Manson JE, Colditz GA, Stampfer MJ, et al. A prospective study of maturity-onset diabetes mellitus and risk

for coronary heart disease and stroke in women. Arch

Intern Med 1991;151(6):1141–7.

24. Heyden S, Heiss G, Bartel AG, Hames CG. Sex differences in coronary mortality among diabetics in Evans

County, Georgia. J Chronic Dis 1980;33(5):265–73.

25. Abbott RD, Donahue RP, Kannel WB, Wilson PW. The

impact of diabetes on survival following myocardial

infarction in men vs women. The Framingham Study.

JAMA 1988;260(23):3456–60.

26. Eaker ED, Chesbro JH, Sacks FM, Wenger NK,

Whisnant JP, Winston M. Cardiovascular disease in

women. Circulation 1993;88:1999–2009.

27. Lee WL, Cheung AM, Cape D, Zinman B. Impact of

diabetes on coronary artery disease in women and men:

a meta-analysis of prospective studies. Diabetes Care

2000;23(7):962–8.

28. Harris MI, Klein R, Cowie CC, Rowland M, Byrd-Holt

DD. Is the risk of diabetic retinopathy greater in nonHispanic blacks and Mexican Americans than in nonHispanic whites with type 2 diabetes? A U.S. population

study. Diabetes Care 1998;21(8):1230–5.

29. Rewers MR, Hamman RF. Risk factors for non–insulindependent diabetes. In: National Diabetes Data Group,

editors. Diabetes in America. 2nd ed. Bethesda, MD:

National Institutes of Health, 1995:179–220. (NIH

Publication No. 95-1468)

30. Keppel KG, Taffel SM. Pregnancy-related weight gain

and retention: implications of the 1990 Institute of

Medicine guidelines. Am J Public Health 1993;83(8):

1100–3.

31. Parker JD, Abrams B. Differences in postpartum weight

retention between black and white mothers. Obstet

Gynecol 1993;81:768–74.

32. Kahn HS, Williamson DF, Stevens JA. Race and weight

in U.S. women: the roles of socioeconomic and marital

status. Am J Public Health 1991;81(3):319–23.

33. Ford ES, Williamson DF, Liu S. Weight change and diabetes incidence: findings from a national cohort of U.S.

adults. Am J Epidemiol 1997;146(3):214–22.

34. Knowler WC, Pettitt DJ, Savage PJ, Bennett PH.

Diabetes incidence in Pima Indians: contributions of

obesity and parental diabetes. Am J Epidemiol

1981;113(2):144–56.

35. Will JC. Self-reported weight loss among adults with

diabetes: results from a national health survey. Diabet

Med 1995;12(11):974–8.

36. Hazuda HP, Haffner SM, Stern MP, Eifler CW. The

effects of acculturation and socioeconomic status on

obesity and diabetes in Mexican Americans. The San

Antonio Heart Study. Am J Epidemiol

1988;128:1289–1301.

37. UK Prospective Diabetes Study Group. Tight blood

pressure control and risk of macrovascular and microvascular complications in type 2 diabetes UKPDS 38. BMJ

1998;317(7160):703–13.

38. Lawrence SC, Bendixen K. His and hers: male and

female anatomy in anatomy texts for U.S. medical students, 1890–1989. Soc Sci Med 1992;35(7):925–34.

39. Stanton AL. The psychology of women’s health: barriers

and pathways to knowledge. In: Stanton AL, Gallant SJ,

editors. The Psychology of Women’s Health. Washington,

DC: American Psychological Association, 1995.

40. Travis CB. Women and Health Psychology: Biomedical

Issues. Hillsdale, NJ: Erlbaum, 1988.

41. Bennett JC. Inclusion of women in clinical trials—

policies for population subgroups. N Engl J Med

1993;329:288–92.
8

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

42. Report of the Office of Research on Women’s Health, Fiscal

Years 1993–1995. Bethesda, MD: National Institutes of

Health, 1997. (Publication No. 97-3702)

43. Tinker LF. Diabetes mellitus—a priority health care

issue for women. J Am Diet Assoc 1994;94(9):976–85.

44. American Diabetes Association. Clinical Practice

Recommendations, 1998. Gestational diabetes mellitus.

Diabetes Care 1998;21(Suppl 1):S60–S61.

45. Reisinger AL. Health Insurance and Access to Care: Issues

for Women. New York: The Commonwealth Fund

Commission of Women’s Health, 1995.

46. Frank JW. The determinants of health: a new synthesis.

Current Issues in Public Health 1995;1(6):233–40.

47. Lynch JW. Social position and health. Ann Epidemiol

1996;6(1):21–3.

48. Krieger N. Embodying inequality: a review of concepts,

measures, and methods for studying health consequences

of discrimination. Int J Health Serv 1999;29(2):

295–352.
9

2

A PROFILE OF WOMEN IN THE UNITED STATES

G.L.A. Beckles, MBBS, MSc, K-A. Ffrench, MPH, D. Hill, MPH, L.D. McNair, PhD

Currently, the issue of individual lifestyles is receiving great attention from both the public health

community and the popular press. Women and

men are urged not to smoke, to eat less fat, to

engage in regular exercise, and to follow healthy

practices to prevent various diseases and use fewer

health services. Unfortunately, emphasizing individual behavior may mean that important social and

economic factors that affect people’s health are neglected.1-4 Factors such as income, employment status, living arrangements, recency of immigration,

and degree of acculturation may all impair the ability of people to keep themselves healthy or to take

care of themselves when they are ill. Approaches to

risk reduction that fail to take account of the limits

of personal choice may therefore do little to change

the health status of the group.5-8 This profile of

women in the United States presents a review of

recent data on important features of the social and

environmental context in which women develop

and live with chronic diseases such as diabetes. The

public health implications of the findings are summarized within the framework of the core public

health functions for thought and action. Thus, the

text should be helpful to public health officials as

they seek to elaborate interventions and policies

appropriate for women at different stages of life. It

also suggests areas for research to reduce the impact

of diabetes on women, to assist in the formulation

of policies, and to identify where more effort is

needed to assure the availability and adequacy of

health care and preventive services.

2.1. Population Size and Growth

Of the 262.8 million residents of the United States

in 1995, 134.4 million, or 51.2%, were female.9

Among all females, 16.8% were children under 12

years of age, 8.1% were adolescents aged 12–17

years, 40.2% were reproductive-aged women 18–44

years, 20.1% were in the middle years (45–64), and

14.8% were elderly women 65 years of age or older.

Thirteen percent of elderly women were 85 years of

age or older.

Between 1995 and 2010, the female population is

projected to grow by 17.7 million;10 more than

three-quarters of that growth will comprise women

aged 45–64 years. After 2010, the total female population is projected to grow more slowly than in

earlier years.10 However, as younger women age out

of their reproductive years, the number of middleaged and older women will continue to increase,

thereby enlarging the population at risk for diabetes

and other chronic diseases.

2.2. Population Composition

Age and Sex

The greater number of females than males in the

total population is the result of a long-term pattern

of greater life expectancy for females in all age

groups that continued in the United States through

the late 1980s.11,12 Around 1990, however, death

rates among U.S. females began to stabilize while

rates for males started to decline rapidly. As a result,

the survival “advantage” of females decreased at all

ages under 85 years (Table 2-1). For example,

between 1979–1981 and 1995, the additional life

expectancy of females compared with males fell

from 7.5 to 6.4 years among infant girls and from

4.2 to 3.4 years among 65-year-old women.
10

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

Despite this recent change in projected survival

among women, which is consistent with a trend

that emerged in many industrialized countries during the 1980s,13 the greater longevity among

women is projected to persist well into the middle

of the 21st century.

A major consequence of the greater longevity of

females is that women outnumber men, especially

in the older age groups.9 This excess of females increases steeply with age, and is most marked among

the elderly; in 1995, for example, there were 176

women aged 75 years or older for every 100 men of

comparable age (Table 2-2). This sex differential

accounts, in part, for the increasing numbers of elderly American women who live alone (Figure 2-1).

Table 2-1. Expectation of life, by age and sex—United States, 1979–81, 1990, 1995

Age Expectation of life (years)

(years) Year Females Males Difference

0 1979–81 77.6 70.1 7.5

1990 78.8 71.8 7.0

1995 78.8 72.4 6.4

15 1979–81 63.8 56.5 7.3

1990 64.7 57.9 6.8

1995 64.7 58.4 6.3

25 1979–81 54.2 47.4 6.8

1990 55.0 48.7 6.3

1995 55.0 49.2 5.8

35 1979–81 44.5 38.2 6.3

1990 45.3 39.6 5.7

1995 45.4 40.1 5.3

45 1979–81 35.2 29.2 6.0

1990 35.9 30.7 5.2

1995 36.0 31.3 4.7

55 1979–81 26.4 21.1 5.3

1990 27.0 22.3 4.7

1995 27.0 22.9 4.1

65 1979–81 18.4 14.2 4.2

1990 18.9 15.1 3.8

1995 18.9 15.5 3.4

75 1979–81 11.6 8.9 2.7

1990 12.0 9.4 2.6

1995 11.9 9.7 2.2

85 1979–81 6.4 5.1 1.3

1990 6.4 5.2 1.2

1995 6.4 5.3 1.1

Source: Reference 12.
A Profile of Women

11

Racial and Ethnic Diversity

The U.S. female population is racially and ethnically heterogeneous.14 In 1995, almost three-quarters

(73.6%) were classified as non-Hispanic white; the

remaining 26.4% belonged to other racial or ethnic

groups (Figure 2-2). A total of 13.3 million females

(of any race) were of Hispanic origin; of the more

than 22 million non-Hispanic nonwhite women,

16.7 million were black, 4.5 million were

Asian/Pacific Islander, and 982,000 were American

Indian or Alaska Native.9 By 2010, minority

females are projected to account for one-third of

U.S. females: Hispanics, 20.6 million; nonHispanic blacks, 19.8 million; Asians/Pacific

Figure 2-1. Percentage of women who lived Islanders, 7.6 million; American Indians, 1.2 milalone, by age—United States, 

1970, 1980, 1995

Source: Reference 24.

0

10

20

30

40

50

60

≥15 65–74 ≥75

Age Group (years)

1995

9

13 14

32

36 37

49

54

32

1980

1970

Percent

Table 2-2. Age-specific female-male ratios, by race/Hispanic origin—United States, 1995

Age group American Asian/Pacific 

(years) All White Black Indian Islander Hispanic*

<18 0.95 0.95 0.97 0.97 0.96 0.91

18–24 0.96 0.95 1.02 0.96 1.01 0.91

25–44 1.01 0.99 1.13 1.01 1.09 0.92

45–54 1.05 1.03 1.21 1.07 1.15 1.06

55–64 1.10 1.08 1.30 1.13 1.18 1.14

65–74 1.25 1.23 1.40 1.21 1.35 1.26

≥75 1.76 1.76 1.90 1.75 1.38 1.60

All ages 1.05 1.04 1.11 1.02 1.07 0.97

*Hispanic may be of any race.

Source: Reference 9.

Figure 2-2. Percentage distribution of female 

population, by race/Hispanic* 

origin—United States, 1995 and 

2010 (projected)

* Hispanic may be of any race.

AmI = American Indian; API = Asian/Pacific Islander.

Sources: References 9, 10.

1995

White

2010

API

Black

AmI

Hispanic

73.6

9.9

0.7

0.8

13

5

12.4

13.5

3.4

67.7
12

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

lion (Figure 2-2).10 These classifications do not adequately describe the considerable heterogeneity

among American women; each racial or ethnic

group is itself diverse. For example, the Asian

American group may include descendants of

Chinese, Japanese, and Filipinos who migrated to

the United States between the mid-1800s and 1910

as well as recent immigrants from countries as varied as India, Vietnam, Korea, Laos, Cambodia, and

Thailand.15-17 Hispanics are also a diverse population

that includes descendants of Spanish colonists who

settled in the southwestern United States in the

1500s as well as persons who originated more

recently from Mexico, Central and South America,

and the Spanish-speaking Caribbean.16,18,19 Finally,

black Americans are becoming increasingly heterogeneous; most are descendants of slaves transported

to the United States during the 17th to 19th centuries. But since the mid-1960s, there has been a

Figure 2-3. Projected percentage change in the number of females, by age and race/Hispanic 

origin—United States, 1995–2010

* Non-Hispanic.

AmI = American Indian; API = Asian/Pacific Islander.

Source: Reference 10.

0

25

50

75

100

125

Hispanic

API*

AmI*

Black*

White*

15–44 45–64 ≥65

Percentage Change

-9.8

5.8

12.5

51

44.6 40.6

67.7

48.8

102.2

109

6.6

21.9

53.3

121.1

86.6

marked increase in immigration from English- and

French-speaking Caribbean and African countries.16,20,21 The percentage of foreign-born blacks is

projected to increase nationwide to 10% of the

total black population by the year 2010;20 however,

foreign-born persons already account for more than

20% of the black population in New York and 10%

in Florida.20

Minority populations are expected to grow at a

faster rate than the U.S. population as a whole.10

From 1995 to 2010, the number of Hispanic and

Asian American women in their middle years or

older is expected to double, and the number of

black women is expected to increase by two-thirds

and American Indian women by almost half 

(Figure 2-3).
12 10 8 6 4 2 0 2 4 6 8 10 12

White*

Black*

White*

AmI*

12 10 8 6 4 2 0 2 4 6 8 10 12 12 10 8 6 4 2 0 2 4 6 8 10 12

White*

Hispanic

White*

API*

12 10 8 6 4 2 0 2 4 6 8 10 12

Age Group (years)

Percent

75–79

≥85

65–69

55–59

45–49

35–39

25–29

5–9

15–19

0–5

75–79

≥85

65–69

55–59

45–49

35–39

25–29

5–9

15–19

0–5

75–79

≥85

65–69

55–59

45–49

35–39

25–29

5–9

15–19

0–5

75–79

≥85

65–69

55–59

45–49

35–39

25–29

5–9

15–19

0–5

Figure 2-4. Population age structures: minority and non-Hispanic white females—United States, 

1995

* Non-Hispanic.

AmI = American Indian; API = Asian/Pacific Islander.

Source: Reference 9.

A Profile of Women

13

Immigration will make a greater contribution to

the increase among Hispanics and Asians/Pacific

Islanders than other groups.21 However, compared

with the white population, the minority population

is composed of a substantially higher proportion of

children and adolescents (33% versus 24%) and

lower proportion of adults aged 65 years (5%–10%

versus 16%) (Figure 2-4). As a result, on average,

minority females are 6 to 10 years younger than

their non-Hispanic white counterparts.9 Thus, even

if the birth rate fell immediately to the level of the

death rate and immigration were stopped, the current youth of the minority groups provide considerable population momentum for future increases in

the numbers of middle-aged and elderly black,

American Indian, Asian/Pacific Islander, and

Hispanic women, the age groups most susceptible

to diabetes and other chronic diseases. Already, the

burden of diabetes falls disproportionately on persons in these racial and ethnic groups.22 The rapid
14

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

growth of these susceptible subpopulations presages

a sharp rise in the burden of diabetes. Increasingly,

greater numbers of women with diabetes will be

women with special cultural needs.

As in the general population, minority women outnumber minority men. Compared with whites,

however, the sex imbalance among blacks and

Hispanics begins at much younger ages and increases more steeply with age (Table 2-2). In addition, it

has been widening since the 1970s,23 whereas

among whites the differential has narrowed recently.9 The greater number of females in the black

population is particularly striking; in 1995, women

outnumbered men by 13% in the relatively young

25–44 age group and by 40% in the 65–74 age

group (Table 2-2). As in the white population, sex

differentials for each minority population were

highest in the 75 or older age group, where there

were 190 black, 175 American Indian, 138

Asian/Pacific Islander, and 160 Hispanic women

per 100 men.

The population dynamics described herein point to

several important implications for health policy, for

the planning of diabetes services for women, and

for the planning of research. First, the expected

rapid growth in the numbers of high-risk women

(middle-aged, elderly, minority) suggests that even

under a simple assumption of constant prevalence,

a substantial increase in the number of women with

diabetes can be anticipated. Therefore, health officials need to reexamine the ability of the health care

system to meet the future needs of these women for

both primary and specialty diabetes services.

Second, the importance of culturally appropriate

prevention education for the population and the

medical profession needs to be emphasized. Third,

research efforts must expand to achieve an understanding of the mechanisms and pathways by which

factors such as duration of residence in the United

States and degree of acculturation alter risks for diabetes among minority groups. Finally, as the feminization of old age continues into this century, government at all levels as well as universities, foundations, and other organizations must expand their

efforts to understand the living arrangements, economic sufficiency, access to health care services, and

health and well-being of elderly women.

Geographic Characteristics

Regional distribution. The percentage of the population that is white is distributed in fairly uniform

fashion across the country but minority populations

are geographically concentrated, a legacy of the historical circumstances and migration patterns of the

various groups.15,16 In 1995, for example, more than

half all black females lived in the South, and in five

southern states (Louisiana, Mississippi, Alabama,

Georgia, South Carolina) and the District of

Columbia, they made up more than one-quarter of

the population.16 Black females also have a substantial presence (19% of the total) in the Northeast

and Midwest, where they account for at least 15%

of the populations in three states (Illinois,

Michigan, and New York). Two-fifths of Asian/

Pacific Islander females live in a single state:

California; one-tenth live in Hawaii, and one-tenth

live in New York.16,17 American Indian females have

a sizable presence only in Alaska, New Mexico, and

Oklahoma.16 Nearly two-thirds of Hispanic females

live in just five states: California, Texas, New

Mexico, Arizona, and Colorado; most of the

remainder live in New York or New Jersey (a total

of 12%), Florida (8%), or Illinois (about 5%).16,19

These patterns of geographic concentration are

expected to continue well into the 21st century.19,21

Thus, the societal impact of the increased burden of

diabetes anticipated among these susceptible groups

is likely to have a major regional component.

Area of residence. In 1995, half of all American

females lived in distinct areas—30.2% as urban

populations in central cities (strictly metropolitan

areas), and 20% as rural populations (strictly nonmetropolitan areas).24,25 The remaining 49.8% lived

in areas contiguous with the central (largest) city.26

Black (54.9%) and Hispanic (48.8%) females were

about twice as likely as white females (25.6%) to

live inside central cities. This is true at all ages, but

the difference is greatest at the extremes of the life

span (Figure 2-5). Among females younger than 18
A Profile of Women

15

years, almost half of the black and Hispanic girls

live in central cities, compared with about onefourth of whites. At age 75 years or older, one-third

of black and two-fifths of Hispanic women live in

central cities compared with about one-seventh of

whites.

Although many fewer (approximately 26 million in

1995) U.S. females live in nonmetropolitan or primarily rural areas, they represent about 1 in 5

white, 1 in 7 black, and 1 in 11 Hispanic females.

Among women aged 18 years or older who live in

these areas, half of white and 60% of black and

Hispanic women are of childbearing age while nearly one-fifth of white, one-fifth of black, and onetenth of Hispanic women are elderly.

Data on geographic characteristics often provide

clues about the health status of populations and can 

help to identify vulnerable, underserved populations. In the United States, region of birth26-30 and

area of residence31-35 are strongly associated with the

principal causes of death (e.g., cardiovascular disease, diabetes, cancer). Wherever they may live,

black American women born in the South have relatively higher mortality rates for diabetes than black

women born in other regions of the country.30

Similarly, women who live in the South are more

likely than women who live in other regions to

report that they have diabetes.36 Women who live in

rural areas are at high risk for diabetes because they

are more likely than urban residents to be obese

and to be inactive;26 in addition, they are more likely to have severely limited access to high-quality

health care and social services because of poverty or

transportation barriers.37

Social and Economic Characteristics

Social position, or socioeconomic status (SES), is a

powerful determinant of health status.1,6-8,38-39

Compared with persons of higher SES, persons of

low SES have reduced life expectancy40 and are

more likely to have chronic diseases;41-43 they also

have higher levels of risk factors for and behaviors

related to chronic disease.44-46 The effect of SES on

health status is not simply a threshold effect, but is

graded and continuous in all populations studied.4,32,38,39 In addition, these effects are cumulative47

and may persist throughout the life course.4,5,30,48 In

the United States, as in other industrialized countries, the disparity in health between persons of low

and high SES is increasing steadily.49

The three indicators most often used to measure

SES are educational attainment, occupation, and

income.50,51 Educational attainment is considered to

influence lifestyle behaviors and values and to provide access to prestigious occupational ranking,

income, and power. It has high validity and, after

early adulthood, is less likely to vary over a lifetime.

Also, educational attainment has stronger association with cardiovascular health-related behaviors

than either occupation or income.50,51 Its strong and

consistent correlation with health practices or

“lifestyle” behaviors may explain its relation to morbidity and mortality. Occupation is considered to

Figure 2-5. Percentage of females who lived

in central cities, by age and 

race/Hispanic* origin—United

States, 1995

* Hispanic may be of any race.

Source: Reference 24.

10

20

30

40

50 White Black Hispanic All races

Age Group (years)

0

Percent

≥75

64–74

55–64

45–54

35–44

25–34

18–24

<18
16

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

be related to differential exposure to noxious environments and to reflect access to medical care and

housing. Income and wealth are thought to influence opportunities for access to more and better

education and health care resources, material living

standards, and other social amenities. We will use

these three indicators to describe the social status of

the female population.

Education. The percentage of American women

who have completed high school increased steeply

between 1970 and 1995.52,53 White women are still

more likely than women in the minority groups to

have had this much education, but the racial/ethnic

gap closed substantially between 1970 and 1995

(Figure 2-6). During this period, percentages of

high school completion increased from 55.0% to

80.0% among white women, from 34.2% to

53.8% among Hispanic women, and from 32.5%

to 74.1% among black women. For all three

groups, even more dramatic increases occurred in

the percentages of women who completed 4 or

more years of college: this percentage more than

doubled among whites (8.4% to 21.0%), doubled

among Hispanics (4.3% to 8.4%), and almost

tripled among blacks (4.6% to 12.9%). The

improvement in college completion for Hispanic

women notwithstanding, there have been discouraging trends in this population.52 First, the level of

high school completion decreased sharply from

1980 to 1990 (65.8% to 50.1%), then increased to

only 53.8% in 1995. Second, the percentage of

Hispanic women who completed college did not

change from 1985 to 1995.

Overall in the United States in the 1980s, women

began to outnumber men as recipients of all earned

degrees conferred, except for first professional (e.g.,

medical doctors, lawyers) and doctoral degrees.52,53

In these areas as well, however, there have been dramatic improvements: in 1970, women earned only

1 of every 20 first professional degrees and about 1

of every 8 doctoral degrees; by 1995, 2 of 5 degrees

in each of these categories were earned by

women.52,53 This reduction in the gender gap in

higher education occurred in all racial or ethnic

minority groups but was greatest among Hispanics

and American Indians, somewhat less so among

Figure 2-6. Percentage of women completing high school and college, by race/Hispanic* 

origin—United States, 1970, 1985, 1995

* Hispanic may be of any race.

Source: Reference 52.

0

20

40

60

80

100

White Black Hispanic

1970 1985 1995

High School College

1970 1985 1995

Percent

55.0

32.534.2

75.1

60.8

47.4

80.0

74.1

53.8

8.4

4.6 4.3

21.0

12.9

8.4 11.0

16.3

7.3
total number employed full-time and the number

who either worked part-time or who were unemployed but looking for work rose by 90% to 100%.

Women living with a spouse were about as likely as

separated women to be in the workforce (61% versus 62%); however, divorced women had higher

rates of participation (74%). In 1995, about 25

million women with children under 18 years of age

were in the civilian labor force; of those with children under 6 years of age, two-thirds worked fulltime.55

Income. In 1995, women had lower incomes than

men at all ages (Table 2-3) and at all levels of educational attainment (Figure 2-7). This pattern held

in all racial or ethnic groups. Between 1970 and

1995, however, women’s earnings increased from

59.2% to 73.8% of men’s earnings among yearround, full-time workers; similar trends were also

seen for hourly earnings. Although the gender gap

in earnings closed among all racial and ethnic

groups, the smaller current gaps among blacks and

Hispanics reflect the lower earnings of men in these

groups more than gains made by women.54

Hispanic and black women have lower earnings

than their white or Asian American counterparts.

A Profile of Women

17

Asian Americans, and even less among blacks. Black

women, however, had already closed the gender gap

as early as 1975; by 1995, black women earned

70% more bachelor’s degrees, 20% more doctoral

degrees, and 34% more first professional degrees

than black men.

Despite the great improvements made by women in

recent years, the sexes still have many differences in

educational attainment. In 1994, for example, more

than two-thirds of the bachelor’s degrees earned in

the fields of the humanities, education, library and

archival sciences, health sciences, and public affairs

were awarded to women, but they received fewer

than one-third of the higher degrees awarded in

business management and administrative services,

computer/information sciences, engineering and

engineering technologies, and physical sciences and

science technologies.52,53 Many of the fields in which

women predominate are characterized by a relatively modest remuneration.53-55

Employment. A striking phenomenon of the last

third of the 20th century is the movement of

women into the paid labor force; between 1970

and 1995, the proportion of females over 15 years

of age who participated in the labor force grew

from 43% to 59%.55 An upward trend was seen in

all age groups under 65 years of age, but the steepest rise was seen among women aged 25–54 years,

three-quarters of whom were in the labor force by

1995.53,55 Among women 55 years or older, participation rates either remained steady or declined

until the mid-1980s, when they began to increase.

By 1995, about half of all women aged 55–64 years

and about 10% of elderly women were participating. Overall participation was somewhat lower for

Hispanic (53%) than for black or white women

(59%), but among teenagers (16–19 years) whites

had higher rates (55%) than blacks and Hispanics

(40%).

Reflecting the increased participation, the percentage of the total paid labor force made up of women

rose from 38.1% to 46% from 1970 to 1995.53 The

Table 2-3. Median annual income of persons 

aged 15 years or older, by age 

and sex—United States, 1995

Age group 

(years) Males ($) Females ($)

15–24 6,913 5,310

25–34 23,609 15,557

35–44 31,420 17,397

45–54 35,586 17,723

55–64 29,980 12,381

≥65 16,484 9,355

Total 22,562 12,130

Source: Reference 57.
18

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

In 1995, median annual earnings among yearround, full-time female workers ranged from

$17,200 for Hispanic women to $24,900 for Asian

American women (Figure 2-8). From 1975 to

1990, the gap between the earnings (in constant

dollars) of black and white women widened steadily

but did not change from 1990 to 1995. In this

period, the gap between Hispanic and white

women increased steadily.

Poverty among women is a particular concern. In

1995, 13.5 million American women were living

below the official poverty level. Thus women

account for about 3 of every 5 poor adults aged 18

years or older.55-57 Most poor women (61.3%) are in

their reproductive years, but nearly 20% are elderly.

At all ages past adolescence, women are more likely

than men to be poor (Table 2-4). The sex differential

narrows during the middle years, but by the time a

woman reaches 65 years of age, she is twice as likely

as an elderly man to live in poverty (Table 2-4). In

general, women are also more likely to be poor if

they have not completed high school, work parttime, are single heads of households, live alone, or

live in central cities or nonmetropolitan areas.53,55,56

Although most poor women (69%) are white,

because of their relatively larger population, they

account for about 12% of the white population.

However, despite the increasing improvement in

educational attainment and income, the poverty

statistics for minority women continue to be especially grave. In 1995, almost one-third of black and

Hispanic women lived below the federal poverty

level compared with about one-eighth of white

women (Table 2-4).57 At all ages, black and

Hispanic women are 2–3 times as likely as white

women to live in poverty (Figure 2-9). The percentage in poverty is lower for Asian/Pacific Islander

women (15% in 1995), but there are wide disparities among Asian subgroups.15,17 Asian women who

have immigrated to the United States since 1965

are much more likely to be poor than earlier immigrants: in 1990, poverty levels ranged from 6%

among Japanese American women to 66% among

Laotians.15,17

Figure 2-7. Median annual income of adults 

aged 25 years or older, by sex 

and educational attainment—

United States, 1995

Source: Reference 57.

0

20

40

60

80

Doctorate

Professional

Master's

Bachelor's

Some College

High School

Grades 9–12

<Grade 9

Dollars (thousands)

Educational Attainment

Women

Men

Figure 2-8. Median annual earnings of 

women who worked full-time 

year round, by race/Hispanic* 

origin—United States, 1970–95

* Hispanic may be of any race.

Source: Reference 57.

15

20

25

30

5

0

10

Asian

Year

Dollars (thousands)

White Black Hispanic

1970 1975 1980 1985 1990 1995
This summary suggests very clearly that the health

of millions of American women is being threatened

by economic insecurity. From the perspective of

diabetes, it is particularly disturbing that poverty is

so common during childhood, when type 1 diabetes usually emerges; during the reproductive

years, when gestational diabetes poses a threat; and

among the very elderly, who frequently become

blind, undergo amputations, or develop heart disease and stroke because of diabetes. The very high

levels of poverty at all ages for black and Hispanic

women, who have an elevated risk for diabetes in

general, are especially compelling because they suggest that many of these women have limited access

to medical and preventive services. Finally, there is

an urgent need to focus research and careful thinking on the impact of poverty on the development

of diabetes and its complications. The emphasis

should be to identify modifiable community-level

and individual-level determinants of risk for use in

prevention efforts, especially among all women in

the childbearing and older age groups.

A Profile of Women

19

Table 2-4. Percentage of persons who lived below the poverty level, by age, sex, and race/

Hispanic* origin—United States, 1995

Age group All White Black Hispanic*

(years) Female Male Female Male Female Male Female Male

<18 21.2 20.4 16.7 15.8 41.8 41.9 41.3 38.7

18–24 21.7 15.0 18.7 13.2 36.4 23.9 34.8 26.6

25–34 15.4 10.0 12.6 8.9 31.8 15.3 28.4 21.7

35–44 10.9 8.0 8.6 7.1 23.5 13.2 26.7 19.6

45–54 8.5 7.0 6.8 5.7 19.8 16.4 21.0 18.3

55–59 12.4 8.1 9.9 7.4 28.0 13.3 25.4 20.2

60–64 11.4 8.8 10.1 8.2 22.6 15.6 29.2 20.8

65–74 11.1 5.6 9.3 5.0 26.1 11.4 26.6 15.4

≥75 16.5 7.2 14.6 6.1 37.6 22.8 33.2 17.2

Total ≥18 13.4 9.0 11.1 7.8 28.1 16.3 28.2 21.4

Total ≥65 13.6 6.2 11.7 5.4 31.1 15.4 28.9 16.0

All ages 15.4 12.2 12.4 9.9 32.4 25.7 32.9 27.7

*Hispanic may be of any race.

Source: Reference 57.

Figure 2-9. Percentage of females who lived

below the federal poverty level,

by age and race/Hispanic* 

origin—United States, 1995

* Hispanic may be of any race.

Source: Reference 57.

0

10

20

30

40

50

Hispanic

Black

White

Percent

≥75

65–74

55–64

45–54

35–44

25–34

19–24

<18

Age Group (years)
Table 2-5. Percentage of adolescent females and women who were overweight in various 

national surveys, by age and race/Hispanic origin—United States, 1988–96

Population Percentage* Sample description (survey)

Adolescent females ≥85th Percentile ≥95th Percentile

Total† 21.4 10.5 Ages 12–17 years (NHANES III, 1988–94)

Non-Hispanic white 20.3 9.3

Non-Hispanic black 29.9 16.0

Mexican American 23.4 14.1

Total 25.9 11.6 Ages 13–18 years (National Longitudinal

Study of Adolescent Health, 1996)‡

Total 25.9 – Ages 12–22 years (National Longitudinal

Non-Hispanic white 22.6 – Study of Adolescent Health, 1996)

Non-Hispanic black 34.0 –

Non-Hispanic American Indian 40.0 –

Non-Hispanic Asian American 15.0 –

Hispanic American 29.1 –

Women Overweight

Total† 48.0 Ages ≥20 years (NHANES III, 1988–94)‡

Non-Hispanic white 45.7

Non-Hispanic black 66.8

Mexican American 67.8

Total† 20.2 Ages ≥18 years (National College Health 

Non-Hispanic white 18.5 Risk Behavior Survey, 1995)§

Non-Hispanic black 35.8

Hispanic 16.8

18–24 years 13.9

≥25 years 29.0

* Percentages for adolescents are for ≥ 85th and ≥ 95th percentiles of body mass index. Percentages for women are for body mass index ≥ 25.0 kg/m2

. † Includes racial and ethnic groups not shown.

‡ Body mass index calculated from measured values of weight and height.

§ Body mass index calculated from self-reported values of weight and height.

Sources: References 68–71.

20

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

Health-Related Behaviors

Several potentially modifiable health behaviors

influence the occurrence of diabetes and are associated with its complications rates. In particular, the

risk of developing diabetes increases progressively

with increasing weight,58-60 weight gain,61,62 body fat

distribution,63 and decreased physical activity.64-67

Overweight. In the United States, overweight is a

major (and worsening) public health problem for

all age and racial or ethnic groups (Table 2-5). In

the Third National Health and Examination Survey

(NHANES III, 1988–1994), 10.5% of adolescent

girls aged 12–17 years were overweight as defined

by a body mass index (weight in kilograms divided

by height in meters squared, kg/m2

) at or above the

sex- and age-specific 95th percentile; an additional

10.7% were at or above the sex- and age-specific

85th percentile cutoff.68,69 Approximately half of

women aged 20 years or older were overweight as

defined by a body mass index of 25.0 kg/m2 or

higher (Table 2-5). Based on these estimates, about

52 million adolescent and adult women are overweight.
A Profile of Women

21

Overweight is particularly common among adolescents and women in several minority groups (Table

2-5). In NHANES III, non-Hispanic black

(16.0%) and Mexican American (14.1%) adolescent girls were more likely to be overweight (95th

percentile of body mass index) than non-Hispanic

whites (9.3%).68,69 The National Longitudinal Study

of Adolescent Health later confirmed these differences; in this survey the prevalence of overweight

(85th percentile of body mass index) was highest for

American Indian (40.0%), non-Hispanic black

(34.0%), and Hispanic (29.1%) adolescent girls;

intermediate for non-Hispanic white girls (22.6%);

and lowest for Asian American girls (15.0%).70

However, the prevalence of overweight varied widely among Hispanic and Asian American subgroups.

Among Hispanic girls, overweight was highest

among Mexican Americans (32.0%), lowest among

Cuban Americans (21.4%), and intermediate for

Puerto Ricans (28.0%) and girls of Central or

South American origin (26.9%); among Asian

American girls, Chinese American (10.9%) and

Filipino American (12.8%) girls were about half as

likely to be overweight as girls of all other Asian

origins combined (20.6%).70

Differences in prevalence of overweight by race or

ethnicity among adolescent girls are similar to those

observed among women in several surveys.68,71-76 In

NHANES III, for example, more than two-thirds

of non-Hispanic black (66.8%) and Mexican

American (67.8%) women aged 20 years or older

were overweight compared with about two-fifths

(45.7%) of non-Hispanic white women (Table 2-5).

Other surveys have reported similar or higher levels

of overweight among American Indian72-74 and Pacific

Islander women (60%).75 In contrast, estimates for

Asian women ranged from 12.0% among Chinese

Americans to 26.0% among Filipino Americans.75

Today, overweight among girls and women must be

seen as a serious public health concern that is

already well entrenched. Both the average weight of

adolescent girls and women and the prevalence of

overweight have shifted upward progressively since

the early 1960s, with the steepest rise occurring

after the late 1970s.69,76-78 Over the ensuing two

decades, the prevalence of overweight doubled

among adolescent girls and rose by more than 40%

among women in all racial or ethnic groups measured. Also of concern is that long-term increases in

both weight and adiposity have also been seen

among preadolescent girls.77,79

Overweight in childhood and adolescence persists

into adulthood;80-82 overweight adolescent girls, for

example, are 40% to 60% more likely than their

peers of normal weight to become overweight

women.81 In addition, many overweight adolescents

can expect to become even more overweight after

childbearing begins because prepregnancy weight

and parity predict future weight gain.83,84 The magnitude of recent trends suggests a populationwide

impact of changes in social and environmental factors. One study, for example, found that a trend

toward increased body mass and weight gain among

young women aged 18–30 years was concurrent

with increased average daily energy intake and

decreased physical activity and physical fitness.78

Physical activity. Although lack of exercise is a risk

factor for diabetes and other major illnesses among

women, most American women do not get regular

exercise.85,86 NHANES III found that 59% of

women aged 20 years or older engaged in little (less

than 3 times per week) or no leisure-time physical

activity.85 In this study, Mexican American (46%)

and non-Hispanic black (40%) women were about

twice as likely as non-Hispanic white women

(23%) to report no leisure-time physical activity.

Overall, very few women (3%) participated in vigorous activity (3 or more times per week). Results

from the Behavioral Risk Factor Surveillance

System surveys for the years 1992–1994, which

included more racial and ethnic groups than

NHANES III, confirmed that study’s findings:

43.6% of black, 33.8% of Asian/Pacific Islander,

34.6% of American Indian, and 41.4% of Hispanic

women aged 18 or older reported engaging in no

regular leisure-time physical activity, compared with

29.3% of whites.72 Older women are less likely than

younger women to undertake regular leisure-time
22

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

Table 2-6. Percentage of female high school and college students who participated in vigorous* 

or moderate† physical activity, were enrolled in a physical education class, and played 

on an intramural sports team, by age, race/Hispanic origin, and grade—United States, 

1995

Vigorous physical Moderate physical Physical education Intramural

Population activity activity class sports team

High school

Total 52.1 20.5 56.8 42.4

Non-Hispanic white 56.7 16.8 61.7 47.1

Non-Hispanic black 41.3 26.4 44.4 34.9

Hispanic 45.2 27.6 44.6 27.3

Grade 9 61.6 27.0 80.8 43.7

Grade 10 59.3 22.9 71.4 47.9

Grade 11 47.2 19.6 41.2 39.4

Grade 12 42.4 13.7 39.1 38.8

College

Total 33.0 19.3 20.1 10.3

Non-Hispanic white 34.7 18.2 19.8 10.7

Non-Hispanic black 27.6 24.6 18.1 7.8

Hispanic 30.6 20.4 19.4 6.3

18–24 years 35.3 20.8 25.5 16.4

≥25 years 29.7 17.0 11.8 1.4

* Activities that caused sweating and hard breathing for at least 20 minutes on ≥ 1 of 7 days preceding the survey. † Walked or bicycled for at least 30 minutes on ≥ 5 of 7 days preceding the survey.

Sources: References 71, 87.

of the poverty level) women. Similarly, about half

of women living in poverty or near poverty and

more than half of those who have not completed

high school do not exercise at all; by comparison,

fewer than one-third of women who are either

more affluent or have at least some college do not

exercise. Furthermore, adolescent girls of all racial

and ethnic origins are less likely to be sedentary as

the educational attainment of the responsible adult

with whom they live rises or as the family income

increases.46

A fuller explanation of the differences between

white and minority women is needed. At all levels

of socioeconomic status, overweight and physical

inactivity are more prevalent among minority than

among white women;86,89 cultural differences may

well play an important role. For example, 

physical activity. In NHANES III, the percentages

of women reporting no leisure-time physical activity at all increased from 17% at ages 20–29, to 30%

at age 50, to 44% at age 70. Even among adolescents and college students, age seems to be related

to exercise habits.71,87 For example, among a nationally representative sample of high school students,

the percentages of girls participating in vigorous

activity fell from 61.6% in grade 9 to 42.4% in

grade 12; for moderate physical activity, the percentages declined from 27.0% to 13.7% (Table 2-6).

Socioeconomic status (SES), degree of acculturation, and generation of residence are also strongly

related to whether women are overweight or do not

engage in regular exercise.46,86,88,89 Women who either

have not completed high school or who live below

the poverty level are twice as likely to be overweight

as better educated or more affluent (300% or more
A Profile of Women

23

differences in prevalence of obesity between black

and white women are virtually constant across levels of SES, whereas differences between Hispanic

and white women decrease sharply with increasing

affluence.86,90 Black women may perceive overweight

to be more acceptable than do white women and

may be encouraged by their social environment to

maintain their weight.91 Among Mexican American

women, however, increasing affluence is strongly

associated with assimilation into the mainstream

non-Hispanic white U.S. society, which may

account for the reduction in body mass.90

The effects of acculturation on risk behaviors have

also been found in national surveys of adolescents

and women.70,86 For example, second-generation (at

least one foreign-born parent) adolescents are more

likely than their first-generation (born in a foreign

country to foreign-born parents) counterparts to be

overweight (30.6% versus 23.1% for Hispanics and

22.0% versus 8.3% for Asian Americans) (Table 

2-7).70 Furthermore, second-generation adolescents

have levels of obesity equivalent to those of U.S.-

born adolescents with U.S.-born parents. In addition, foreign-born women who have resided in the

United States for at least 15 years are likely to

report levels of overweight similar to those of U.S.-

born women, whereas those resident for less than

15 years report lower levels (Table 2-7).

This summary provides evidence of disturbing

trends in obesity and physical inactivity, especially

among younger females. Results of the few studies

reported here do not establish cause and effect

between socioeconomic status, duration or generation of residence, and behavioral risk factors among

adolescent girls and women. Still, they offer some

evidence of major increases in the average weight

and level of physical inactivity among women at all

stages across the lifespan, from preadolescence to

later adulthood. The magnitude of the increases in

these major determinants of diabetes risk suggests a

populationwide impact of changes in social and

environmental factors. With the current emphasis

on health promotion, health officials and

researchers need to pay more attention to understanding the processes that precipitate (and protect

against) changes in these health behaviors and environmental exposures.

2.3. Psychosocial Determinants of Health

Behaviors and Health Outcomes

The general status of the health of U.S. women

presents an apparent paradox. While living 7 years

longer than men on average, their more frequent

reports of illness and utilization of health services

suggest that they experience poorer health than

men.92-95 Sex-related differences in socialization,

social environment, and health attitudes and 

Table 2-7. Percentage of adolescent 

females and women who were 

overweight* or did not exercise, 

by race/Hispanic origin, 

generation,† and duration of 

residence—United States, 1995

No physical

Population Overweight activity

Adolescent females (grades 7–12)

Non-Hispanic white 22.6 –

Non-Hispanic back 34.0 –

Hispanic 29.1 –

First generation 23.1 –

Second generation 30.6 –

Third generation 31.0 –

Asian American 15.0 –

First generation 8.3 –

Second generation 22.0 –

Third generation 20.3 –

Women (aged ≥18 years)

Born in U.S. 37 37

Not born in U.S.

Resident ≥15 years 35 55

Resident <15 years 25 69

* Body mass index (kg/m2

) ≥ 85th percentile for age and sex.

† First generation = child and both parents not born in U.S.; Second 

generation = child born in U.S., at least one parent not born in 

U.S.; Third generation = child and both parents born in U.S.

Sources: References 70, 86.
24

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

behaviors may account for much of the observed

discrepancy between men and women.

There are three general categories of psychosocial

influences on women’s overall health in the United

States. The first category includes factors related to

the social environment (e.g., influence of marital

and family status, role strain and conflict, and

social support; community norms regarding healthrelated attitudes and behaviors). The second group

of psychosocial determinants involves those factors

influencing women’s interactions with the health

care system, such as access to services and relationships with health care providers. The final category

includes psychological variables related to the development of health beliefs, such as locus of control

and confidence in health interventions. Taken

together, these factors provide a context for understanding the influence of social and psychological

factors on women’s health behaviors and outcomes.

The Social Environment

The social environment, broadly conceptualized as

social networks encompassed by family, marital,

and social relationships, exerts a strong influence on

women’s health-related behaviors and outcomes. It

is primarily within this environment that individuals learn attitudes about health and help-seeking, as

well as observe the practice of health-related behaviors.95-97 According to a recent report of the Public

Health Service Task Force on Women’s Health

Issues,98 the family can provide an important source

of social support as well as an arena within which

women exert significant effects on family health.

For this reason, women’s experiences in the family

are of particular interest when examining the social

context of health behaviors.

The Task Force identified two aspects of women’s

roles within the family that merit attention for their

contribution to women’s health experiences: 

1) women’s increased employment outside of the

home, combined with primary responsibility for

child rearing and home-related responsibilities, and

2) increases in divorce, which result in higher numbers of woman-headed households. The effects of

these changes in women’s roles within the family

include direct as well as indirect effects on health.

For many, with divorce comes a decline in household income, which may restrict access to health

services and bring additional financial stress.

Similarly, significant changes in women’s employment and family roles are often accompanied by

greater demands placed on those women who are

already experiencing role overload and conflict.97

Such stresses can lead to greater vulnerability to

physical as well as psychological problems. Thus,

women’s social position, as represented by the roles

played within their households, can have a significant impact on their health status.

Social support. Social support is a mechanism for

promoting and restoring health related to the psychological consequences of one’s roles within the

household. Social support can be conceptualized as

the extent and quality of one’s social relationships

and networks that provide the following functions:

esteem (or emotional support), informational support, companionship, and instrumental support.99

Thus, social support can serve a number of functions that are related to enhanced psychological

well-being.

The effects of social support on the relationship

between stress and illness have been widely

studied.99,100 Lower levels of social support have consistently predicted higher rates of morbidity and

mortality.93,100,101 Although these findings are robust,

the process accounting for the positive effects of

social support remains unclear. The influence of

social support on health may operate through several possible pathways.93 For example, the relationship

may be due to indirect or direct influences of social

support and social networks on actual health behaviors,102,103 either by providing resources that increase

access to health services (e.g., transportation, financial support), or by increasing the likelihood of

health-promoting or health-damaging behaviors.104

Alternatively, the relationship between social 

support and health may be explained by the psychological consequences of increased social

support.93 That is, increased social support may be
A Profile of Women

25

related to a greater sense of control and selfesteem,102,105 which in turn can increase the probability of health-promoting behaviors. For example,

it has been shown that women receive and use

social support more than men do.106,107 This is 

consistent with women’s higher rates of healthpromoting behaviors and lower rates of mortality

but not with their higher rates of morbidity.

Women’s roles in providing increased levels of social

support can also contribute to their higher morbidity rates.99 For example, women tend to be involved

with a wider range of people, are more responsive

to others, and are more likely to provide caregiving

services.108 Women are also more likely to provide

social support to others and more likely to initiate

and sustain support networks.101,109 This pattern of

increased social support, both in terms of initiating

support for oneself and providing it to others, can

have contradictory effects on women’s health. By

increasing opportunities for women to experience

the negative consequences of the caregiving role,

increased social support can place greater demands

on their emotional and physical resources.93 In sum,

social support may influence the health of women

and men differently. These apparently discrepant

effects on health highlight the significance of

women’s roles in social networks.

Women’s multiple social roles are viewed as potent

contributors to overall levels of health. It appears

that it is not the mere presence or absence of multiple roles that influences women’s health outcomes,

but other aspects of such roles that may mediate

this relationship. For example, marriage is associated with better health for women and men, and

people who are both married and employed have

the best health. On the other hand, women who

are employed but not married and also have children have poorer levels of health than nonmarried

working women without children.110 For women

who are married and employed, having children

does not negatively influence health outcome.

Therefore, the stresses associated with motherhood

pose a greater health risk to women who are not

married than to those who are married.110

These findings are consistent with research indicating that married women having multiple roles (e.g.,

wife, worker, mother) experience positive health

benefits.110,111 However, other research has found

that women working outside the home have worse

health than do men who work.112,113 The discrepancy between these findings underscores the necessity

to consider the overall context of women’s social

roles when attempting to isolate the contribution of

specific factors on overall health.

Socioeconomic factors. An inverse relationship exits

between SES and health; lower SES is associated

with higher rates of morbidity and mortality.114,115

Women, in particular, experience disproportionately more health problems that result from poverty

than do men. This relationship may be a function

of two different, yet potentially related, mechanisms. On the one hand, lower SES is associated

with decreased access to health services, which can

negatively affect health outcome. Alternatively,

those in lower SES groups are more likely to perceive some life events as more negative and uncontrollable than those in higher SES groups.116 This

cognitive style is also associated with lower health

ratings.116 Hanner suggests a similar relationship

among education, health status, self-esteem, and

the likelihood of engaging in health-promoting

behaviors.117 SES may have a direct influence on

health outcomes through its impact on health resource and services options. For example, inadequate

insurance coverage and access to services have been

cited as major barriers to health care for Asian

American,118 Hispanic,119 and Native American

women.120 Conversely, SES may affect health outcomes indirectly by influencing psychosocial variables such as health locus of control and self-esteem.

For black women, the relationship between SES

and health is moderated by the influences of ethnicity and gender, which have also been associated

with variations in SES.115 Because the SES of blacks

tends to be lower than that of whites,121 and the

SES of women is generally lower than that of

men,122 African American women are particularly
26

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

vulnerable to the negative effects of SES on health.

The weathering hypothesis put forth by Geronimus

is consistent with this perspective.123 According to

Geronimus, deteriorating reproductive health outcomes for African American women in their early

adult years are a function of their “cumulative

socioeconomic disadvantage.”

This relationship between SES and health is also

illustrated by racial variation in the mortality rates

for specific diseases. The diseases that cause death

for African American women at higher rates than

for white women are also the diseases often linked

to SES (e.g., diabetes, lung disease, cerebrovascular

disease, cirrhosis of the liver).124 Even HIV/AIDS,

which was once primarily associated with homosexuality, has a strong economic determination.

Groups that currently have a high risk of contracting HIV (either through sex or injection drug use)

include groups that tend to be economically vulnerable: poor women and men, prostitutes, and young

people living in high-risk social environments.125

Thus, SES represents a number of significant social

and environmental factors that have powerful

effects on the health status of women of color.

Risk behaviors such as tobacco and alcohol use are

also related to social and economic influences, and

thus can lead to negative health outcomes for

women. In fact, examining risk behaviors may illuminate our understanding of how social and economic influences are exerted upon health. Women

who are younger, divorced, have higher levels of

education, and are employed report higher rates of

alcohol consumption.126 Relatedly, white women

tend to consume more alcohol at all ages than do

African American women.126

There are also racial and SES-related differences in

rates of women’s tobacco use.127 In general, the

prevalence of cigarette smoking is highest among

American Indian or Alaska Native women, intermediate among non-Hispanic white and non-Hispanic

black women, and lowest among Asian and

Hispanic women; women who have a high school

education or less are more likely than their counterparts to report current cigarette smoking. Although

sex differences in health risk behaviors have long

been noted,93 such variation among women points

to the influences of social and economic factors on

health-promoting versus health-damaging behaviors. Social norms regarding alcohol and tobacco

use may vary as a function of SES-related variables

and thus increase the likelihood that some groups

of women will be at greater risk of engaging in

these behaviors. For example, Baines cites the ceremonial use of tobacco as a cultural norm influencing tobacco use and therefore risk for cardiovascular

disease, cancer, and related medical conditions in

Native American women.120

In summary, a number of behaviors related to

sociodemographic characteristics and social roles are

associated with women’s health outcomes. Although

the relationships among these factors are not consistently linear, they do demonstrate the need for 

considering these aspects of women’s social environments as they affect health-related behaviors,128

particularly as they influence the development of

community norms regarding health behaviors. The

pattern of variation in women’s risk behaviors in

relation to socioeconomic status demonstrates that

health status is a function of one’s social context in

addition to individual characteristics. Thus, the

social environment exerts a powerful influence on

health status, through both 1) the effects of community norms and the influences of social roles and

2) SES-related factors.

Interactions with the Health Care System

Access. A person with adequate access to health care

services can make timely use of personal health

services to achieve the best possible outcomes.129-131

Health insurance coverage, having a usual source of

care, and satisfaction with care are among the indicators of access that have been studied extensively.131-138 These studies have shown that health insurance coverage is necessary but not sufficient for

adequate access to health care services. Nevertheless,

a major barrier to health care is cost, and health

insurance provides people with the means to overcome financial barriers to care.129,130,139
A Profile of Women

27

Most full-time workers have access to health care

through private insurance, primarily employmentbased; unemployed people and those who work for

low wages often have no coverage. In the mid1960s, the jointly sponsored federal-state Medicaid

and federally sponsored Medicare programs were

implemented to provide health insurance protection to low-income persons, the disabled, and persons 65 years of age or older.140

Data from several national surveys confirm that the

majority of females are covered by some form of

health care insurance.131,132,141 These surveys have also

shown that minority women, poor women (family

income-to-poverty ratio less than 1.00), and those

near poverty (family income-to-poverty ratio

between 1.00 and 1.24) are less likely than other

women to be covered.131,132,141,142 For example, the

1996 Current Population Survey (CPS) found that

only about 7 of 10 Hispanic women and 8 of 10

black women were covered compared with 9 of 10

white women (Figure 2-10).142 The CPS also found

that, regardless of racial or ethnic group, poor

women were less likely to be insured.

Most women (about 70%) have private coverage,

primarily employment-based; however, minority

women are considerably less likely than white women to have private coverage (Figure 2-11). Women

also rely more heavily than men on government

health insurance programs. In 1996, approximately

one-quarter of females were covered through Medicaid and Medicare compared with just one-fifth of

males.142 Black and Hispanic women are more than

twice as likely as white women to rely on Medicaid

coverage (28.0% and 24.5% versus 10.9%). More

women than men are covered through Medicare

simply because women live longer. The percentages

of women covered by Medicare are consistent with

the proportions of elderly women in each racial or

ethnic group (Figure 2-11).

One reason why women rely more heavily than

men on government programs, especially Medicaid,

is because they are more likely to be poor.53,141 Figure

2-11 demonstrates clearly that poverty is strongly

related to reduced levels of private coverage and to

increased levels of coverage through a government

program. Thus, irrespective of racial or ethnic origin, poor women are more likely than other women

to be covered through the Medicaid program:

whites, 42.6% versus 10.6%; blacks, 59.7% versus

51.2%; Hispanics, 51.4% versus 24.5% (Figure 

2-11). Because Medicaid is primarily a program for

poor mothers and their children, it is used most

prominently during the childbearing years when

women are most at risk of being poor.55,56 The high

levels of poverty among minority women, their

youth, and high fertility may combine to make

them more vulnerable to dependence on health care

coverage through Medicaid.

Women are more prone than men to discontinuous

employment and part-time and low-paying jobs,

which frequently makes them less likely to receive

employment benefits that would include health

insurance coverage. In addition, because they are

more than twice as likely as men to be covered as a

Figure 2-10. Health insurance coverage 

among all females and poor* 

females, by race/Hispanic†

origin—United States, 1996

* Poor = family income-to-poverty ratio less than 1.00.

† Hispanic may be of any race.

Source: Reference 142. Percent

0

20

40

60

80

100

Not insured

Insured

White Black Hispanic

All Females Poor Females

White Black Hispanic

86.9

13.1

80.9

19.3

69.6

30.4

71.1

28.9

76.0

24.0

64.0

36.0
28

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

dependent, they are more vulnerable to loss of coverage through separation, divorce, and widowhood.53,55,141 As of 1996, 19.4 million females (14%

of the female population) were uninsured; of these,

14.6 million were white, 3.5 million were black, 4.4

million were Hispanic of any race, and 7.6 million

were considered poor or near poor.142 Women of

minority racial and ethnic origin and women of low

SES were overrepresented among the uninsured.

Black and Hispanic women, who constituted 24%

of all women in 1996, accounted for 41% of the

uninsured; poor and near-poor women, who comprised 21% of all women in that year, accounted

for 40% of the uninsured. Sex-specific data on health

insurance coverage are very limited. However, the

1995 National Health Interview Survey found that

14.3% of adolescent girls aged 10–18 years were without health care coverage.143 Among adolescents aged

12–17 years, 3.8 million (16.1%) were uninsured,

representing nearly 13.9% of whites, 20% of blacks,

30% of Hispanics, and 30% of those in poverty.

Thus, socioeconomic and demographic factors such

as income, ethnicity, marital status, age, and educational attainment affect a woman’s ability to obtain

health care coverage. States have broad discretion in

determining eligibility criteria for Medicaid, but

these criteria vary between states and can change

from year to year within states.140 Consequently,

Medicaid does not provide comprehensive health

care coverage for many poor and minority reproductive-aged women who are at increased risk for

gestational diabetes and early-onset type 2 diabetes.

In contrast, Medicare provides coverage for 95% of

the nation’s aged, but beneficiaries are responsible

for charges for services not covered by the program,

including most prescription drugs and long-term

nursing care. States can use Medicaid funds to “buy

in” Medicare coverage to provide coverage for prescription drugs, nursing home care, premiums, and

cost sharing for low-income Medicare beneficiaries.138 Recent data indicate that Medicare beneficiaries covered by Medicaid are more likely than those

not covered to be women, nonwhite, nursing home

residents, and poor (annual incomes less than

$10,000). But older beneficiaries covered by

Medicaid are less likely to receive recommended

preventive care and to be satisfied with the quality

Figure 2-11. Type of health care insurance coverage among all females and poor* 

females, by race/Hispanic† origin—United States, 1996

* Poor = family income-to-poverty ratio less than 1.00.

† Hispanic may be of any race.

Source: Reference 142. Percent

0

20

40

60

80

100 Private Medicaid Medicare

White Black Hispanic

All Females Poor Females

White Black Hispanic

73.4

10.6

15.8

51.2

28.0

10.9

43.8

24.5

6.9

25.7

42.6

16.5 15.8

59.7

12.1 13.3

51.4

6.7
A Profile of Women

29

of care they receive. Thus, both Medicaid and

Medicare fall short of providing important coverage

that women need, especially poor women and

working women who support children.

Furthermore, even when women are employed and

supporting children, they may earn too much to

qualify for programs such as Medicaid but too little

to afford private insurance.

In addition to concerns about lack of coverage, policy makers, health care professionals responsible for

assuring access, and researchers need to consider

that underinsurance is also an important issue for

women.130,144,145 This review suggests strongly that

regardless of the type of coverage, large numbers of

women do not have adequate protection against the

cost of health care. Absence of appropriate insurance coverage forces women to forego needed services, especially preventive services that provide early

detection, successful treatment, and continuity of

care essential for effective management of serious

diseases such as diabetes.146

Utilization. Women seek health services more frequently and use a greater variety of these services

than do men.92 One explanation may be that

women are socialized to provide the bulk of home

health services and social support,93,98,106 which

makes them more aware of health-related problems

and thus more ready to seek medical services for

such problems. At the same time, their socialization

as caretakers and providers of social support may

protect women from negative health outcomes in

the long run. Thus, it should not be surprising that

unmarried women have fewer negative health consequences than unmarried men, because men are

not socialized to seek health services.92

Three differences in the socialization of women and

men have been advanced that relate to health

behavior:92

• Females are socialized to be aware of their physical discomforts; males are taught to ignore them.

The likely result is that women are more aware

of their physical conditions.

• Women are more willing than men to discuss

physical complaints with health care providers

and others;92 men are more likely to keep such

complaints to themselves. This difference

appears consistent with sex-typed behavior: discussing personal information, particularly about

illness, is more consistent with the female role.

Such behavior on the part of boys can easily be

viewed as evidence of weakness.

• Women appear more likely to curtail their activity level when ill, reflecting their greater attention to signs of illness and disease. Women are

also more likely than men to believe that health

service providers and their interventions will be

effective, and they are more likely to believe that

preventive behaviors will have positive results.

Not surprisingly, women are more likely than

men to engage in preventive behaviors, such as

using vitamins, obtaining a physical exam when

they are well, not smoking cigarettes, and

refraining from heavy alcohol use.

The more frequent use of health services by women

can be seen as a function not merely of their having

greater illness rates, but also a different socialization

toward health and illness. Although women can be

broadly characterized as disposed to taking action

on their health complaints, here also ethnic differences are apparent. Social factors such as language,

lack of insurance coverage, cultural values, and

opinions on the role of health professionals are all

important. Asian American women, for example,

are frequently reluctant to discuss their sexuality.118

Not surprisingly, Asian American women use preventive health services such as Pap smears and

breast exams less often than other groups of women

and have low survival rates for breast and cervical

cancer.118

Patient/provider relationship. Women have access to

greater amounts of health communications than

men, and they ask more health-related questions of

their providers.92,147-149 They also receive more empathy from their providers.149,150 One might conclude
30

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

that women are generally more satisfied than men

with the relationship they have with their providers,

and one might expect that women have a greater

belief that health services are effective. In trying to

characterize attitudes of women about their

providers and about the effectiveness of health care,

however, one must again consider ethnicity. For

example, Asian American, Hispanic, and Native

American women all experience barriers to obtaining health care services that often translate into

lower utilization, thereby blunting the effects of a

positive orientation about health care.118 For example, a culturally sanctioned belief among Hispanic

women is that individuals are responsible for their

own health outcomes, and this factor tends to discourage care-seeking.119 Among Native American

women, cultural norms related to interpersonal

communications and attitudes about health and

wellness affect the provider/patient relationship; if

physicians do not pay attention to these norms,

they may harm their relationship with the patient

and thus create a barrier to care.120

Personality Characteristics

Self-esteem. Higher self-esteem is associated with

increased likelihood that a person will engage in

health-promoting behaviors.96,105,151 Not surprisingly,

higher self-esteem is related to decreased levels of

smoking and alcohol and drug use152 and to

increased exercise;151 lower self-esteem is associated

with greater frequency of risk behaviors related to

HIV transmission.153 In addition, women high in

self-esteem have been found to perceive themselves

at lower risk for HIV infection than women low in

self-esteem.

One might surmise that women with high selfesteem are more interested in maintaining their

health, but most research on the health effects of

self-esteem has not considered the ethnicity of

female participants. Thus, generalizing these findings to all groups of women is premature.

Health locus of control. Based on the concept of

internal and external locus of control,154 individual

attitudes toward control over personal health can be

attributed to belief in the role of internal forces that

an individual can direct, the role of external forces

directed by powerful others (such as health professionals), or the role of chance (i.e., fate or luck).

High levels of internal control among women have

been positively correlated with preventive health

behaviors,155 health-promoting behavior (such as

exercise),92,156 and help-seeking and reports of overall

good health.92 Conversely, low internal control has

been associated with less preventive behavior, higher reports of illness, and less confidence in the outcomes of treatment interventions.155 The concepts

of internal control, the role of professional control,

and the impact of fate may be especially relevant to

diabetes. Persons with this disorder often curse their

fate, yet they must be prepared to control their own

health status through careful self-management and

trust in professionals for oversight and guidance. At

this point, however, it is not clear whether findings

about internal control can be applied to minority

women, as studies have generally not focused on

them. Furthermore, there is evidence that this

model may not fit Hispanic women, whose strong

belief that health is under individual control has

been cited as reducing their access to care.119

Connection with traditional health beliefs. Higher

educational attainment is associated with higher

levels of internal control for both women and

men.157 Correspondingly, women with lower education and SES have been found to believe more

strongly in fate and chance than women of higher

SES.116 Thus, women of lower SES may be at

greater risk of holding health beliefs that are not

conducive to health-promoting behaviors.

It would be easy to conclude that inappropriate

health beliefs lead to negative health outcomes, and

that the solution is to educate women both formally and informally. The issue is not quite straightforward, however. For example, it is not clear whether

such beliefs result from one’s health status or actually give rise to health outcomes.114 Second, health

beliefs should not be considered purely individual

characteristics, or traits, that might be susceptible

to adjustment. Rather, it may be useful to 
A Profile of Women

31

conceptualize them as a component of overall

health socialization that varies in relation to a

woman’s particular social context (e.g., SES, socialization within family and community of origin,

current social roles and networks).158 Specifically,

the attitudes and expectations one holds about the

import of health-promoting and health-damaging

behavior reflect one’s general notions about health.

The evidence presented above suggests that

women’s health orientation, as shaped by socialization experiences, influences their levels of knowledge about health issues, perceptions of symptoms,

interest in seeking care or treatment, and confidence in the benefits of treatment. Together, such

psychological variables ultimately affect morbidity

and mortality rates as well as women’s general 

experiences within the health care system. Clearly,

psychosocial factors strongly affect women’s health

through attitudes, behaviors, and social influences,

and these influences must be included in any accurate description and explanation of women’s health

status.

2.4. Public Health Implications

The findings from this literature review demonstrate that the social status of U.S. women

improved markedly since the early 1970s. Over the

ensuing decades, however, several social and environmental themes emerged or persisted—including

some that pertain specifically to diabetes—that currently affect the health status of women. Many of

these themes recur across the lifespan, combine to

increase women’s risk for diabetes, and can impede

both individual and societal efforts to prevent this

disease. Many of these issues are common to all

women; others are peculiar to specific subgroups.

Issues common to all women include

• The large increase expected in the number of

women at risk for diabetes.

• A trend toward increasing prevalence of major

risk factors for diabetes (i.e., overweight and lack

of physical activity).

• Economic insecurity and risk for poverty at all

ages over 18 years of age.

• The growth in the number of older women, or

the “feminization of old age.”

• The increasing number of elderly women who

live alone.

Other issues common to specific groups of women

include those that are related to demographic

changes among women of minority racial and ethnic origin. Between 1995 and 2010, the number of

minority women—American Indian, Asian/Pacific

Islander, black, and Hispanic—will increase by

approximately 15 million. Also affecting this

increase is the impact of immigration and acculturation. Among adolescents and women, duration of

residence and acculturation are associated with the

development of a diabetogenic risk profile.

The public health implications of these issues identified are organized according to the three core

functions of public health practice as recommended

by the Institute of Medicine: assessment, policy

development, and assurance.159 These core functions

provide a framework for thought and action on the

impact of diabetes on women’s health.

Assessment

Surveillance. The magnitude of the increasing

trends in major risk factors for diabetes (overweight, weight gain, and low levels of physical

activity), especially among adolescent and young

adult women, suggests a populationwide impact of

changes in social and environmental factors and

calls for more systematic monitoring of these major

risk factors for diabetes using a life-stage approach.

Women at highest risk of developing diabetes and

its complications may be the least likely to have

access to preventive health care services. Therefore,

there is a need for systematic monitoring and

reporting of health insurance coverage, changes in

Medicaid (including buy-ins to Medicare), and

other state-based insurance programs to provide
32

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

information on their impact on access to care

among women, notably during adolescence and the

reproductive and elderly years.

The greatest growth in the size of the female population is expected in the age and ethnic groups at

highest risk for diabetes; much of this change will

be concentrated regionally. The reporting of the

expected increase in the prevalence and incidence of

diabetes in women by regional concentration, nativity, duration and generation of residence, and degree

of acculturation would provide useful information

for allocating resources and for planning and programming appropriate services for this population.

Socioeconomic status, region or area of residence,

and place of birth are often as strongly associated

with health status as currently used risk markers

(e.g., race, ethnicity). Appropriate and valid indicators of social status and social context are needed

for routine use in assessing the burden of diabetes

and its complications among women of all racial

and ethnic groups.

Research. More intensive study is needed to determine the contribution of cumulative gestational

weight gain to overweight among middle-aged

women, to identify modifiable determinants of the

sharp decline in physical activity among schoolaged girls, and to identify types of physical activity

that appeal to women in various age, cultural, and

socioeconomic groups.

In addition, among immigrant adolescent girls and

older women, factors such as acculturation and

duration of residence are positively associated with

having a diabetogenic profile. Additional research is

needed to identify protective health behaviors

among immigrant groups, to develop intervention

strategies aimed to preserve these behaviors, and to

develop effective strategies for translating this

knowledge to other groups of women.

An increasing number of elderly women are at risk

for poverty and are living alone. This population

will require additional community-based services

and support to carry out daily activities and to

access appropriate health services. The assessment

of community barriers to self-management of diabetes and other chronic diseases could provide data

for programmatic activity and identify potentially

modifiable determinants of such barriers.

Policy Development

The planning and programming of appropriate

services and interventions for women will require

input from many agencies at the federal, state, and

local levels. For instance, collaboration between the

appropriate health and education agencies will be

required to develop and implement programs

aimed at 1) ensuring that schools comply with federal recommendations for healthy diets and the

availability of healthy foods, and 2) integrating education on the importance of healthy eating habits

and physical education into school curricula for all

grades, especially in junior and senior high schools.

Women who are at risk for poverty are also least

likely to have adequate health care insurance coverage. Ensuring financial access to adequate preventive care for women with diabetes and other chronic diseases is an important strategy for reducing the

burden of disease in high-risk populations. This

would benefit individuals and society at large.

Assurance

In general, women are the initial providers of primary care to family members or to their extended

family. Women are socialized to be more aware of

health-related problems and thus are more likely to

seek medical services for their problems.93 This is in

addition to the fact that many women work and

provide support to family and community members. At the same time, self-care or preventive care

may not be a priority for many women who work

outside of or in the home, women who are heads of

households, women who are poor or nearly poor,

and women responsible for providing for their 

parents and members of their extended family. To

facilitate healthy behaviors in this population, innovative models of health care delivery that include

features such as extended hours, culturally compe-
A Profile of Women

33

tent providers, and access to preventive care services

and education in traditional and nontraditional settings would make the use of services—especially

preventive care services—more accessible.

Efforts at the state and local levels to increase access

through the provision of quality care services for

persons with diabetes and other chronic diseases are

important for women at all ages in the life cycle.

Extending this approach to elderly women would

further necessitate intersectoral collaboration (e.g.,

among health, social services, organizations in the

voluntary sector) to promote increased awareness

and availability of community services that specifically target the needs of elderly women who live

alone.
34

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

References

1. Lynch JW. Social position and health. Ann Epidemiol

1996;6(1):21–3.

2. Becker MH. A medical sociologist looks at health promotion. J Health Soc Behav 1993;34(1):1–6.

3. Davison C, Frankel S, Smith GD. The limits of lifestyle:

re-assessing “fatalism” in the popular culture of illness

prevention. Soc Sci Med 1992;34(6):675–85.

4. Adler NE, Boyce T, Chesney MA, et al. Socioeconomic

status and health. The challenge of the gradient. Am

Psychol 1994;49:15–24.

5. Lynch JW, Kaplan GA, Salonen JT. Why do poor people behave poorly? Variation in adult health behaviors

and psychological characteristics by stages of the socioeconomic life course. Soc Sci Med 1997;44(6):809–19.

6. Kaplan GA. People and places: contrasting perspectives

on the association between social class and health. Int J

Health Serv 1996;26(3):507–19.

7. Link BG, Phelan J. Social conditions as fundamental

causes of disease. J Health Soc Behav 1995;Spec No:

80–94.

8. Williams DR. Socioeconomic differentials in health: a

review and redirection. Soc Psychol Q 1990;53:81–99.

9. Deardorff KE, Hollmann FW, Montgomery PM. U.S.

Population Estimates by Age, Sex, Race, and Hispanic

Origin: 1990–1995. Population Paper Listings, No. 41.

Washington, DC: Population Division, U.S. Bureau of

the Census, 1996.

10. U.S. Bureau of the Census. Population Projections of the

United States, by Age, Sex, Race, and Hispanic Origin:

1995 to 2050. Current Population Reports, Series P25,

No. 1130. Washington, DC: U.S. Government Printing

Office, 1996.

11. McFalls, JA Jr. Population: a lively introduction.

Updated 3rd ed. Popul Bull 1998;53(3):1–47.

12. Kranczer S. Mixed life expectancy changes. Stat Bull

1996;77(4):29–36. Data used with permission from

publisher.

13. Waldron I. Recent trends in sex mortality ratios for

adults in developed countries. Soc Sci Med 1993;36(4):

451–62.

14. Wallman KK, Hodgdon J. Race and ethnic standards for

federal statistics and administrative reporting. Directive

No. 15. Stat Reporter, 1977(July):450–4.

15. Leigh WA, Lindquist MA. Women of Color Health Data

Book. Washington, DC: Office of Research on Women’s

Health, 1998. (NIH Publication No. NIH 98-4247)

16. Centers for Disease Control and Prevention. Chronic

Disease in Minority Populations. Atlanta: Centers for

Disease Control and Prevention, 1994.

17. Takeuchi DT, Young KNJ. Overview of Asian Pacific

Islander Americans. In: Zane NWS, Takeuchi D, Young

KNJ, editors. Confronting Critical Health Issues of Asian

and Pacific Islander Americans. Thousand Oaks, CA:

Sage, 1994:3–21.

18. De Vita CJ, Pollard KM. Increasing diversity of the U.S.

population. Stat Bull Metrop Insur Co 1996;77(3):

12–17.

19. del Pinal JH. Hispanic Americans in the United States:

young, dynamic, and diverse. Stat Bull Metrop Insur Co

1996; 77(4):2–13.

20. Reid J. Immigration and the future of the U.S. black

population. Popul Today 1986;14(2):6–8.

21. Smith JP, Edmonston B, editors. The New Americans:

Economic, Demographic, and Fiscal Effects of Immigration.

Washington, DC: National Academy Press, 1997.

22. Carter JS, Pugh JA, Monterrosa A. Non–insulindependent diabetes mellitus in minorities in the United

States. Ann Int Med 1996;125(3):221–32.

23. Markides KS. Consequences of gender differentials in

life expectancy for black and Hispanic Americans. Int J

Aging Hum Dev 1989;29(2):95–102.

24. U.S. Census Bureau. <http://www.census.gov/population/

censusdata/urdef.txt>. Released October 1995.

25. Office of Technology Assessment. Health Care in Rural

America, OTA-H-434. Washington, DC: U.S.

Government Printing Office, 1990.

26. U.S. Census Bureau. <http://www.census.gov/

population/www/estimates/metrodef.html>. Last revised:

May 9, 1997.
A Profile of Women

35

27. Greenberg MR, Schneider D. Region of birth and mortality of blacks in the United States. Int J Epidemiol

1992;21(2):324–8.

28. Fang J, Madhavan S, Alderman MH. Nativity, race, and

mortality: influence of region of birth on mortality of

U.S.-born residents of New York City. Hum Biol 1997;

69(4):533–44.

29. Schneider D, Greenberg MR, Lu LL. Region of birth

and mortality from circulatory diseases among black

Americans. Am J Public Health 1997;87(5):800–4.

30. Schneider D, Greenberg MR, Lu LL. Early life experiences linked to diabetes mellitus: a study of AfricanAmerican migration. J Natl Med Assoc 1997;89(1):

29–34.

31. Sorlie PD, Backlund E, Johnson NJ, Rogot E. Mortality

by Hispanic status in the United States. JAMA 1993;

270(20):2464–8.

32. Haan MN, Kaplan GA, Camacho T. Poverty and health.

Prospective evidence from the Alameda County study.

Am J Epidemiol 1987;125(6):989–98.

33. Anderson RT, Sorlie PD, Backlund E, Johnson N,

Kaplan GA. Mortality effects of community socioeconomic status. Epidemiology 1997;8(1):42–7.

34. Waitzman NJ, Smith KR. Phantom of the area: povertyarea residence and mortality in the United States. Am J

Public Health 1998;88(6):973–6.

35. Sternberg S. Study shows yawning gaps in U.S. health

care. Longevity affected by environment. USA TODAY,

December 4, 1997, pp. 1A and 11A.

36. Centers for Disease Control and Prevention. Diabetes

Surveillance 1997. Atlanta, GA: Centers for Disease

Control and Prevention, 1997.

37. Bushy, A. Health issues of women in rural environments: an overview. J Am Womens Assoc 1998;53(2):

53–6.

38. Susser MW, Watson W. Sociology in Medicine. 3rd ed.

New York: Oxford University Press, 1985.

39. Marmot MG, Kogevinas M, Elston MA. Social/economic

status and disease. Annu Rev Public Health 1987;8:111–35.

40. Rogot E, Sorlie PD, Johnson NJ. Life expectancy by

employment status, income, and education in the

National Longitudinal Mortality Study. Public Health

Rep 1992;107(4):457–61.

41. Pincus T, Callahan LF, Burkhauser RV. Most chronic

diseases are reported more frequently by individuals with

fewer than 12 years of formal education in the age

18–64 U.S. population. J Chronic Dis 1987;40(9):

865–74.

42. Baquet CR, Horm JW, Gibbs T, Greenwald P.

Socioeconomic factors and cancer incidence among

blacks and whites. J Natl Cancer Inst 1991;83(8):551–7.

43. Kaplan GA, Keil JE. Socioeconomic factors and cardiovascular disease: a review of the literature. Circulation

1993;88:1973–98.

44. Winkleby MA, Fortmann SP, Barrett DC. Social class

disparities in risk factors for disease: eight-year prevalence patterns by level of education. Prev Med 1990;

19(1):1–12.

45. Brunner EJ, Marmot MG, Nanchahal K, et al. Social

inequality in coronary risk: central obesity and the metabolic syndrome. Evidence from the Whitehall II study.

Diabetologia 1997;40(11):1341–9.

46. Lowry R, Kann L, Collins JL, Kolbe LJ. The effect of

socioeconomic status on chronic disease risk behaviors

among U.S. adolescents. JAMA 1996;276(10):792–7.

47. Lynch JW, Kaplan GA, Shema SJ. Cumulative impact of

sustained economic hardship on physical, cognitive, psychological, and social functioning. N Engl J Med 1997;

337(26):1889–95.

48. Marmot MG, Shipley MJ. Do socioeconomic differences in mortality persist after retirement? 25 year 

follow-up of civil servants from the first Whitehall study.

BMJ 1996;313(7066):1177–80.

49. Pappas G, Queen S, Hadden W, Fisher G. The increasing disparity in mortality between socioeconomic groups

in the United States, 1960 and 1986. N Engl J Med

1993;329(2):103–9.

50. Liberatos P, Link BG, Kelsey JL. The measurement of

social class in epidemiology. Epidemiol Rev 1988;10:

87–121.
36

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

51. Winkleby MA, Jatulis DE, Frank E, Fortmann SP.

Socioeconomic status and health: how education,

income, and occupation contribute to risk factors for

cardiovascular disease. Am J Public Health 1992;82(6):

816–20.

52. U.S. Bureau of the Census. Statstical Abstract of the

United States, 1997. Washington, DC, 1997.

53. Costello C, Stone AJ, editors. The American Woman

1994–95: Where We Stand. New York: W.W. Norton &

Company, Inc., 1994.

54. Jacobs EE, editor. Handbook of U.S. Labor Statistics.

First Edition. Maryland: Berman Press, 1997.

55. Bianchi SM, Spain D. Women, work, and family in

America. Popul Bull 1996;51(3):24–7.

56. O’Hare WP. A new look at poverty in America. Popul

Bull 1996;51(2):1–44.

57. U.S. Bureau of the Census. “Current Population Survey:

March Supplement, 1995;” <http://ferret.bls.census.gov/

macro/031996/pov/4_001.htm>.

58. National Institutes of Health Consensus Development

Panel. Health implications of obesity. Ann Intern Med

1985;103(1):147–51.

59. Pi-Sunyer FX. Medical hazards of obesity. Ann Intern

Med 1993;119:655–60.

60. Colditz GA, Willet WC, Stampfer MJ, et al. Weight as a

risk factor for clinical diabetes in women. Am J Epidemiol

1990;132(3):501–13.

61. Hanson RL, Narayan KMV, McCance DR, et al. Rate

of weight gain, weight fluctuation, and incidence of

NIDDM. Diabetes 1995;44(3):261–6.

62. Ford ES, Williamson DF, Liu S. Weight change and diabetes incidence: findings from a national cohort of U.S.

adults. Am J Epidemiol 1997;146(3):214–22.

63. Haffner SM, Stern MP, Mitchell BD, Hazuda HP,

Patterson JK. Incidence of type II diabetes in MexicanAmericans predicted by fasting insulin, and glucose levels, obesity, and body-fat distribution. Diabetes 1990;

39(3):283–8.

64. Manson JE, Rimm EB, Stampfer MJ, et al. Physical

activity and incidence of non–insulin-dependent diabetes mellitus in women. Lancet 1991;338(8770):774–8.

65. Haapanen N, Miilunpalo S, Vuori I, Oja P, Pasanen M.

Association of leisure-time physical activity with the risk

of coronary heart disease, hypertension, and diabetes in

middle-aged men and women. Int J Epidemiol 1997;

26(4):739–47.

66. Colditz GA, Coakely E. Weight, weight gain, activity,

and major illnesses: the Nurses’ Health Study. Int J

Sports Med 1997;18(Suppl 3):S162–70.

67. Lee IM, Paffenbarger RS Jr, Hennekens CH. Physical

activity, physical fitness, and longevity. Aging (Milano)

1997;9:2–11.

68. CDC. Update: National Center for Health Statistics.

<http://www.cdc.gov/nchs/fastats/overwt.htm>. Last

accessed December 2000.

69. Troiano RP, Flegal KM, Kuczmarski RJ, Campbell SM,

Johnson CL. Overweight prevalence and trends for children and adolescents. Arch Pediatr Adolesc Med 1995;

149(10):1085–91.

70. Popkin BM, Udry JR. Adolescent obesity increases significantly in second and third generation U.S. immigrants: the National Longitudinal Study of Adolescent

Health. J Nutr 1998;128(4):701–6.

71. CDC. CDC surveillance summaries. MMWR 1997

;46(SS-6):1–56.

72. Hahn RA, Teutsch SM, Franks AL, Chang M-H, Lloyd

EE. The prevalence of risk factors among women in the

United States by race and age, 1992–1994: opportunities for primary and secondary prevention. J Am Med

Womens Assoc 1998;53(2):96–104, 107.

73. Ellis JL, Campos-Outcalt D. Cardiovascular disease risk

factors in Native Americans: a literature review. Am J

Prev Med 1994;10(5):295–307.

74. Strauss KF, Mokdad A, Ballew C, et al. The health of

Navajo women: findings from the Navajo Health and

Nutrition Survey, 1991–1992. J Nutr 1997;127(10

Suppl):2128S–33S.

75. Crews DE. Obesity and diabetes. In: Zane NWS,

Takeuchi DT, Young KNJ, editors. Confronting Critical

Health Issues of Asian and Pacific Islander Americans.

Thousand Oaks, CA: Sage, 1994:174–208.

76. Kuczmarski RJ, Flegal KM, Campbell SM, Johnson CL.

Increasing prevalence of overweight among U.S. adults:

the National Health and Nutrition Examination

Surveys, 1960 to 1991. JAMA 1994;272(3):205–11.
A Profile of Women

37

77. Freedman DS, Srinivasan SR, Valdez RA, Williamson

DF, Berenson GS. Secular increases in relative weight

and adiposity among children over two decades: the

Bogalusa Heart Study. Pediatrics 1997;99(3):420–6.

78. Lewis CE, Smith DE, Wallace DD, Williams OD, Bild

DE, Jacobs DR Jr. Seven-year trends in body weight and

associations with lifestyle and behavioral characteristics

in black and white young adults: the CARDIA Study.

Am J Public Health 1997;87(4):635–42.

79. Campaigne BN, Morrison JA, Schumann BC, et al.

Indexes of obesity and comparisons with previous

national survey data in 9- and 10-year-old black and

white girls: the National Heart, Lung, and Blood

Institute Growth and Health Study. J Pediatr 1994;124:

675–80.

80. Srinivasan SR, Bao W, Wattigney WA, Berenson GS.

Adolescent overweight is associated with adult overweight and related multiple cardiovascular risk factors:

the Bogalusa Heart Study. Metabolism 1996;45(2):

235–40.

81. Serdula MK, Ivery D, Coates RJ, Freedman DS,

Williamson DF, Byers T. Do obese children become

obese adults? A review of the literature. Prev Med

1993;22(2):167–77.

82. Guo SS, Roche AF, Chumlea WC, Gardner JD,

Siervogel RM. The predictive value of childhood body

mass index values for overweight at age 35 y. Am J Clin

Nutr 1994;59(4):810–19.

83. Wolfe WS, Sobal J, Olson CM, Frongillo EA Jr,

Williamson DF. Parity-associated weight gain and its

modification by sociodemographic and behavioral factors: a prospective analysis in U.S. women. Int J Obes

Relat Metab Disord 1997;21(9):802–10.

84. Smith DE, Lewis CE, Caveny JL, Perkins LL, Burke

GL, Bild DE. Longitudinal changes in adiposity associated with pregnancy. The CARDIA Study. Coronary

Artery Risk Development in Young Adults Study. JAMA

1994;271(22):1747–51.

85. Crespo CJ, Keteyian SJ, Heath GW, Sempos CT.

Leisure-time physical activity among U.S. adults. Results

from the Third National Health and Nutrition

Examination Survey. Arch Intern Med 1996;156(1):93–8.

86. Brown ER, Wyn R, Cumberland WG, et al. Women’s

Health-Related Behaviors and Use of Clinical Preventive

Services. New York: The Commonwealth Fund, 1995.

87. Kann L, Warren CW, Harris WA, et al. Youth risk

behavior surveillance—United States, 1995. MMWR

1996;45(SS-4):1–84.

88. CDC. Prevalence of selected risk factors for chronic disease by education level in racial/ethnic populations—

United States, 1991–1992. MMWR 1994;43(48):894–9.

89. Winkleby MA, Kraemer HC, Ahn DK, Varady AN.

Ethnic and socioeconomic differences in cardiovascular

disease risk factors: findings from the Third National

Health and Nutrition Examination Survey, 1988–1994.

JAMA 1998;280(4):356–62.

90. Hazuda HP, Mitchell BD, Haffner SM, Stern MP.

Obesity in Mexican American subgroups: findings from

the San Antonio Heart Study. Am J Clin Nutr 1991;

53(6 Suppl):1529S–34S.

91. Stevens J, Kumanyika SK, Keil JE. Attitudes toward body

size and dieting: differences between elderly black and

white women. Am J Public Health 1994;84(8):1322–5.

92. Corney RH. Sex differences in general practice attendance and help-seeking for minor illness. J Psychosom Res

1990;34(5):525–34.

93. Shumaker SA, Hill DR. Gender differences in social

support and physical health. Health Psychol 1991;10(2):

102–111.

94. Verbrugge LM. The twain meet: empirical explanations

of sex differences in health and mortality. J Health Soc

Behav 1989;30(3):282–304.

95. Verbrugge LM, Wingard DL. Sex differentials in health

and mortality. Women Health 1987;12(2):103–45.

96. Duffy ME. Determinants of health promotion in

midlife women. Nurs Res 1988;37(6):358–62.

97. Doyal L. What Makes Women Sick: Gender and the

Political Economy of Health. Basingstoke, England:

Macmillan, 1995.

98. U.S. Department of Health and Human Services.

Women’s Health. Report of the Public Health Service Task

Force on Women’s Health Issues. Vol. II. Washington, DC:

U.S. Government Printing Office, 1996.

99. Reifman A, Biernat M, Lang E. Stress, social support,

and health in married professional women with small

children. Psych Women Quart 1991;15:431–5.
38

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

100. Antonucci TC. Social support: theoretical advances,

recent findings, and pressing issues. In: Sarason IG,

Sarason BR, editors. Social Support: Theory, Research,

and Applications. Boston: Martinus Nijhoff, 1985:21–7.

101. Antonucci TC, Akiyama H. An examination of sex differences in social support in mid and late life. Sex Roles

1987;17:737–49.

102. Cohen S. Psychosocial models of the role of social support in the etiology of physical disease. Health Psychol

1988;7(3):269–97.

103. Dean K. Self-care components of lifestyles: the importance of gender, attitudes, and the social situation. Soc

Sci Med 1989;29(2):137–52.

104. Kaplan RM, Hartwell SL. Differential effects of social

support and social network on physiological and social

outcomes in men and women with type II diabetes mellitus. Health Psychol 1987;6(5):387–98.

105. Muhlenkamp AF, Sayles JA. Self-esteem, social support,

and positive health practices. Nurs Res 1986;35(6):334–8.

106. Flaherty J, Richman J. Gender differences in the perception and utilization of social support: theoretical perspectives and an empirical test. Soc Sci Med 1989;

28(12):1221–8.

107. Vaux, A. Social Support: Theory, Research, and Intervention. New York: Praeger, 1988.

108. Kessler RC, McLeod JD, Wethington E. The costs of

caring: a perspective on the relationship between sex and

psychological distress. In: Sarason IG, Sarason BR, editors. Social Support: Theory, Research, and Applications.

Boston: Martinus Nijhoff, 1985:491–506.

109. Belle D. Lives in Stress: Women and Depression. Beverly

Hills, CA: Sage, 1987.

110. Verbrugge LM. Gender and health: an update on

hypotheses and evidence. J Health Soc Behav 1985;

26(3):156–82.

111. Haavio-Mannila E. Inequalities in health and gender.

Soc Sci Med 1986;22(2):141–9.

112. Haynes SG, Feinleib M, Kannel WB. The relationship

of psychosocial factors to coronary heart disease in the

Framingham Study. III. Eight-year incidence of coronary

heart disease. Am J Epidemiol 1980;111(1):37–58.

113. Zappert LT, Weinstein HM. Sex differences in the

impact of work on physical and psychological health.

Am J Psychiatry 1985;142(10):1174–8.

114. Anderson NB, Armstead CA. Toward understanding the

association of socioeconomic status and health: a new

challenge for the biopsychosocial approach. Psychosom

Med 1995;57(3):213–25.

115. McNair LD, Roberts GW. Social and behavioral influences on African American women’s health. In:

Blechman E, Brownell K, editors. Behavioral Medicine

and Women: A Comprehensive Handbook. New York:

Guilford, 1998:821–25.

116. Raja SN, Williams S, McGee R. Multidimensional

health locus of control beliefs and psychological health

for a sample of mothers. Soc Sci Med 1994;39(2):

213–20.

117. Hanner ME. Factors related to promotion of healthseeking behaviors in the aged. Unpublished doctoral dissertation, The University of Texas at Austin, 1986.

118. Helstrom AW, Coffey C, Jorgannathan P. Asian

American women’s health. In: Blechman EA, Brownell

KD, editors. Behavioral Medicine and Women: A

Comprehensive Handbook. New York: Guilford, 1998:

826–32.

119. Woodward AM. Hispanic women and health care. In:

Blechman EA, Brownell KD, editors. Behavioral Medicine and Women: A Comprehensive Handbook. New York:

Guilford, 1998:833–7.

120. Baines DR. Native American women and health care.

In: Blechman EA, Brownell KD, editors. Behavioral

Medicine and Women: A Comprehensive Handbook. New

York: Guilford, 1998:839–42.

121. Jaynes G, Williams R. A Common Destiny: Blacks and

American Society. Washington, DC: National Academy

Press, 1989.

122. Amott T, Matthaei J. The promise of comparable worth:

a socialist-feminist perspective. In: Kesselman A, McNair

LD, Schniedewind N, editors. Women: Images and Realities. A Multicultural Anthology. Mountain View, CA:

Mayfield Press, 1995:177–82.

123. Geronimus AT. The weathering hypothesis and the

health of African American women and infants: evidence and speculations. Ethn Dis 1992;2(3):207–21.
A Profile of Women

39

124. Beckles GLA, Blount SB, Jiles RB. African Americans.

In: Chronic Disease in Minority Populations. Atlanta:

Centers for Disease Control and Prevention, 1994.

125. McNair LD, Roberts GW. Pervasive and persistent risks:

factors influencing African American women’s HIV/

AIDS vulnerability. J Black Psychol 1997;23:180–91.

126. National Institute on Alcohol Abuse and Alcoholism.

Sixth Special Report to the U.S. Congress on Alcohol and

Health. Washington, DC: Government Printing Office,

1990. (DHHS Publication No. [ADM] 87-1519)

127. U.S. Department of Health and Human Services.

Women and Smoking. A Report of the Surgeon General.

Rockville, MD: U.S. Department of Health and Human

Services, Public Health Service, Office of the Surgeon

General, 2001.

128. Woods NF, Lentz M, Mitchell E. The new woman:

health-promoting and health-damaging behaviors.

Health Care Women Int 1993;14(5):389–405.

129. Institute of Medicine, Committee on Monitoring Access

to Personal Health Care Services. Millman ML, editor.

Access to Health Care in America. Washington, DC:

National Academy Press, 1993.

130. Bashshur R, Smith DG, Stiles RA. Defining underinsurance: a conceptual framework for policy and empirical

analysis. Med Care Rev 1993;50(2):199–218.

131. Ammons L. Demographic profile of health-care coverage

in America in 1993. J Natl Med Assoc 1997;89(11):

737–44.

132. Vistnes JP, Monheit AC. Health Insurance Status of the

U.S. Civilian Noninstitutionalized Population. Rockville,

MD: Agency for Health Care Policy Research, 1997.

(AHCPR Publication No. 97-0030. MEPS Research

Findings No. 1)

133. Weinick RM, Zuvekas SH, Drilea S. Access to Health

Care—Sources and Barriers, 1996. Rockville, MD:

Agency for Health Care Policy and Research, 1997.

(AHCPR Pub. No. 98-001. MEPS Research Findings

No. 3)

134. Moy E, Bartman BA, Weir MR. Access to hypertensive

care. Effects of income, insurance, and source of care.

Arch Intern Med 1995;155(14):1497–1502.

135. Sox CM, Swartz K, Burstin HR, Brennan TA. Insurance

or a regular physician: which is the most powerful predictor of health care? Am J Public Health 1998;88(3):

364–70.

136. Ettner SL. The timing of preventive services for women

and children: the effect of having a usual source of care.

Am J Public Health 1996;86(12):1748–54.

137. Lambrew JM, DeFriese GH, Carey TS, Ricketts TC,

Biddle AK. The effects of having a regular doctor on

access to primary care. Med Care 1996;34(2):138–51.

138. Merrell K, Colby DC, Hogan C. Medicare beneficiaries

covered by Medicaid buy-in agreements. Health Aff

1997;16(1):175–84.

139. Weissman JS, Stern R, Fielding SL, Epstein AM.

Delayed access to health care: risk factors, reasons, and

consequences. Ann Intern Med 1991;114(4):325–31.

140. Waid MO. Brief Summaries of Medicare & Medicaid.

Baltimore, MD: U.S. Department of Health and

Human Services, Health Care Financing

Administration, AHCAG, 1997.

141. Reisinger AL. Health Insurance and Access to Care: Issues

for Women. New York: The Commonwealth Fund

Commission on Women’s Health, 1995.

142. U.S. Bureau of the Census. <http://ferret.bls.census.gov/

macro/031997/noncash/6_000.htm>. Current Population Survey, March 1997. Last accessed March 2001.

143. Newacheck PW, Brindis CD, Cart CU, Marchi K, Irwin

CE. Adolescent health insurance coverage: recent changes

and access to care. Pediatrics 1999;104:195–202.

144. Monheit AC. Underinsured Americans: a review. Annu

Rev Public Health 1994;15:461–85.

145. Short PF, Banthin JS. New estimates of the underinsured younger than 65 years. JAMA 1995;274(16):

1302–6.

146. Brown ER, Wyn R, Cumberland WG, et al. Women’s

Health-Related Behaviors and Use of Clinical Preventive

Services. New York: The Commonwealth Fund

Commission on Women’s Health, 1995.

147. Weisman CS, Teitelbaum MA. Women and health care

communication. Patient Educ Couns 1989;13(2):183–99.
40

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

148. Pendleton DA, Bochner S. The communication of medical information in general practice consultations as a

function of patients’ social class. Soc Sci Med 1980;

14A(6):669–73.

149. Hooper EM, Comstock LM, Goodwin JM, Goodwin

JS. Patient characteristics that influence physician behavior. Med Care 1982;20(6):630–8.

150. Hall JA, Irish JT, Roter DL, Ehrlich CM, Miller LH.

Gender in medical encounters: an analysis of physician

and patient communication in a primary care setting.

Health Psychol 1994;13(5):384–92.

151. McAuley E, Jacobson L. Self-efficacy and exercise participation in sedentary adult females. Am J Health Promot

1991;5(3):185–91.

152. Corbin WR, McNair LD, Carter J. Self-esteem differences among problem drinking males and females. J

Alcohol and Drug Education 1996;42:1–14.

153. McNair LD, Carter JA, Williams MK. Self-esteem, gender, and alcohol use: relationships with HIV risk perception and behaviors in college students. J Sex Marital

Ther 1998;24:29–36.

154. Pender NJ. Health Promotion in Nursing Practice. 2nd ed.

Norwalk, CT: Appleton-Century-Crofts, 1987.

155. Seeman M, Seeman TE. Health behavior and personal

autonomy: a longitudinal study of the sense of control

in illness. J Health Soc Behav 1983;24(2):144–60.

156. Liao KLM, Hunter M, Weinman J. Health-related

behaviors and their correlates in a general population

sample of 45-year-old women. Psychol and Health 1995;

10:171–84.

157. Galanos AN, Strauss RP, Pieper CF. Sociodemographic

correlates of health beliefs among black and white 

community-dwelling elderly individuals. Int J Aging

Hum Dev 1994;38(4):339–50.

158. Rotter JB. Generalized expectancies for internal versus

external control of reinforcement. Psychol Monogr 1966;

80(1):1–28.

159. Institute of Medicine. The Future of Public Health.

Washington, DC: National Academy Press, 1988.

42

CASE STUDIES

Type 1 Diabetes:

At 5:30 p.m. on a weeknight, Sarah gets off her fourth phone call since coming home from school after

track practice. She squeezed in a snack between and during calls. She and three girlfriends have made

plans to go cosmic bowling late on Friday night—a lot of people from school will be there. A friend will

drive. Her parents just got home. Now Sarah will have a quick dinner with her family before leaving

to babysit. After returning, she has to complete her homework and try to get to bed at a reasonable hour.

She will start her day at 5:30 a.m., making sure she has enough time to “look good” before taking the

school bus.

Sarah takes her insulin four to six times a day with meals and snacks, and at bedtime. She tries very

hard to be inconspicuous with her diabetes management, even though she knows that she must consider

her diabetes constantly with every decision and plan that she makes. This routine is fairly automatic

now, since she was diagnosed with type 1 diabetes 12 years ago, when she was 4. Sarah carries her

insulin and glucometer in her backpack. She checks her blood sugar levels before meals, and periodically, four to seven times a day. She gets tired of pricking her fingers.

Sarah knows how important it is to control her blood sugar levels to prevent complications such as kidney failure and blindness. Still, Sarah has mixed feelings sometimes because the better her blood sugar

control is, the more weight she gains. Sarah is heavier than most of her friends, and her clothes don’t fit.

Summertime at the beach is the worst.

Sometimes Sarah is hassled at school for having her syringes. She recalls the policy statement on the

JDRF Web site and the discussion at the ADA-sponsored camp she attended this summer regarding testing and the use of medications in schools. She hopes the policies in her school will change; in the meantime, Sarah has asked her doctor at her appointment today about the possibility of getting an insulin

pump. It would be so much more convenient, and it would probably improve her blood sugar control.

Sarah received her shot for birth control today, so she knows that her blood sugar levels will be more difficult to control for 1 to 2 weeks. She tries not to worry too much about having blood sugar levels that

may be too low or too high. Sarah learns continually how to take care of her diabetes and her health.

Type 2 Diabetes:

LaTonya comes into the house out of breath. She’s wearing sweatpants and a loose shirt. She has been

walking along the road for 45 minutes, alone, avoiding dogs and cars. It was boring; none of her friends

would come along. Hungrily, she looks through the kitchen cabinets, trying to find a snack that will be

low in calories, sugar, and fat; taste great; and also satisfy her appetite. 

It seems that her favorite foods for as long as she can remember have included lots of fat and sugar. It

has been a challenge for LaTonya to introduce new foods and beverages into her daily diet and to ask

her family and friends to support her by buying new foods and learning healthier ways to prepare

favorite foods. The dietitian at the clinic has helped her figure out foods to choose that will help control

her diabetes and work well with her medication and activity schedule.

Since her doctor told her that she had type 2 diabetes last year, near her 13th birthday, she has been

trying hard to lose some weight and to exercise. It has been difficult because she has been heavy as

long as she can remember. Her four younger brothers and sisters are having chips and soft drinks,

watching cartoons in the other room. She’s going to try her hardest to eat only healthy foods tonight

even though her old favorites seemed so flavorful, and her new snack foods taste so plain.
43

3

THE ADOLESCENT YEARS

J.M. Norris, MPH, PhD, G.J. Klingensmith, MD

This chapter presents a summary of data and information in the current literature on diabetes in female

adolescents and women aged 10–19 years. Adolescence

characterizes a time of marked physical and psychological transition for young women. The majority of adolescents who are diagnosed with diabetes in these early

years have type 1 diabetes; recently, however, an

increasing number of adolescents are being diagnosed

with type 2 diabetes. The latter condition is likely to

increase the burden of type 2 diabetes now and for

years to come. This chapter describes the economic,

sociocultural, and environmental context in which

adolescents with diabetes live and the impact of this

disease on the health of adolescents and young women,

including increased mortality, psychosocial and behavioral issues (e.g., eating disorders, insulin manipulation), and frequent hospitalization. The public health

implications of these findings are framed by the three

core functions of public health: assessment, which

includes surveillance and research; policy development;

and assurance. Highlights include discussions on institutional behaviors and other environmental factors

that predispose adolescents to the development of diabetes and its complications. Interagency collaboration

is presented as an important strategy for public health

action.

The primary form of diabetes among children and

adolescents aged 10–19 years is type 1 diabetes, 

formerly known as insulin-dependent diabetes mellitus. Therefore, most data presented in this chapter

refer to type 1 diabetes unless otherwise noted.

Recently, however, research suggests that type 2 

diabetes, formerly called non–insulin-dependent

diabetes mellitus, is emerging as a public health

problem among adolescents, particularly in certain

ethnic subgroups.1

For women, adolescence is a time of transition,

both psychological and physical, which may have a

negative impact on the health of those with diabetes. Psychological changes during adolescence 

may affect how one copes with diabetes and its care

regimen, and the physical changes during adolescence may make it more difficult to control diabetes regardless of the level of adherence to the

diabetes care regimen.

3.1. Prevalence, Incidence, and Trends

Prevalence

In 1990, the estimated prevalence of type 1 diabetes in the United States among persons younger

than 20 years was 1.7 per 1,000.2 Thus, approximately 123,000 persons in this age group have diabetes. Because the risk of diabetes is similar among

boys and girls in this age range, an estimated

61,500 girls younger than 20 years have type 1 diabetes. The prevalence of type 1 diabetes is slightly

higher among white girls than among those of

other races.2 The prevalence of type 2 diabetes

among young persons has not been measured in

most populations. One exception is the Pima

Indians of Arizona, a population at very high risk

for type 2 diabetes; the prevalence of type 2 diabetes among girls increased from 7.2 per 1,000

during 1967–1976 to 28.8 per 1,000 during

1987–1996 among those aged 10–14 years, and

from 27.3 per 1,000 to 53.1 per 1,000 among

those aged 15–19 years during the same time periods.3 The most recent prevalence estimates for the

Pima Indians aged 15–19 years is 50.9 per 1,000, a

rate that stands in sharp contrast to that of 1.7 per

1,000 for type 1 diabetes among those aged 0–19

years. Recent data indicate that type 2 diabetes is
44

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

being diagnosed more frequently among adolescents in other minority groups, and as such, is a

major cause for public health concern.1

Incidence

The incidence of type 1 diabetes among girls aged

10–19 years varies by race and ethnicity.4-7 In the

early to mid-1980s, among white girls aged 10–14

years, the incidence was 22.4 per 100,000 per year.4

This incidence was slightly higher than that among

Hispanic (18.3/100,000/year)4 and black

(8.3/100,000/year)5 girls in the same age group.

However, among girls aged 15–19 years, the incidence of type 1 diabetes was slightly higher among

blacks (10.9/100,000/year)5 than among whites

(8.1/100,000/year) and Hispanics

(7.0/100,000/year).4 In all racial/ethnic groups, the

risk of type 1 diabetes was lower among girls aged

15–19 years than among those aged 10–14 years.4,5

In Chicago, during 1985–1990, the annual incidence of type 1 diabetes in black girls was 22.4 per

100,000 among those aged 10–14 years and 13 per

100,000 among those aged 15–17 years.6 This same

study showed a type 1 diabetes incidence in

Hispanic girls of 15.5 per 100,000 among those

aged 10–14 years and 11.6 per 100,000 among

those aged 15–17 years. In Allegheny County,

Pennsylvania, between 1990 and 1994, the annual

incidence of type 1 diabetes among those aged

10–14 years was 23.6 per 100,000 among nonwhites (includes blacks and other groups) compared

with 24.9 per 100,000 among whites.7 Interestingly,

the type 1 diabetes incidence among those aged

15–19 years was higher in nonwhites compared

with whites (30.4/100,000 versus 11.2/100,000,

respectively). This was seen in both male and

female patients.7

A review of the medical records of children and

adolescents with diabetes at a hospital in Cincinnati

found that the incidence of type 2 diabetes among

girls aged 10–19 years was 9 per 100,000 in 1994.8

In this population, black girls accounted for 69%

of girls with type 2 diabetes but only 9.7% of those

with type 1 diabetes. Incidence of type 2 diabetes

among those aged 10–19 years rose from 1.2 per

100,000 in 1992 to 7.2 per 100,000 in 1994.

Overall, type 2 diabetes accounted for 3%–10% of

new cases from 1982 to 1992, but for 33% in

1994.8

Trends

The incidence of type 1 diabetes varies both seasonally and yearly. In the United States, the incidence

of type 1 diabetes declines during the warm summer months.4-7 Because this seasonal pattern occurs

only among school-aged children, it suggests that

factors related to attending school (e.g., infections,

stress) may be related to the etiology or clinical

diagnosis of type 1 diabetes.

A subsequent report from Allegheny County,

Pennsylvania, suggests that there is an epidemic of

diabetes in nonwhite adolescents.7 The incidence

among nonwhites aged 15–19 years during

1990–1994 (30.4/100,000) was more than 2 times

higher than during 1985–1989 (13.8/100,000) and

more than 3 times higher than during 1980–1984

(7.6/100,000). The dramatic increase was not seen

in whites. The authors did not give sex-specific data

so it is unclear whether boys and girls had similar

increases. This epidemic of diabetes may be either

the result of an increasing incidence of type 1 diabetes among nonwhites or of another type of diabetes, such as type 2 diabetes, that has been

misclassified as type 1 diabetes.7 Data from Chicago

did not show an increasing incidence of type 1 diabetes in either black or Hispanic girls aged 0–17

years between 1985 and 1990.6

The incidence of adolescent type 2 diabetes appears

to be increasing over time among both boys and

girls. In the Cincinnati study, the rate of type 2 diabetes among adolescents increased 10-fold between

1982 and 1994, from 0.7 per 100,000 to 7.2 per

100,000.8

3.2. Sociodemographic Characteristics

Of adolescent girls with type 1 diabetes in the

United States, 92% are white, about 4% are black,

and the remaining 4% are Hispanic or Asian

American.9 This racial distribution is very different

from that of adolescent girls with type 2 diabetes;
The Adolescent Years

45

in the Cincinnati study, 69% were black, and the

remainder were white.8

Type 1 diabetes is thought to result from the interaction between genetic susceptibility and exposures

that can cause diabetes. (See Section 3.4.) Some, if

not all, of the genetic predisposition for type 1 diabetes lies in the possession of the human leukocyte

antigen markers DR3 and DR4. Differences in the

frequency of these high-risk genetic markers in ethnic and racial groups in the United States may

explain, in part, the racial/ethnic disparities in the

distribution of type 1 diabetes.10

The majority of girls with diabetes live in (24%) or

just outside (52%) a metropolitan area.9,11 The education of adolescent girls with diabetes resembles

that of the general population of adolescent girls

without diabetes9 but specific data are not

available.11 Data on the marital status, employment,

and personal income of adolescent girls with diabetes are also not available. The education and

income distribution of the families of adolescent

girls with diabetes resembles that of the general

population.9,11 Data on the socioeconomic status of

American Indian adolescent girls with diabetes are

not available. However, given that American Indian

families are more likely to live below the poverty

level than are families in the general U.S. population (27% versus 10%),12 American Indian adolescent girls with diabetes are more likely to be living

in poverty than are girls with diabetes in the general

population.

3.3. Impact of Diabetes on Health Status

Complications of Diabetes: Type 1

Adolescent girls with type 1 diabetes are at risk for

both acute and chronic complications; acute complications are more common and have greater

impact. Diabetic ketoacidosis is the most prevalent

acute complication and commonly occurs at the

onset of type 1 diabetes. Its underlying cause is

insulin deficiency. In a cohort of children and adolescents aged 9–16 years with diabetes who were

monitored for 8 years, 30% of the girls had at least

one episode of ketoacidosis.13 Episodes are characterized by excessive thirst and urination followed by

nausea and vomiting. If untreated, diabetic ketoacidosis can lead to coma and death.

Hypoglycemia, another acute complication of diabetes, may range from very mild lowering of blood

glucose levels with minimal or no symptoms to

severe hypoglycemia resulting in very low glucose

levels, nerve damage, coma, and death if not treated. Estimates of the incidence of hypoglycemia vary

because different glucose levels have been used to

define cases. In the same cohort of children and

adolescents aged 9–16 years cited above, 21% had

at least one episode of hypoglycemia, and adolescent boys (26%) were more likely to have hypoglycemia than adolescent girls (7%).13

The chronic complications of diabetes include eye

disease, kidney disease, nerve damage, heart disease,

and circulatory problems. Diabetic eye disease, or

retinopathy, is characterized by alterations in the

small blood vessels of the retina. The most severe

form of diabetic retinopathy, proliferative diabetic

retinopathy, can lead to blindness if untreated.14 By

age 20, 40%–60% of persons with diabetes have

some retinopathy, and 2% have the more severe

proliferative diabetic retinopathy.14-16 At least one

study has found that adolescent girls have a higher

risk of progressing to proliferative retinopathy than

adolescent boys.17 Although the presence of

retinopathy among adolescents is usually asymptomatic, it is a predictor of proliferative retinopathy

and future vision loss if untreated.

Diabetic kidney disease, or nephropathy, is diagnosed by measuring albumin levels in the urine.

Microalbuminuria, or low levels of albumin in the

urine, is a precursor to proteinuria (macroalbuminuria), or high levels of urinary protein. Persistent

proteinuria signals a decline in renal function that

leads to end-stage renal disease, a relatively common cause of death among persons with type 1 diabetes. Almost 22% of adolescents with diabetes

have some form of albuminuria: 18% have microalbuminuria, and 4% have persistent proteinuria.18
46

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

Among 164 adolescents with diabetes, adolescent

girls were nearly 60% more likely than boys to

develop microalbuminuria after 8 years of followup (24% and 15%, respectively).19 However, a separate study of the progression of microalbuminuria

among adolescents (mean age 17 years) with type 1

diabetes found no difference between girls and boys

in the risk of progression of microalbuminuria.20

The presence and progression of both nephropathy

and retinopathy are associated with sustained

hyperglycemia.14,16,20-23 The higher prevalence of both

diabetic retinopathy and nephropathy among adolescent girls than among boys may be related to the

difficulties that adolescent girls have in maintaining

diabetes control during puberty or to the earlier

onset of puberty in girls.24

A significant comorbidity of diabetes in adolescence

is periodontal disease, a condition rarely otherwise

seen during adolescence.25,26 Periodontal disease typically coincides with the onset of puberty among

children with type 1 diabetes. Hormonal changes,

particularly in young women with diabetes, appear

to trigger this onset.25

The prevalence of periodontal disease among adolescents with diabetes is 11%–16% compared with

1% in the adolescent population at large.25 It is easier to attribute dental disease to diabetes in this life

stage because in the general population, the occurrence of such illness is typically more common at

older ages.26

The adolescent years are characterized by the rapid

physical growth and hormonal changes of puberty,

which can affect diabetes management. During this

time, increasing insulin resistance and associated

physiological changes make diabetes control more

difficult.27 The difference between adolescents and

adults with diabetes was clearly shown in the

Diabetes Control and Complications Trial

(DCCT), in which the average hemoglobin A1c (a

measure of long-term blood glucose control) of

adolescents was significantly higher than that of

adults who were receiving the same care.28 In addition to the hormonal changes complicating diabetes

management, the adolescent years are marked by

psychological changes. Adolescents are establishing

independence from their family, and peer relationships become more important. Adolescent pressures

to conform to peer standards may interfere with

routine diabetes management and the planning

constraints that diabetes care requires. Moreover,

although adolescents may intellectually understand

the relationship between current diabetes management and long-term health, translating this knowledge into consistent day-to-day behavior is difficult

for teens and young adults.29

The DCCT has suggested that intensive therapy to

control glucose levels in adolescents effectively

delays the onset and slows the progression of both

diabetic retinopathy and nephropathy.28 Unfortunately, intensive therapy doubles a person’s risk of

becoming overweight. The increased risk of weight

gain could hinder adherence to this regimen, particularly among adolescent girls.

Although research regarding the full array of complications of type 1 diabetes is necessary for adolescent populations, it will be equally important to

know the type of diabetes that causes them. This

distinction is important because misclassification of

type 2 as type 1 appears to be common.1

Complications of Diabetes: Type 2

Among black and Hispanic adolescents, the onset

of type 2 diabetes often resembles that of type 1.1

Complications among children with type 2 diabetes

will closely resemble those complications associated

with type 1: retinopathy and nephropathy as well as

cardiovascular disease and neuropathy. However, it

is instructive to note that type 2 diabetes is expected to mirror type 1 in outcomes, such as limitations

on usual activities, school absences, days spent in

bed, use of medications, hospitalization, and

increased physician contacts.1

Risk of Death

Between 1960 and 1980, the mortality rate among

girls aged 10–19 years with type 1 diabetes was
The Adolescent Years

47

1.92 per 1,000 person-years, which is almost 5

times greater than the mortality rate of the general

population of girls in this age group.30 More recently, a Swedish study reported the mortality rate

among adolescent girls with diabetes to be 0.49 per

1,000 person-years, which still represents a 2.5-fold

increased risk of death.31 Another study has estimated that the life expectancy of a person aged 10–19

years with diabetes will be reduced by 17 years.32

Fifty percent of the deaths among adolescents with

diabetes are due to acute complications, some of

which occur at the onset of the disease. Other 

causes of death in this age group are causes unrelated to diabetes (31%), other diabetes complications

(9%), kidney disease (5%), and cardiovascular disease (5%).30

Adolescent girls have been found to have a significantly greater risk than adolescent boys of dying of

ketoacidosis at the onset of type 1 diabetes.33 An

early study of persons with type 1 diabetes diagnosed between 1965 and 1980 reported that 8 persons died at the onset of diabetes. All of these

persons were adolescents (aged 8–17 years), and 7

of the 8 were girls.33 These results parallel those of

another study from the same research center that

suggested that the onset of diabetes was more severe

among girls than boys.34 However, reasons for this

more severe onset in girls were not clear. Moreover,

this difference may no longer exist. A more recent

study found no difference between adolescent boys

and girls in deaths at onset.31

Hospitalizations

Persons with diabetes are more likely to be hospitalized than persons without diabetes. Reasons for

hospitalization are primarily related to treatment

and metabolic control and to complications of diabetes, most commonly kidney disease, eye disease,

stroke, and ischemic heart disease. A review of

national survey data found that among U.S. girls

and women younger than age 20, diabetes was listed on the hospital discharge record for approximately 25,000 hospitalizations per year and was the

primary reason for almost 20,000 of these 

hospitalizations. The average hospital stay was 5

days.35 In a separate study, girls aged 10–14 years

with diabetes were 8 times as likely to be admitted

to the hospital and had 6 times as many days in the

hospital as girls without diabetes. Girls aged 15–19

years with diabetes were 3 times as likely to be hospitalized and had 3 times as many days in the hospital as girls the same age without diabetes.36

Until recently, children and adolescents were routinely hospitalized when type 1 diabetes was diagnosed, primarily to stabilize their glucose levels and

provide diabetes education. In the past 20 years,

however, many health care providers have been

using outpatient management at the time of diagnosis.37 This trend has reduced hospitalization costs

and lessened disruption to the child and family.

Hospitalizations after onset of diabetes were also

frequent among children and adolescents until

recently. A 1982 study found that 39% of girls aged

10–19 years with preexisting diabetes had one or

more hospital admissions within a year. Poor metabolic control and infection accounted for over 50%

of these hospital admissions.38 With the advent of

home blood glucose monitoring and outpatient

educational programs, the need for hospitalization

to improve metabolic control has decreased.38-40

From 2% to 10% of all hospitalizations for diabetes

are attributed to diabetic ketoacidosis.41 Rates of

hospitalization for diabetic ketoacidosis are higher

among children and adolescents than among adults.

The annual incidence of hospital admissions for

diabetic ketoacidosis among children younger than

15 years is 53.6 per 1,000.42 In a study of adolescents aged 15–18 years, girls of all races had more

diabetes hospitalizations than did boys, primarily

due to diabetic ketoacidosis.43 The researchers speculated that compared with young men, young

women may have more frequent high-risk behaviors

(e.g., low levels of physical activity, insulin omission, or disordered eating), and be less likely to

comply with medical treatment, be more likely to

have biologic factors that negatively affect glucose

control. These issues are discussed later in this

chapter.
48

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

Several studies have suggested that diabetic adolescents of lower socioeconomic status may be at

increased risk for hospitalizations.38,43-45 A Rhode

Island study found that diabetic adolescents living

in poverty had a higher frequency (71%) of readmission to the hospital than adolescents in all other

socioeconomic groups.38 The authors speculated

that children in poverty may have difficulty practicing effective self-care or interacting with health care

providers. 

Risk of hospitalization is also associated with emotional and behavioral problems in adolescent girls

with diabetes, suggesting that they may be demonstrating high-risk behaviors resulting in poor metabolic control.40,46

Based on available data,30,31,36 estimates of population attributable risk fractions suggest that eliminating diabetes from the U.S. adolescent population

would eliminate 2.5%–6.3% of the deaths and

3.2%–10.5% of the hospitalizations in this age

group.

Disabilities

Because adolescents with diabetes have generally

had the disease for a relatively short time, physical

disabilities associated with type 1 diabetes are rare

among adolescents. However, diabetes can have a

psychological impact on adolescents—particularly

adolescent girls—that may result in mental health

disabilities. However, of the three studies to examine this issue, only one addresses girls specifically.

One study of school performance found that adolescents with diabetes performed more slowly on a

series of visual-motor tasks and had lower scores on

tests of reading, spelling, and arithmetic than adolescents without diabetes.47 This disparity could be

due to more absences from school among adolescents with diabetes or to a diabetes-related impairment of psychosocial development, cognitive

functioning, or even visual impairments. Another

study found selective impairment in cognitive functioning among adolescents (aged 10–19 years) with

diabetes, particularly among those who were

younger than age 5 when diabetes was diagnosed

and those with poor metabolic control.48 A third

study suggested that girls may be more likely than

boys to have impaired cognitive functioning: adolescent girls with diabetes performed more poorly

on several neuropsychological measures and had

poorer verbal intelligence scores than adolescent

boys with diabetes.49

Depression is another risk factor for adolescents

with diabetes, particularly girls. Twelve percent of a

cohort of adolescents with diabetes described themselves as “possibly depressed.”50 In this study, and in

a study of adolescent girls with diabetes, the prevalence of depression was associated with the level of

self-esteem.50,51 In another study of adolescents with

diabetes, girls were found to have a higher rate of

depression and anxiety than boys.52 Because these

studies did not include adolescents without diabetes

for comparison, it is unclear whether this prevalence is higher than in the general population.

However, studies that have compared the mental

health of adolescents with diabetes with that of

adolescents in the general population show conflicting results. In one study, adolescents with diabetes

experienced more depression, dependency, and

withdrawal than those without diabetes.53 However,

their overall self-perceived competence in multiple

areas and their peer relationships were not different

from those of other adolescents. A second study

found that psychiatric disorders, such as somatic

symptoms, sleep disturbances, compulsions, and

depressive moods, were more prevalent among adolescent girls with diabetes than among those without diabetes;54 however, these findings did not hold

true in another study.55 Adolescent girls with diabetes have also been shown to have higher rates of

suicidal ideation than girls without diabetes.56 The

higher depression rates among adolescent girls with

type 1 diabetes may not be related to diabetes itself

but rather to the increased strain of having a chronic disease.57

Two studies of the impact of diabetes on adolescents’ quality of life found that both adolescent
The Adolescent Years

49

girls and boys with diabetes were generally satisfied

and not worried, and that diabetes had only a modest impact on their lives.58,59 However, other studies

have found that adolescents view diabetes as a controlling or limiting factor in their lives and a threat

to their health status and their future.60 Adolescents

have reported that dietary restrictions and the need

to inject insulin and test blood make them feel

alienated from their peers.61 At least two studies

have found that adolescent girls report a more negative impact of diabetes on their lives than do adolescent boys.61,62 However, whether this finding

reflects a sex difference in the severity of the disease

or in the perception of its impact is not clear.

3.4. Health-Related Behaviors

Environmental Exposures

Several environmental exposures have been examined as potential causes of diabetes. At least one

study has suggested that lack of breast-feeding and

early introduction of cow’s milk protein may

increase a child’s risk for type 1 diabetes,63 but contradictory findings have been reported.64,65

Childhood diets high in cow’s milk protein, cereal

protein, and total protein have been associated with

increased risk for type 1 diabetes.66,67 Although consumption of nitrates, nitrites, or nitrosamines during childhood has been associated with type 1

diabetes,67-69 these findings have also been contradicted.66 Coffee,70 sugar,71 and milk consumption72

are positively correlated with type 1 diabetes rates:

countries that consume the greatest amounts of

these foods also have the highest rates of type 1 diabetes. Studies suggest that exposure to picornaviruses,73 herpes viruses,74,75 mumps,76 rubella,77 and

retroviruses78 may also trigger type 1 diabetes in

children and adolescents. Finally, negative events in

the first 2 years of life, events that result in difficult

adaptation, deviant behavior during childhood, and

a chaotic family life have been associated with an

increased risk for type 1 diabetes in children and

adolescents.79-81

Although lifestyle choices, such as smoking and

physical inactivity, do not appear to play a role in

the development of type 1 diabetes, they may affect

a person’s risk for the long-term complications of

the disease. The three health risk factors that have

the greatest negative impact on persons with diabetes are smoking, obesity, and insufficient physical

activity. In addition to being risk factors for the

complications of type 1 diabetes, obesity, a high-fat

diet, and lack of physical activity have been identified as risk factors for type 2 diabetes among

adults82 and may increase an adolescent’s risk for

type 2 diabetes.

Smoking

Tobacco use continues to be a health risk in all segments of society. Among high school students, the

prevalence of cigarette smoking is 30%–40%.83

Among high school girls, the prevalence of tobacco

use is significantly lower among blacks (12.2%)

than among non-Hispanic whites (39.8%) and

Hispanics (32.9%).83

Tobacco use, particularly cigarette smoking, has

been shown to increase the risk for cardiovascular

disease in the general population. Both persons

with type 1 and those with type 2 diabetes have an

increased incidence of cardiovascular events, including circulatory problems and heart disease.84 Many

studies have shown that, among persons with type

1 diabetes, smoking increases the risk of death

attributable to cardiovascular disease and may also

increase the incidence of microvascular disease,

including nephropathy and retinopathy.85-87

Because of these increased risks, persons with diabetes have even more reason than the general population to refrain from using tobacco. However, most

studies have not documented a lower prevalence of

tobacco use among adolescents and young adults

with diabetes than among those without diabetes.88

The 1988 Behavioral Risk Factor Surveillance

System found that the prevalence of smoking was

actually greater among persons aged 18–34 years

with diabetes (33.1%) than in the general population (28.7%).89 Similarly, a study of young adults

(average age 21 years) with diabetes at the

University of Liverpool reported that patients
50

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

whose diabetes developed before age 10 were as

likely to smoke as those whose diabetes developed

in adolescence or young adulthood.88 The median

age for initiating smoking was 16 years and also did

not differ by age at onset of diabetes. In addition,

this study found that only 31% of the patients

admitted to smoking when questioned, whereas

48% had evidence of recent tobacco use from their

urinalysis. This finding suggests that, regardless of

smoking history, all young persons with diabetes

should be counseled on the adverse health risks of

tobacco use and should be given information about

smoking cessation programs.

In addition to increased cardiovascular risks,

increased acute illness has been documented among

teens who are smokers. One study found that teens

who smoked were 2 times more likely than teens

who did not smoke to have been hospitalized and 3

times more likely to spend the day in bed. In addition, 24% of smokers but only 8% of nonsmokers

reported themselves to be in poor health.89 Data

specifically for adolescents with diabetes were not

available. However, multivariate analysis suggests

that 50%–75% of the excess illness among young

smokers with diabetes is related to the interaction

between smoking and diabetes.89 It is not clear

whether this excess illness is a direct effect of smoking or whether smoking is an indicator of increased

risk-taking behavior and poor compliance with diabetes-related management. In either case, tobacco

use remains an identifiable risk factor for diabetesrelated illness and death.

Obesity

The prevalence of obesity is increasing among the

general population and among children and adolescents.90,91 The National Health and Nutrition

Examination Surveys of the U.S. population

(NHANES I, II, and III) have documented increases in the prevalence of overweight and obesity in all

segments of the population, including adolescent

girls.91-94 The percentage of female adolescents at or

above the 85th percentile for age increased from

15.8% in NHANES II (1976–1980) to 22.7% in

NHANES III (1988–1994).91 Black girls are 

disproportionately affected: 8.8% of all girls aged

12–18 years but 14.4% of black girls this age are in

the very obese group. Thus not only are a greater

percentage of adolescents overweight, but the

degree of obesity has also increased, especially

among girls of racial/ethnic minorities.

Obesity and type 1 diabetes. Adolescents with type 1

diabetes are at risk for excessive weight gain. Use of

intensified insulin therapy carries with it an

increased risk for weight gain,28 which may contribute to an increase in the prevalence of obesity

and increased body mass index (BMI) among adolescents with type 1 diabetes.95 The DCCT suggested that a weight gain of 8–10 pounds per year was

associated with intensified management.96 Providing

adolescents with dietary counseling before they

begin and during therapy may be essential to the

success of intensive diabetes management.

Persons with type 1 diabetes who attempt weight

loss through standardized weight-loss programs

have approximately the same success rate as the

general population.95 Weight management programs

that improve body image and increase self-confidence and self-esteem may allow teens to practice

better overall diabetes management.95

Obesity and type 2 diabetes. Type 2 diabetes is

caused by insulin resistance in combination with

decreased beta cell ability to respond to increasing

hyperglycemia. Because obesity is associated with

increased insulin resistance,97 the increased prevalence of obesity among adolescent girls may play an

important role in the dramatic increase in the incidence of type 2 diabetes among adolescents that

began in the early 1990s.8,98-102 In a Cincinnati

study,8 as many as 30% of adolescents whose diabetes was diagnosed in 1994 lacked evidence of islet

cell autoimmunity and had a high BMI suggestive

of type 2 diabetes rather than type 1 diabetes. In

contrast, only 4% of teens whose diabetes was diagnosed in 1982 were considered to have type 2. This

increase is consistent with the higher incidence of

type 2 diabetes among adults and is thought to be

related to the increasing levels of obesity in the U.S.
The Adolescent Years

51

population.90,97,103 Black, Hispanic, and American

Indian youth are overrepresented among adolescents with type 2 diabetes, just as they are among

obese adolescents.8,100,101 However, factors other than

obesity may determine risk for type 2 diabetes.97

Insufficient Physical Activity

Dietary evaluation of obese persons with type 2

diabetes suggests that their caloric intake is not

markedly different from that of persons who are

not obese.104 However, persons who are not obese

expend significantly more calories than obese persons. A study of the Pima Indians that explored the

association between physical activity and risk for

diabetes found that persons who had diabetes by

age 35 reported having had significantly less leisuretime physical activity during their teenage years

than those without diabetes.105 Women with diabetes reported only 1 hour of leisure-time activity

per week between the ages of 12 and 18 years, but

those without diabetes reported 2–3 times as much

activity. This study suggests that relatively minor

increases in leisure-time activity, particularly among

teenaged girls, may markedly decrease the risk for

type 2 diabetes in adulthood. The importance of

insufficient physical activity as a risk factor for type

2 diabetes appears to be related to the increased

insulin resistance found in persons with low levels

of physical activity.27

Adolescent girls with type 1 diabetes can also benefit from increased physical activity. Increased physical fitness improves insulin sensitivity and increases

cardiovascular fitness.29 Although much of the educational information given to patients with type 1

diabetes stresses the importance of exercise,106 some

studies suggest that young people with type 1 diabetes may not exercise as much as their agematched peers without diabetes.29 The reasons given

by patients for the lower level of exercise were

weather constraints, inadequate time, and difficulty

of exercise.

Among adults of all racial and ethnic origins,

women are much less likely than men to participate

in regular or vigorous physical activity.107 This sex

difference is apparent by the start of high school83

and increases markedly through the 12th grade.

Among 12th-grade girls, only 9.1% of blacks but

18.8% of non-Hispanic whites and 20.9% of

Hispanics report participating in vigorous physical

activity 3 or more times a week. Participation rates

for 12th-grade boys were 42.3% for blacks, 46.1%

for whites, and 46.4% for Hispanics. These cultural

differences in participation in vigorous physical

activity need to be considered in planning strategies

to engage girls with diabetes in physical fitness programs.

Pregnancy

The birth rate for teens has been dropping steadily

throughout the 1990s.108 Nevertheless, many teens

choose to become sexually active, and their risk for

pregnancy should be addressed by their health care

providers.109 The appropriate time to begin discussions about responsible family planning and the

impact of diabetes on pregnancy and childbearing

is during the middle school years as adolescent girls

mature and experience menarche. This discussion

can be quite positive, emphasizing the likelihood of

a future normal pregnancy and of the birth of a

healthy baby, if careful attention is paid to diabetes

control prior to and throughout the pregnancy and

delivery.110 It is helpful to the adolescent and her

parents to hear this discussion because popular culture often presents childbearing in a woman with

diabetes as being difficult or impossible.

For the teen who chooses to be sexually active, confidential counseling on appropriate birth control or

referral for these services should be part of the diabetes health care team’s routine practice.109 The

importance of preconception counseling cannot be

overemphasized to the teen, as well as the need for

early notification of the diabetes health care team

when an unplanned pregnancy is suspected. The

risk of congenital anomalies in the offspring is

reduced 10-fold by careful diabetes management in

the 3 months prior to and during pregnancy.110 The

care of the pregnant patient with diabetes is one of

the major recent advances in diabetes care, and the

adolescent patient should be made aware of the
52

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

importance of intensified diabetes management

during this time of her life so she and her unborn

child can benefit from this new information.

Adherence to Diabetes Management Tasks

As mentioned earlier in the chapter, the adolescent

years are characterized by the rapid physical growth

and hormonal changes of puberty, which can affect

diabetes management. During this time, increasing

insulin resistance and associated physiological

changes make diabetes control more difficult.111

Care for both type 1 and type 2 diabetes has

become more complex as practitioners have

addressed issues raised by the DCCT. Patients with

type 1 and type 2 are increasingly asked to monitor

their blood glucose 3 or 4 times a day and to

administer insulin 2 to 4 times a day. Recent surveys have shown that patients are responding to this

advice by increasing the frequency of blood testing

and insulin injections; however, most patients with

type 1 diabetes still monitor their blood glucose

fewer than 4 times per day and take only 2 doses of

insulin per day.112 Patients are also given a meal plan

designed to provide a constant carbohydrate intake

and consistency in meal timing. Those patients who

are striving for more intensified diabetes management are encouraged to learn the associations

between food intake, exercise, and insulin dose and

their effects on blood glucose levels and to adjust

their diabetes management accordingly throughout

the day to achieve near-normal blood sugar levels.28

Although mastery of these complex algorithms can

improve diabetes control, complying with such a

complicated regimen is difficult for even the most

sophisticated and mature adult. The spontaneity

and impulsiveness of adolescence compound the

difficulties of compliance.

Studies have shown that knowledge correlates poorly with adherence to medical recommendations,113

and this finding holds true for adolescents with diabetes.114 Concrete objectives, such as insulin administration and self-monitoring of blood glucose, are

considerably easier to comply with than the more

complex behavioral lifestyle changes required for

appropriate dietary and exercise programs.115-117

However, studies show that adolescents with diabetes have difficulty consistently complying with

insulin administration.118,119 In one such study, a

questionnaire completed anonymously by adolescents and their parents attending a diabetes clinic

for a routine diabetes evaluation demonstrated that

25% of adolescents had missed at least one insulin

injection in the 10 days preceding their clinic

visit.118 Almost 80% of the adolescents reported

some mismanagement of their blood glucose monitoring, including altering the test strip to produce a

lower blood glucose number, making up a test

result rather than doing the test, or replacing a test

result that was considered too high. Additionally,

over 80% had eaten inappropriate foods at least

once, and more than half had missed a meal or a

snack at least once during the 10 days before the

visit. Researchers did not obtain information about

exercise and appropriate management of exercise.

However, as teenagers are increasingly asked to

adjust their caloric intake for activity, mismanagement of exercise is likely to be as common as mismanagement of dietary intake and blood glucose

monitoring. The risks of diabetes mismanagement

increase as adolescents become older and generally

have more responsibility for their own diabetes

management.40,119 These findings underscore the

importance of a gradual transition of diabetes management from parents to adolescents and of continued comanagement until independent management

can be successfully established.52,119

There is a dearth of data on adherence to diabetes

management plans. However, limited data indicate

that glycemic control after diagnosis is typically

poor, as evidenced by mean glycated hemoglobin

values of 10% to 13%.1 Among Pima Indian children and adolescents, microvascular disease

(microalbuminuria) and cardiovascular risk factors

(e.g., hypercholesterolemia, elevated blood pressure)

were already common at diagnosis and the prevalences were higher at the 10-year follow-up.120

Teens who adhere to diabetes regimens have been

shown to have higher self-esteem and greater 
The Adolescent Years

53

confidence in their ability to accomplish diabetes

management tasks.119 This issue is particularly relevant to adolescent girls, since adolescence is a time

when girls are more susceptible to feelings of low

self-esteem and incompetence. Some research findings suggest that participation in activities such as

team sports and diabetes camps may increase feelings of self-worth and competence among young

women and may improve adherence to diabetes

routines, including diet plans and exercise recommendations.

Recurrent Episodes of Ketoacidosis

A small subset of persons with diabetes have recurrent episodes of diabetic ketoacidosis. The risk for

this syndrome is greatest among adolescents, is

more common among women than men, and is

associated with living in a single-parent home, with

a stepparent, or outside the immediate family

home.40,44,121,122 Other risk factors are abusing drugs

or alcohol or having a parent who does so, receiving

public assistance, and being older than 14 years. No

physiological factors are known to contribute to

this syndrome.40,44,121,122 Because these episodes of

ketoacidosis generally resolve when an adult

assumes responsibility for monitoring the adolescent’s blood glucose levels and administering insulin

doses, they are most likely caused by diabetes mismanagement.118,121,122 The risk for recurrent episodes

of ketoacidosis has also been shown to decrease

when the adolescent is cared for by a multispecialty

team that comprises a nurse educator, a dietitian, a

counselor, and the diabetes physician.44,121 In addition, frequent outpatient contact can decrease the

hospital readmission rate for ketoacidosis among

adolescents.44,121

Extreme inattention to the essentials of diabetes

care during adolescence, as evidenced by recurrent

ketoacidosis or recurrent severe hypoglycemia, is an

indicator of excessive risk for the early development

of diabetes complications and death. One study

monitored 26 persons who had had recurrent diabetic ketoacidosis as adolescents (case patients) and

compared them with a group matched for age and

diabetes duration (control patients).123 After 10.5

years of follow-up, 5 case patients had died of diabetes-related disorders (2 of diabetic ketoacidosis, 2

of hypoglycemia, and 1 of end-stage renal disease).

No diabetes-related deaths were reported in the

control group. Sixty-seven percent of the surviving

case patients but only 25% of control patients had

diabetes-associated complications.

Two of the case patients continued to have frequent

diabetic ketoacidosis. Of the 28 pregnancies among

the case patients, 13 (46%) involved complications,

compared with 2 (7%) of the 27 pregnancies

among the control group. Overall, case patients

reported a lower quality of life than the control

group. A separate 20-year follow-up study reported

similar findings.124 These studies point to the need

to identify adolescents at risk for recurrent episodes

of diabetic ketoacidosis or hypoglycemia and to

develop effective intervention strategies to decrease

the risks for acute illness, long-term complications,

and death.

3.5. Psychosocial Determinants of Health

Behaviors and Health Outcomes

Social Environment

Family and social support are important determinants of health behaviors and health outcomes of

adolescents with diabetes. A child’s diabetes has

wide-ranging effects on the family. When a child’s

diabetes is diagnosed, parents have to come to

terms with their child’s loss of health and the medical concomitants of diabetes, such as episodes of

hypoglycemia, hyperglycemia, ketoacidosis, and

hospitalizations. Shock, bewilderment, anxiety, fear,

insomnia, depression, and guilt are common immediate reactions of parents to the diagnosis of a

child’s diabetes. In general, most of these parental

feelings resolve during the first year after diagnosis.125 However, both maternal depression and overall emotional stress have been shown to increase

over time.45 One study found that families of adolescents with diabetes rated their general functioning to be worse than did families of healthy

adolescents.126 Another study suggested that an adolescent daughter’s diabetes was perceived to draw

the whole family closer but to have a negative effect

on the spousal relationship.127
54

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

Few childhood diseases rival diabetes in the high

degree of family involvement needed for day-to-day

management: the regimen for daily diabetes care

involves injections of insulin, monitoring of blood

glucose levels, and changes in the composition and

timing of the child’s diet. For young children with

diabetes, family members, primarily mothers,

assume responsibility for diabetes care and continue

to be involved in some aspects of care throughout

adolescence. Adolescence is a particularly sensitive

time because it marks the transition from family

responsibility to adolescent independence. By age

13, most teenagers with diabetes can perform all

regimen-specific tasks; however, they continue to

need parental supervision and support to ensure

that they adhere to the regimen and to assist them

in solving diabetes management problems. Parents

tend to give more responsibility for diabetes care to

adolescent girls than to adolescent boys.128 However,

adolescents who have the most responsibility for

their diabetes regimen have been shown to have the

poorest diabetes control.129 This finding may

explain, in part, why adolescent girls have more

problems with diabetes control than adolescent

boys24 and why better communication between adolescent daughters and their mothers is associated

with better adherence to diabetes care.130 Other

family characteristics that influence adolescents’

adherence to the diabetes regimen include family

cohesion, parents’ perception of family organization,131 family communication,128 and overall quality

of family life.132

In addition to family support, social support is a

critical factor in facilitating motivation and normal

development and in helping adolescents with diabetes cope with an otherwise unpredictable and

confusing situation.133 Role models are a major

form of social support. One study showed that adolescents improved their attitudes toward diabetes

when they were able to interact with an adult with

diabetes.134 A relationship with an empathetic,

respected adult who has successfully dealt with diabetes and built a life and career without allowing

diabetes to interfere appears to alleviate the adolescent’s sense of doom.

The support of friends and peers is also important

to adolescents with diabetes. Although adolescents

have reported that family members provide more

support for their diabetes care than friends, they

have also reported that family members and friends

provide comparable levels of support for physical

activity and that friends are more important than

family members in helping them feel good about

diabetes.135

Networks focusing on diabetes care seem to have a

positive impact on adolescents with diabetes. The

implementation of a comprehensive diabetes care

network for adolescents reduced the frequency of

diabetic ketoacidosis in one intervention study.121

For adolescents, networks are largely made up of

family and friends. Schools could also act as an

important network for adolescents. Parents of children with diabetes have voiced their concern over

the poor liaison they have with schools and teachers’ lack of diabetes knowledge.136

Legal Environment

On occasion, the lack of knowledge on the part of

school administrators and faculty has resulted in

discriminatory practices affecting young people

with diabetes, necessitating legal remedies to ensure

educational access and accommodation of the needs

of adolescents with diabetes.

Although adolescents with diabetes have a right to

“free, appropriate public education,”137 as established through the Rehabilitation Act of 1973, the

Americans with Disabilities Act and the Individuals

with Disabilities Education Act litigation has sometimes been required to ensure that children are safe,

adequately trained faculty can address diabetes

emergencies, and reasonable accommodation for

diabetes management needs is provided.137 Plans to

ensure access and accommodation must be individualized to reflect the needs of the person with diabetes as well as the educational environment. That

said, in school settings, minimum standard requirements specific to diabetes are generally lacking.
The Adolescent Years

55

Interactions with the Health Care System

Access to care. Although families with and without a

child with diabetes have similar health insurance

coverage, the cost of health care is greater for families of a child with diabetes. In one study, out-ofpocket health care expenses for families of a child

with diabetes were 49% higher than for families of

nondiabetic children.138 In addition, working parents of a child with diabetes were twice as likely to

be absent from work for reasons related to child

care and health.138 Another study found that

10%–30% of families of a child with diabetes

received no health insurance reimbursement for the

cost of insulin, syringes, or blood testing strips.139

Because the management of diabetes requires frequent blood glucose testing as well as regular contact with health care professionals, lack of coverage

for blood glucose testing supplies and copayments

represent barriers to health care, even for fully

insured persons. Seventeen percent of families of a

child with diabetes had out-of-pocket expenses that

exceeded 10% of their income. Total family health

care expenses as a share of household income were

50% higher for families of a child with diabetes

than for families of a child without diabetes.139 The

higher out-of-pocket expenses are more detrimental

to families of low socioeconomic status. And, of

course, families without any health insurance face

the greatest barriers to proper diabetes management

and control.

Patient/provider relationship. Among teenagers with

diabetes, the patient/provider relationship involves

the parents as well as the physician and the patient.

The patient/provider relationship strongly influences the amount of diabetes education the adolescent receives, the likelihood that the adolescent will

keep diabetes care appointments, and the adolescent’s general acceptance of the disease. A national

survey suggested that over 90% of parents were satisfied with the treatment and information that they

and their child had received at diagnosis.136 A separate study found that after diagnosis, parents of

adolescent girls had favorable attitudes toward the

physician’s personal qualities and professional competence and had neutral attitudes toward the cost

and convenience of health care.140 The teenaged

girls were even more satisfied than their parents

with the physician’s personal qualities. Girls in families who were satisfied with the physician’s professional competence adhered better to the diabetes

self-care regimen. In addition, the girls who were

satisfied with their physician’s professional competence had fewer diabetes-related hospitalizations.140

3.6. Concurrent Illness as a Determinant of

Health Behaviors and Health Outcomes

Eating Disorders

During childhood and adolescence, the long-term

sequelae of diabetes rarely cause major illnesses. The

illnesses that affect children and adolescents with

diabetes are predominantly related to psychosocial

issues, especially those leading to extreme diabetes

mismanagement. Eating disorders are one of the

most critical associated disorders among teens with

diabetes. The prevalence rate of eating disorders

among the general population is reported to be

between 1.3% and 11%,141,142 and research suggests

that the prevalence among young women with type

1 diabetes may be much higher.143,144

The two most common eating disorders among

adolescent girls with diabetes are anorexia nervosa

and bulimia nervosa. An examination of the characteristics of these disorders and the issues contributing to their development illustrates why young

women with diabetes may be at increased risk for

eating disorders. The definitions of these disorders

have been established by the American Psychiatric

Association and are in the Diagnostic and Statistical

Manual of Mental Disorders, Fourth Edition (DSMIV).145

Anorexia nervosa. Anorexia nervosa is characterized

by all of the following factors:

• Weight that is at least 15% below that expected

for age and height because of weight loss or failure to gain weight during the growth period.
56

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

• A fear of weight gain or fatness despite being

underweight.

• Disturbed body image.

• Among postmenarcheal adolescents, interruption of menstrual cycles for at least 3 months.

Anorexia can involve restricting food intake alone

or restricting accompanied by binge eating and

purging.

The issues that persons with anorexia struggle with

are an excessive need to meet perfectionist standards, a fear of emerging sexuality, and a fear of

being unable to control life’s demands. In teens and

younger children, anorexia is frequently a symptom

of the fear of growing up.146

Children or adolescents with diabetes are encouraged to have perfect diabetes control, even though

this goal may be a physiological impossibility.

Among adolescent girls with diabetes, parental

expectations for them to perform all diabetes tasks

perfectly and their own expectations of achieving

perfect glucose control can lead to feelings of failure

and the belief that they have lost control of the

demands of daily life. The additional and inevitable

emphasis on food and the sometimes rigid recommended eating schedules may increase the risk for

anorexia. The frequent dissociation of normal

hunger cues from eating and a deemphasis on the

pleasure of food may cause adolescents with diabetes to view food as another entity to manage

rather than a source of nourishment and comfort.

The combination of food issues and the inability to

achieve perfect blood glucose control appears to

contribute to the development of anorexia in adolescents with diabetes.

Bulimia nervosa. Bulimia nervosa is characterized by

all of the following:

• Repeated episodes of binge eating with frequent

compensatory behaviors to prevent weight gain,

which may include vomiting or misuse of laxatives and diuretics.

• Lack of control during binge episodes.

• Self-evaluation unduly influenced by weight.

Among adolescents with diabetes, compensatory

behaviors to prevent weight gain may also include

misusing insulin by eliminating or decreasing the

insulin dose, thus eliminating the food through glycosuria. Unlike persons with anorexia nervosa,

those with bulimia nervosa usually maintain a normal weight for age and height, though weight may

fluctuate considerably.146

The central issue for persons with bulimia nervosa

is a feeling of living behind a facade. An adolescent

girl with bulimia tends to believe everyone thinks

she is pretty or mature and capable, and she fears

that others will find out that she is not really that

perfect and will be angry and disappointed with

her. Although perfect blood glucose control is not a

realistic expectation for persons with diabetes, adolescent girls with bulimia and diabetes need to present a facade of perfection to hide their “failure”

from parents and health care providers. Thus,

bulimic girls with diabetes frequently report excellent blood glucose control and “no difficulties” with

diabetes management but have very elevated hemoglobin A1c levels. Because of the strong inverse correlation between bulimic symptoms (binging and

purging) and metabolic control in teenage girls

with diabetes,147 persistent hyperglycemia should

alert health care providers to suspect bulimia.

Predisposing factors for eating disorders. Families of

children with eating disorders have been characterized as enmeshed and overprotective, unable to

resolve conflict, and rigid in their interactions.

These same characteristics have also been noted in

families of persons with difficult-to-control diabetes.148 Thus, the characteristics that make it difficult for a family to cope with a chronic illness may

also predispose the affected member to an eating

disorder.

In addition to diabetes management issues, diabetes

treatment outcomes and outcome measures may be

risk factors for disordered eating among adolescent
The Adolescent Years

57

girls with diabetes. The use of weight as a method

of evaluating diabetes control is a major risk factor.

Weight loss is an indicator of poor control and

weight gain a possible indicator of lack of adherence to the prescribed food plan. This emphasis on

weight is psychologically difficult for many adolescent girls and may be an additional trigger for eating disorders for the teen with diabetes.

Finally, the stress related to having a chronic illness

can exacerbate other difficulties for both the patient

and the family and make the eruption of a latent

eating disorder more likely. Persons with diabetes

who are struggling with issues of identity or adjustment brought about by the diagnosis of a chronic

illness are at higher risk of developing eating disorders than are those who are coping fairly well with

life.149

Frequency of eating disorders among adolescent girls

with diabetes. Despite the apparent increased risk

for factors predisposing teens with diabetes to eating disorders, the first case of anorexia nervosa in a

person with diabetes was not reported until 1973.150

Between 1973 and 1984, there were only 10

reports involving a total of 31 patients.144 Those 10

studies, however, firmly established the coexistence

of eating disorders among patients with type 1 diabetes. Since the mid-1980s, several prevalence studies151-153 and treatment reports151,154 have been

published. Despite controversy over the precise rate

of eating disorders among women with diabetes,

current evidence suggests that this rate is at least

equal to that among women in the general population and may be significantly higher.143,155

A series of studies that used paper-and-pencil questionnaires found a significantly higher incidence of

anorexia and bulimia among patients with diabetes

than among those without diabetes.153,155,156

Although the results are quite compelling, these

studies rely on paper-and-pencil measures and thus

lack the diagnostic rigor of interview methods.

Other studies that have included an interview in

addition to paper-and-pencil measurements have

found that the incidence of eating disorders among

young women with diabetes is equal to, but not

higher than, that among the general population of

young women.157

The use or misuse of insulin to manipulate weight

must also be considered an eating disorder among

girls and young women with diabetes. Many young

women who do not meet DSM-IV criteria for eating disorders manipulate their insulin to alter their

weight and experience significant eating problems,

which are generally termed “subclinical eating disorders.” For example, girls with excessive fear of

hypoglycemia eat more to prevent hypoglycemia,

but then they feel guilty for overeating. This reaction may precipitate a cycle of overeating but without increasing insulin because of fears of weight

gain.151 If insulin manipulation is included in the

definition of an eating disorder, the incidence of

eating disorders is much higher among women with

diabetes than among the general population.143,155,158

The strict definitions for anorexia and bulimia nervosa include a time factor requiring the abnormal

behavior to persist for 3 or more months before the

diagnosis is established. However, because of the

serious implications of eating disorders among adolescents with diabetes, any episodes of binging

accompanied by compensatory purging behavior

among young women with diabetes should warrant

attention.

The major concern for diabetic young women with

eating disorders is the high risk of secondary complications. One study reported finding 15 women

with eating disorders among a cohort of 208

women with diabetes.155 Of these 15, 11 had

retinopathy (6 with proliferative changes), 6 had

nephropathy, 6 had neuropathy, and 4 had painful

neuropathy that remitted with weight gain.

A 4–5-year follow-up study of 91 young women

with diabetes found highly or moderately disordered eating in 29% of these women.143 Of those

with highly disordered eating behavior, 86% had

retinopathy at follow-up, compared with 24% of

those without disordered eating behavior. These
58

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

studies underscore the importance of identifying

young diabetic women with eating disorders.

Treatment of eating disorders. Treatment of any eating disorder should use a coordinated team

approach that includes a therapist, a nutritionist,

and a physician or a nurse practitioner. Recovering

from eating disorders is difficult for adolescent girls.

Although in some ways these girls may make a real

effort to recover, they frequently undermine their

treatment by surreptitiously not adhering to the

recommended treatment plan. Unfortunately, the

prognosis remains guarded for diabetic adolescents

with anorexia or bulimia.159,160

Among patients with diabetes, treatment of eating

disorders must be closely coordinated with diabetes

management. Allowing more flexibility in the target

blood glucose range and adjusting food choices may

be necessary until the eating disorder improves.154

Otherwise, the treatment should not differ from

that of patients without diabetes.

Other Psychiatric Disorders Affecting Diabetes

Management

During adolescence, several psychiatric disorders

may become apparent. The two that have the greatest implications for adolescents with diabetes are

bipolar disease (manic-depression) and panic attacks.

Adolescents with bipolar disease may be unable to

organize themselves adequately to adhere to the

schedule required for diabetes care. Because spontaneity and impulsiveness are hallmarks of adolescence, the diagnosis of mania may be delayed until

the behavior is dangerous to the adolescent or to

others. By this time, glucose control may have been

poor for months or even years. Once appropriate

treatment is instituted, diabetes control may not be

adequate for many additional months because other

issues in the life of the patient must also be brought

into equilibrium.

Panic attacks classically appear in late adolescence

and the early twenties.146 Because the feelings of

extreme anxiety that characterize panic attacks may

mimic the epinephrine release of a hypoglycemic

episode, patients may react to them by decreasing

their insulin doses. Only by carefully documenting

blood glucose levels during an event can the correct

diagnosis be reached and appropriate medication

instituted. As long as the symptoms persist, good

diabetes control is difficult because of the patient’s

fear of hypoglycemia. Excessive blood glucose testing, especially in the absence of documented hypoglycemia, should suggest the diagnosis of an anxiety

disorder. One study of Pima Indians has reported

that 8% of children with diabetes displayed symptoms of depression or eating disorders.1

Community Norms and Acculturation

Community norms and acculturation in the United

States are structured around the majority white

racial/ethnic group. Because most adolescent girls

with type 1 diabetes are white, there are no studies

on the effect of acculturation on health behaviors

and outcomes in adolescents with diabetes.

However, community norms have a large impact on

the health behaviors of adolescent girls with and

without diabetes. The desire of adolescents not to

be different may affect adherence to diet and regular glucose monitoring. Society’s emphasis on being

thin may also negatively affect an adolescent girl’s

adherence to a diabetes regimen of tight metabolic

control, which can result in weight gain.

3.7. Public Health Implications

Teenaged girls do not appear to fare as well with

their diabetes as their male counterparts. They

experience higher mortality and morbidity from

this disease. With increasing trends in risk factors

such as obesity, lack of physical activity, and smoking among adolescent women, the prevalence of

diabetes and its complications will increase. The

public health and medical communities must begin

to work together to identify modifiable societal and

individual-level factors that can be used to develop

effective interventions for the prevention and control of diabetes in this age group.

Assessment

There is much that needs to be done to assess the

special needs of adolescent girls with diabetes.
The Adolescent Years

59

Further studies are needed to

• Elucidate the relationship between smoking and

other risk-taking behaviors and acute illness and

general health status.

• Identify the determinants of eating disorders.

• Assess the prevalence and determinants of the

major complications of diabetes mellitus, including dental disorders.

• Assess the impact of community-level and individual-level socioeconomic status on the health

status of adolescents with diabetes.

• Determine the prevalence and incidence of type

1 and type 2 diabetes in adolescents.

Policy Development

Professional organizations and advocacy groups can

play an important role in the development and promotion of policy initiatives to reduce barriers to

diabetes care and to improve adherence among 

adolescent girls with diabetes. Policies that empower adolescent girls to take control of their diabetes

management, provide special diabetes education

opportunities for teens, support smoking prevention and cessation programs, and ensure access to

counseling and family planning services for sexually

active teens with diabetes could prevent or delay

the onset of major complications and reduce the

burden of disease in this population. The development of guidelines for assessing eating disorders

among adolescent girls with diabetes would

enhance the recognition of disease processes and

facilitate early identification and treatment. Body

image and weight management are serious concerns

for all adolescents; however, the manipulation of

insulin for weight control is a behavior with serious

consequences. Effective interventions for weight

management need to be structured to focus on the

improvement of self-confidence and body image. In

addition, opportunities for physical activity that

could become a lifelong practice would enhance the

attainment and maintenance of good glycemic control as well as weight management.

Furthermore, to facilitate self-management behaviors for adolescents with diabetes, it is important

that a consensus is reached on policies regarding

medicines and treatment of diabetes in school settings. The collaboration of advocates and policy

makers from local communities, medicine, public

health, and education sectors would enhance this

process. Finally, policies are needed to provide reimbursement for insulin administration devices that

are appropriate for adolescents.

Assurance

The transition into adulthood and independence

from parents or other authority figures is marked

with many challenges for adolescents, even more so

for adolescents with diabetes. At the same time,

support from family, peers, and other members of

the community is essential to help control this disease. Maintaining a balance between these two

opposing features of the needs of adolescents with

diabetes is a challenge for the public health community. Opportunities for counseling and education should be provided in settings frequented by

adolescents, including schools, churches, camps,

community centers, and social and athletic clubs.

Knowledge and awareness of the public health

impact of diabetes and its complications need to be

widespread in the community, especially among

teachers in public schools, among leaders of the

faith community, and among providers of social

services. All schools should ensure healthy food

choices. The health delivery system should assure

the availability of providers who are sensitive to the

needs of adolescent women and who are competent

in the care of adolescents with type 1 and type 2

diabetes. This would improve adherence to diabetes

self-care practices and improve clinical outcomes for

women with diabetes in this age group.
60

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

References

1. Fagot-Campagna A, Pettitt DJ, Engelgau MM, et al.

Type 2 diabetes among North American children and

adolescents: an epidemiologic review and a public health

perspective. J Pediatr 2000;136(3):664–72.

2. LaPorte RE, Matsushima M, Chang Y-F. Prevalence and

incidence of insulin-dependent diabetes. In: National

Diabetes Data Group, editors. Diabetes in America. 2nd

ed. Bethesda, MD: National Institutes of Health,

1995:37–46. (NIH Publication No. 95-1468)

3. Dabelea D, Hanson RL, Bennett PH, Roumain J,

Knowler WC, Pettitt DJ. Increasing prevalence of type

II diabetes in American Indian children. Diabetologia

1998;41(8):904–10.

4. Kostraba JN, Gay EC, Cai Y, et al. Incidence of insulindependent diabetes mellitus in Colorado. Epidemiology

1992;3(3):232–8.

5. Wagenknecht LE, Roseman JM, Alexander WJ.

Epidemiology of IDDM in black and white children in

Jefferson County, Alabama, 1979–1985. Diabetes

1989;38(5):629–33.

6. Lipton RB, Fivecoate JA. High risk of IDDM in African

American and Hispanic children in Chicago,

1985–1990. Diabetes Care 1995;18(4):476–82.

7. Libman IM, LaPorte RE, Becker D, Dorman JS, Drash

AL, Kuller L. Was there an epidemic of diabetes in nonwhite adolescents in Allegheny County, Pennsylvania?

Diabetes Care 1998;21(8):1278–81.

8. Pinhas-Hamiel O, Dolan LM, Daniels SR, Standiford

D, Khoury PR, Zeitler P. Increased incidence of

non–insulin-dependent diabetes mellitus among adolescents. J Pediatr 1996;128:608–15.

9. Cowie CC, Eberhardt MS. Sociodemographic characteristics of persons with diabetes. In: National Diabetes

Data Group, editors. Diabetes in America. 2nd ed.

Bethesda, MD: National Institutes of Health,

1995:85–116. (NIH Publication No. 95-1468)

10. Dorman JS, LaPorte RE, Stone RA. Worldwide differences in the incidence of type 1 diabetes are associated

with amino acid variation at position 57 of the HLADQ beta chain. Proc Natl Acad Sci USA

1990;87(19):7370–4.

11. Gay EC, Hamman RF, Carosone-Link PJ, et al.

Colorado IDDM registry: lower incidence of IDDM in

Hispanics. Comparison of disease characteristics and

care patterns in biethnic population. Diabetes Care

1989;12(10):701–8.

12. Paisano EL. The American Indian, Eskimo, and Aleut

population. In: Current Population Reports. Special

Studies Series. Washington, DC: U.S. Department of

Commerce, Economic and Statistics Administration,

Bureau of the Census, 1995:23–189.

13. Dumont RH, Jacobson AM, Cole C, et al. Psychosocial

predictors of acute complications of diabetes in youth.

Diabet Med 1995;12(7):612–8.

14. Klein R, Klein B. Vision disorders in diabetes. In:

National Diabetes Data Group, editors. Diabetes in

America. 2nd ed. Bethesda, MD: National Institutes of

Health, 1995:293–338. (NIH Publication No. 95-1468)

15. Fairchild JM, Hing SJ, Donaghue KC, et al. Prevalence

and risk factors for retinopathy in adolescents with type

1 diabetes. Med J Aust 1994;160(12):757–62.

16. Bonney M, Hing SJ, Fung AT, et al. Development and

progression of diabetic retinopathy: adolescents at risk.

Diabet Med 1995;12(11):967–73.

17. Malone JI, Grizzard S, Espinoza LR, Achenbach KE,

Van Cader TC. Risk factors for diabetic retinopathy in

youth. Pediatrics 1984;73(6):756–61.

18. Quattrin T, Waz W, Duffy L, et al. Microalbuminuria in

an adolescent cohort with insulin-dependent diabetes

mellitus. Clin Pediatr (Phila) 1995;34:12–17.

19. Janner M, Knill SE, Diem P, Zuppinger KA, Mullis PE.

Persistent microalbuminuria in adolescents with type 1

(insulin-dependent) diabetes mellitus is associated to

early rather than late puberty. Results of a prospective

longitudinal study. Eur J Pediatr 1994;153(6):403–8.

20. Rudberg S, Dahlquist GG. Determinants of progression

of microalbuminuria in adolescents with IDDM.

Diabetes Care 1996;19(4):369–71.

21. Jackson RL, Ide CH, Guthrie RA, James RD.

Retinopathy in adolescents and young adults with onset

of insulin-dependent diabetes in childhood.

Ophthalmology 1982;89(1):7–13.
The Adolescent Years

61

22. Cerutti F, Sacchetti C, Vigo A, et al. Course of retinopathy in children and adolescents with insulin-dependent

diabetes mellitus: a 10-year study. Ophthalmologica

1989;198(3):116–23.

23. Weber B, Burger W, Hartmann R, Hovener G, Malchus

R, Oberdisse U. Risk factors for the development of

retinopathy in children and adolescents with type 1

(insulin-dependent) diabetes mellitus. Diabetologia

1986;29(1):23–9.

24. Hamburg BA, Inoff GE. Relationships between behavioral factors and diabetic control in children and adolescents: a camp study. Psychosom Med 1982;44(4):321–39.

25. Loe H, Genco RJ. Oral complications of diabetes. In:

National Diabetes Data Group, editors. Diabetes in

America. 2nd ed. Bethesda, MD: National Institutes of

Health, 1995:501–6. (NIH Publication No. 95-1468)

26. Loe H. Periodontal disease. The sixth complication of

diabetes mellitus. Diabetes Care 1993;16(1):329–34.

27. Mayer-Davis EJ, D’Agostino R Jr, Karter AJ, et al.

Intensity and amount of physical activity in relation to

insulin sensitivity: the Insulin Resistance Atherosclerosis

Study. JAMA 1998;279(9):669–74.

28. DCCT Research Group. Effect of intensive diabetes

treatment on the development and progression of longterm complications in adolescents with insulin-dependent diabetes mellitus: Diabetes Control and

Complications Trial. J Pediatr 1994;125(2):177–88.

29. Loman DG, Galgani CA. Physical activity in adolescents

with diabetes. Diabetes Educ 1996; 22:121–5.

30. Dorman JS, LaPorte RE, Kuller LH, et al. The

Pittsburgh Insulin-Dependent Diabetes Mellitus

(IDDM) Morbidity and Mortality Study. Mortality

results. Diabetes 1984;33(3):271–6.

31. Sartor G, Nystrom L, Dahlquist GG. The Swedish

Childhood Diabetes Study: a sevenfold decrease in

short-term mortality? Diabet Med 1991;8(1):18–21.

32. Panzram G. Mortality and survival in type 2

(non–insulin-dependent) diabetes mellitus. Diabetologia

1987;30(3):123–31.

33. Dorman JS, LaPorte RE, Tajima N, Orchard TJ, Becker

DJ, Drash AL. Differential risk factors for death in

insulin-dependent diabetic patients by duration of disease. Pediatr Adolesc Endocrinol 1986;15:289–99.

34. Drash AL, LaPorte RE, Becker DJ, et al. Epidemiologic

studies in children with diabetes mellitus and their families: the Allegheny County Registry experience. In:

Chiumello G, Sperling M, editors. Recent Progress in

Pediatric Endocrinology. New York: Raven Press,

1983:124–36.

35. Aubert RE, Geiss LS, Ballard DJ, Cocanougher B,

Herman WH. Diabetes-related hospitalization and hospital utilization. In: National Diabetes Data Group, editors. Diabetes in America. 2nd ed. Bethesda, MD:

National Institutes of Health, 1995:553–69. (NIH

Publication No. 95-1468)

36. Sutton L, Plant AJ, Lyle DM. Services and cost of hospitalization for children and adolescents with insulindependent diabetes mellitus in New South Wales. Med J

Aust 1990;152(3):130–6.

37. Kostraba JN, Gay EC, Rewers M, Chase HP,

Klingensmith GJ, Hamman RF. Increasing trend in outpatient management of children with newly diagnosed

IDDM. Colorado IDDM Registry, 1978–1988.

Diabetes Care 1992;15(1):95–100.

38. Fishbein HA, Faich GA, Ellis SE. Incidence and hospitalization patterns of insulin-dependent diabetes mellitus. Diabetes Care 1982;5(6):630–3.

39. Davidson J, Alogna M. Assessment of program effectiveness at Grady Memorial Hospital. In: Steiner G,

Laurence P, editors. Educating Diabetic Patients. New

York: Springer Publishing Company, 1981:329–49.

40. Challen AH, Davies AG, Williams RJ, Baum JD.

Hospital admissions of adolescent patients with diabetes.

Diabet Med 1992;9(9):850–4.

41. Faich GA, Fishbein HA, Ellis SE. The epidemiology of

diabetic acidosis: a population-based study. Am J

Epidemiol 1983;117(5):551–8.

42. Rutstein DD, Berenberg W, Chalmers TC, Child CG

3rd, Fishman AP, Perrin EB. Measuring the quality of

medical care. N Engl J Med 1976;294(11):582–8.
62

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

43. Cohn BA, Cirillo PM, Wingard DL, Austin DF, Roffers

SD. Gender differences in hospitalizations for IDDM

among adolescents in California, 1991. Diabetes Care

1997;20(11):1677–82.

44. Glasgow AM, Weissberg-Benchell J, Tynan WD, et al.

Readmissions of children with diabetes mellitus to a

children’s hospital. Pediatrics 1991;88(1):98–104.

45. Kovacs M, Iyengar S, Goldston D, Obrosky DS, Stewart

J, Marsh J. Psychological functioning among mothers of

children with insulin-dependent diabetes mellitus: a longitudinal study. J Consult Clin Psychol 1990;58(2):

189–95.

46. Kovacs M, Charron-Prochownik D, Obrosky D. A longitudinal study of biomedical and psychosocial predictors of multiple hospitalizations among young people

with insulin-dependent diabetes mellitus. Diabet Med

1995;12(2):142–8.

47. Ryan CM, Longstreet C, Morrow L. The effects of diabetes mellitus on the school attendance and school

achievement of adolescents. Child Care Health Dev

1985;11(4):229–40.

48. Ryan CM. Neurobehavioural complications of type 1

diabetes. Examination of possible risk factors. Diabetes

Care 1988;11(1):86–93.

49. Northam E, Bowden S, Anderson V, Court J.

Neuropsychological functioning in adolescents with diabetes. J Clin Exp Neuropsychol 1992;14(6):884–900.

50. Close H, Davies AG, Price DA, Goodyer IM.

Emotional difficulties in diabetes mellitus. Arch Dis

Child 1986;61(4):337–40.

51. Sullivan BJ. Adjustment in diabetic adolescent girls: II.

Adjustment, self-esteem, and depression in diabetic adolescent girls. Psychosom Med 1979;41(2):127–38.

52. La Greca AM, Swales T, Klemp S, Madigan S, Skyler JS.

Adolescents with diabetes: gender differences in psychosocial functioning and glycemic control. Childrens

Health Care 1995;24(1):61–78.

53. Grey M, Cameron ME, Lipman TH, Thurber FW.

Psychosocial status of children with diabetes in the first

2 years after diagnosis. Diabetes Care 1995;18(10):

1330–6.

54. Blanze BJ, Rensch-Riemann BS, Fritz-Sigmund DI,

Schmidt MH. IDDM is a risk factor for adolescent psychiatric disorders. Diabetes Care 1993;16(12):1579–87.

55. Lavigne JV, Traisman HS, Marr TJ, Chasnoff IJ.

Parental perceptions of the psychological adjustment of

children with diabetes and their siblings. Diabetes Care

1982;5(4):420–6.

56. Goldston DB, Kovacs M, Ho VY, Parrone PL, Stiffler L.

Suicidal ideation and suicide attempts among youth

with insulin-dependent diabetes mellitus. J Am Acad

Child Adolesc Psychiatry 1994;33(2):240–6.

57. Jacobson AM. Depression and diabetes. Diabetes Care

1993;16(12):1621–3.

58. DCCT Research Group. Reliability and validity of a diabetes quality-of-life measure for the Diabetes Control

and Complications Trial (DCCT). Diabetes Care

1988;11(9):725–32.

59. Striegel-Moore RH, Nicholson TJ, Tamborlane WV.

Prevalence of eating disorder symptoms in preadolescent

and adolescent girls with IDDM. Diabetes Care

1992;15(10):1361–8.

60. Kyngas H, Barlow J. Diabetes: an adolescent’s perspective. J Adv Nurs 1995;22(5):941–7.

61. Eiser C, Flynn M, Green E, et al. Quality of life in

young adults with type 1 diabetes in relation to demographic and disease variables. Diabet Med 1992;9(4):

375–8.

62. Challen AH, Davies AG, Williams RJ, Haslum MN,

Baum JD. Measuring psychosocial adaptation to diabetes in adolescence. Diabet Med 1988;5(8):739–46.

63. Gerstein HC, VanderMeulen J. The relationship

between cow’s milk exposure and type 1 diabetes. Diabet

Med 1996;13(1):23–9.

64. Norris JM, Beaty B, Klingensmith GJ, et al. Lack of

association between early exposure to cow’s milk protein

and beta-cell autoimmunity. Diabetes Autoimmunity

Study in the Young (DAISY). JAMA 1996;276(8):

609–14.

65. Norris JM, Scott F. A meta-analysis of infant diet and

insulin-dependent diabetes mellitus: do biases play a

role? Epidemiology 1996;7(1):87–92.
The Adolescent Years

63

66. Verge CF, Howard NJ, Irwig L, Simpson JM, Mackerras

D, Silink M. Environmental factors in childhood

IDDM. A population-based, case-control study. Diabetes

Care 1994;17(12):1381–9.

67. Dahlquist GG, Blom LG, Persson LA, Sandstrom AI,

Walls SG. Dietary factors and the risk of developing

insulin-dependent diabetes in childhood. BMJ

1990;300(6735):1302–6.

68. Virtanen SM, Jaakkola L, Ylonen K, et al. Nitrate and

nitrite intake and the risk for type 1 diabetes in Finnish

children. Childhood diabetes in a Finland study group.

Diabet Med 1994;11(7):656–62.

69. Kostraba JN, Gay EC, Rewers M, Hamman RF. Nitrate

levels in community drinking waters and risk of IDDM.

An ecological analysis. Diabetes Care 1992;15(11):

1505–8.

70. Tuomilehto J, Tuomilehto-Wolf E, Virtala E, LaPorte

RE. Coffee consumption as a trigger for insulin-dependent diabetes in childhood. BMJ 1990;300(6725):642–3.

71. Pozzilli P, Bottazzo GF. Coffee or sugar. Which is to

blame in IDDM? Diabetes Care 1991;14(2):144–5.

72. Scott F. Cow milk and insulin-dependent diabetes mellitus: is there a relationship? Am J Clin Nutr 1990;51(3):

489–91.

73. Craighead JE, Huber SA, Sriram S. Animal models of

picornavirus-induced autoimmune disease: their possible

relevance to human disease. Lab Invest 1990;63(4):

432–46.

74. Pak CY, Eun HM, McArthur RG, Yoon JW. Association

of cytomegalovirus infection with autoimmune type 1

diabetes. Lancet 1988;2(86a):1–4.

75. Sairenji T, Daibata M, Sorli CH, et al. Relating homology between the Epstein-Barr virus BOLF1 molecule and

HLA-DQw8 beta chain to recent-onset type 1 (insulindependent) diabetes mellitus. Diabetologia 1991;34(1):

33–9.

76. Helmke K. Virus infections and diabetes mellitus. In:

Becker Y, editor. Virus Infections and Diabetes Mellitus.

Boston: Matinua Nijhoff Publishing, 1987:127–42.

77. Ginsberg-Fellner F, Witt ME, Yagihashi S, et al.

Congenital rubella syndrome as a model for type 1

(insulin-dependent) diabetes mellitus: increased prevalence of islet cell surface antibodies. Diabetologia 1984;

27(Suppl):87–9.

78. Suenaga K, Yoon JW. Association of beta-cell-specific

expression of endogenous retrovirus with development

of insulitis and diabetes in NOD mouse. Diabetes 1988;

37(12):1722–6.

79. Thernlund GM, Dahlquist GG, Hansson K, et al.

Psychological stress and the onset of IDDM in children.

Diabetes Care 1995;18(10):1323–9.

80. Robinson N, Lloyd CE, Fuller JH, Yateman NA.

Psychosocial factors and the onset of type 1 diabetes.

Diabet Med 1989;6(1):53–8.

81. Robinson N, Fuller JH. Role of life events and difficulties in the onset of diabetes mellitus. J Psychosom Res

1985;29(6):583–91.

82. Hamman RF. Genetic and environmental determinants

of non–insulin-dependent diabetes mellitus (NIDDM).

Diabetes Metab Rev 1992;8(4):287–338.

83. Kann L, Warren CW, Harris WA, et al. Youth risk

behavior surveillance—United States, 1995. MMWR

CDC Surveill Summ 1996;45(SS-4):1–84.

84. Krolewski AS, Warram JH. Epidemiology of late complications of diabetes. In: Kahn CR, Weir GC, editors.

Joslin’s Diabetes Mellitus. 13th ed. Malver, PA: Lea &

Febiger, 1994:605–19.

85. Chase HP, Jackson WE, Hoops SL, Cockerham RS,

Archer PG, Obrien D. Glucose control and the renal

and retinal complications of insulin-dependent diabetes.

JAMA 1989;261(8):1155–60.

86. Chase HP, Garg SK, Marshall G, et al. Cigarette smoking increases the risk of albuminuria among subjects

with type 1 diabetes. JAMA 1991;265(5):614–7.

87. Chaturvedi N, Stephenson J, Fuller J. The relationship

between smoking and microvascular complications in

the EURODIAB IDDM Complications Study. Diabetes

Care 1995;18(6):785–92.
64

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

88. Masson EA, MacFarlane IA, Priestly CJ, Wallymahmed

ME, Flavell HJ. Failure to prevent nicotine addiction in

young people with diabetes. Arch Dis Child 1992;

67(1):100–2.

89. Gay EC, Cai Y, Gale SM, et al. Smokers with IDDM

experience excess morbidity. The Colorado IDDM

Registry. Diabetes Care 1992;15(8):947–52.

90. Kuczmarski RJ, Flegal KM, Campbell SM, Johnson CL.

Increasing prevalence of overweight among U.S. adults.

The National Health and Nutrition Examination

Surveys, 1960 to 1991. JAMA 1994;272(3):205–11.

91. Troiano RP, Flegal KM. Overweight children and adolescents: description, epidemiology, and demographics.

Pediatrics 1998;101(3Suppl):497–504.

92. National Center for Health Statistics. Plan and

Operation of the Health and Nutrition Examination

Survey, United States, 1971–1973. Vital Health Statistics,

Series 1, No. 10, Washington, DC: U.S. Government

Printing Office, 1973.

93. McDowell A, Engel A, Massey J, Maurer K. Plan and

Operation of the Second National Health and Nutrition

Examination Survey, United States, 1976–1980. Vital

Health Statistics, Series 1, No. 15. Washington, DC:

U.S. Government Printing Office, 1981.

94. National Center for Health Statistics. Plan and

Operation of the Third National Health and Nutrition

Examination Survey, 1988–1994. Department of Health

and Human Services, Vital and Health Statistics, Series

1, No. 32. Hyattsville, MD: National Center for Health

Statistics, 1994. (Publication No. PHS 94-1308)

95. Thomas-Dobersen DA, Butler-Simon N, Fleshner M.

Evaluation of a weight management intervention program in adolescents with insulin-dependent diabetes

mellitus. J Am Diet Assoc 1993;93(5):535–40.

96. The Diabetes Control and Complications Trial Research

Group. The effect of intensive treatment of diabetes on

the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J

Med 1993;329(14):977–86.

97. Cowie CC, Harris MI, Silverman RE, Johnson EW,

Rust KF. Effect of multiple risk factors on differences

between blacks and whites in the prevalence of

non–insulin-dependent diabetes mellitus in the United

States. Am J Epidemiol 1993; 137(7):719–32.

98. Scott CR, Smith JM, Cradock MM, Pihoker C.

Characteristics of youth-onset non–insulin-dependent

diabetes mellitus and insulin-dependent diabetes mellitus at diagnosis. Pediatrics 1997;100(1):84–91.

99. Babu SR, Walravens P, Wang T, et al. Disease heterogeneity at the onset of diabetes in children evaluated

with multiple “biochemical” autoantibody screening and

DQ typing. Diabetes 1996;45(Suppl 2):201A.

100. Jones KL. Non–insulin-dependent diabetes in children

and adolescents: the therapeutic challenge. Clin Pediatr

(Phila) 1998;37(2):103–10.

101. Pettitt DJ, Bennett PH, Saad MF, Charles MA, Nelson

RG, Knowler WC. Abnormal glucose tolerance during

pregnancy in Pima Indian women. Long-term effects on

offspring. Diabetes 1991;40(Suppl 2):126–30.

102. Dean HJ, Mundy RL, Moffatt M. Non–insulin-dependent diabetes mellitus in Indian children in Manitoba.

CMAJ 1992;147(1):52–7.

103. Pinhas-Hamiel O, Zeitler P. Insulin resistance, obesity,

and related disorders among black adolescents. J Pediatr

1996;129(3):319–20.

104. Ravussin E, Lillioja S, Knowler WC, et al. Reduced rate

of energy expenditure as a risk factor for body-weight

gain. N Engl J Med 1988;318(8):467–72.

105. Kriska AM, LaPorte RE, Pettitt DJ, et al. The association of physical activity with obesity, fat distribution,

and glucose intolerance in Pima Indians. Diabetologia

1993;36(9):863–9.

106. Chase HP. Understanding Insulin-Dependent Diabetes.

Denver: Department of Pediatrics, University of

Colorado Health Sciences Center, 1995.

107. Crespo CJ, Keteyian SJ, Heath GW, Sempos CT.

Leisure-time physical activity among U.S. adults. Results

from the Third National Health and Nutrition

Examination Survey. Arch Intern Med 1996;156(1):

93–8.

108. Guyer B, MacDorman MF, Martin JA, Peters KD,

Strobino DM. Annual summary of vital statistics—

1997. Pediatrics 1998;102(6):1333–49.

109. Beschart J. Oral contraception and adolescent women

with insulin-dependent diabetes mellitus: risks, benefits,

and implications for practice. Diabetes Educ 1996;22(4):

374–8.
The Adolescent Years

65

110. Freinkel N, Dooley SL, Metzger BE. Care of the pregnant woman with insulin-dependent diabetes mellitus.

N Engl J Med 1985;313(2):96–101.

111. Amiel SA, Simonson DC, Sherwin RS, Lauritano AA,

Tamborlane WV. Exaggerated epinephrine responses to

hypoglycemia in normal and insulin-dependent diabetic

children. J Pediatr 1987;110(6):832–7.

112. Mortensen HB, Hougaard P. Comparison of metabolic

control in a cross-sectional study of 2,873 children and

adolescents with IDDM from 18 countries. The

Hvidore Study Group on Childhood Diabetes. Diabetes

Care 1997;20(5):714–20.

113. La Greca AM. Behavioral aspects of diabetes management in children and adolescents. Diabetes

1982;31(Suppl 2):12A.

114. McCaul KD, Glasgow RE, Schafer LC. Diabetes regimen behaviors. Predicting adherence. Med Care 1987;

25(9):868–81.

115. Summerson JH, Konen JC, Dignan MB. Association

between exercise and other preventative health behaviors

among diabetics. Public Health Rep 1991;106(5):543–7.

116. Glasgow RE, McCaul KD, Schafer LC. Barriers to regimen adherence among persons with insulin-dependent

diabetes. J Behav Med 1986;9(1):65–77.

117. Marrero DG, Fremion AS, Golden MP. Improving compliance with exercise in adolescents with insulin-dependent diabetes mellitus: results of a self-motivated home

exercise program. Pediatrics 1988;81(4):519–25.

118. Weisberg-Benchell J, Glasgow AM, Tynan WD, Wirtz P,

Turek J, Ward J. Adolescent diabetes management and

mismanagement. Diabetes Care 1995;18(1):77–82.

119. Daviss WB, Coon H, Whitehead P, Ryan K, Burkley M,

McMahon W. Predicting diabetic control from competence, adherence, adjustment, and psychopathology. 

J Am Acad Child Adolesc Psychiatry 1995;34(12):

1629–36.

120. Fagot-Campagna A, Burrows NR, Williamson DF. The

public health epidemiology of type 2 diabetes in children and adolescents: a case study of American Indian

adolescents in the Southwestern United States. Clin

Chim Acta 1999;286(1-2):81–95.

121. Golden MP, Herrold AJ, Orr DP. An approach to prevention of recurrent diabetic ketoacidosis in the pediatric population. J Pediatr 1985;107(2):195–200.

122. Drozda DJ, Dawson VA, Long DJ, Freson LS, Sperling

MA. Assessment of the effect of a comprehensive diabetes management program on hospital admission rates

of children with diabetes mellitus. Diabetes Educ 1990;

16(5):389–93.

123. Kent LA, Gill GV, Williams G. Mortality and outcome

of patients with brittle diabetes and recurrent ketoacidosis. Lancet 1994;344(8925):778–81.

124. Tattersall R, Gregory R, Selby C, Kerr D, Heller S.

Course of brittle diabetes: 12-year follow-up. BMJ 1991;

302(6787):1240–3.

125. Jacobson AM, Hauser ST, Lavori P, et al. Adherence

among children and adolescents with insulin-dependent

diabetes mellitus over a 4-year longitudinal follow-up: I.

The influence of patient coping and adjustment. 

J Pediatr Psychol 1990;15(4):511–26.

126. Gowers SG, Jones JC, Kiana S, North CD, Price DA.

Family functioning: a correlate of diabetic control? 

J Child Psychol Psychiatry 1995;36(6):993–1001.

127. Dashiff CJ. Parents’ perceptions of diabetes in adolescent daughters and its impact on the family. J Pediatr

Nurs 1993;8(6):361–9.

128. Anderson BJ, Auslander WF, Jung KC, Miller JP,

Santiago JV. Assessing family sharing of diabetes responsibilities. J Pediatr Psychol 1990;15(14):477–92.

129. La Greca AM. Children with diabetes and their families:

coping and disease management. In: Field TM, McCabe

PM, Schneiderman N, editors. Stress and Coping Across

Development. Hillsdale, NJ: Erlbaum, 1988:139–59.

130. Bobrow ES, Avruskin TW, Siller J. Mother-daughter

interaction and adherence to diabetes regimens. Diabetes

Care 1985;8(2):146–51.

131. Hauser ST, Jacobson AM, Lavori P, et al. Adherence

among children and adolescents with insulin-dependent

diabetes mellitus over a 4-year longitudinal follow-up:

II. Immediate and long-term linkages with the family

milieu. J Pediatr Psychol 1990;15(4):527–42.
66

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

132. Satin W, La Greca AM, Zigo MA, Skyler JS. Diabetes in

adolescence: effects of multifamily group intervention

and parent simulation of diabetes. J Pediatr Psychol

1989;14(2):259–75.

133. Albrecht T, Edelman M. Communicating Social Support.

Beverly Hills, CA: Sage Publications, 1987.

134. Daley B. Sponsorship for adolescents with diabetes.

Health Soc Work 1992;17(3):173–82.

135. La Greca AM. Peer influences in pediatric chronic illness: an update. J Pediatr Psychol 1992;17(6):775–84.

136. Lessing DN, Swift PG, Metcalfe MA, Baum JD. Newly

diagnosed diabetes: a study of parental satisfaction. Arch

Dis Child 1992;67(8):1011–3.

137. American Diabetes Association.

<http:\\www.diabetes.org/advocacy/discrimination_and_

school.asp>. Last accessed: 1/12/2001.

138. Songer TJ. The socioeconomic impact of diabetes upon

families with IDDM children. Diabetes 1991;40:(Suppl):

556A.

139. Songer TJ, LaPorte RE, Lave JR, Dorman JS, Becker

DJ. Health insurance and the financial impact of

IDDM in families with a child with IDDM. Diabetes

Care 1997;20(4):577–84.

140. Hanson CL, Henggeler SW, Harris MA, Mitchell KA,

Carle DL, Burghen GA. Association between family

members’ perceptions of the health care system and the

health of youths with insulin-dependent diabetes mellitus. J Pediatr Psychol 1988;13(4):543–54.

141. Stancin T, Link DL, Reuter JM. Binge eating and purging in young women with IDDM. Diabetes Care 1989;

12(9):601–3.

142. Hay WW, Groothuis JR, Hayward AR, Levin MJ, editors. Adolescence. In: Lange Medical Book. Current

Pediatric Diagnosis & Treatment. Stamford, CT:

Appleton & Lange, 1997:85–128.

143. Rydall AC, Rodin GM, Olmsted MP, Devenyi RG,

Daneman D. Disordered eating behavior and microvascular complications in young women with insulindependent diabetes mellitus. N Engl J Med 1997;

336(26):1849–54.

144. Birk R, Spencer ML. The prevalence of anorexia nervosa, bulimia, and induced glycosuria in IDDM females.

Diabetes Educ 1989;15(4):336–41.

145. American Psychiatric Association. Diagnostic and

Statistical Manual of Mental Disorders. 4th ed. (DSM-IV).

Washington, DC: American Psychiatric Association,

1994.

146 Hay WW, GGroothuis JR, Hayward AR, Levin MJ, editors. Psychosocial aspects of pediatrics and psychiatric

disorders. In: Lange Medical Book: Current Pediatric

Diagnosis & Treatment. Stamford, CT: Appleton &

Lange, 1997:154–94.

147. Rodin GM, Johnson LE, Garfinkel PE, Daneman D,

Kenshole AB. Eating disorders in female adolescents

with insulin-dependent diabetes mellitus. Int J Psychiatry

Med 1986–87;16(1):49–57.

148. Minuchin S. Psychosomatic Families. Cambridge, MA:

Oxford University Press, 1978.

149. Jacobson AM. The psychological care of patients with

IDDM. N Engl J Med 1996;334(19):1249–53.

150. Bruch H. Eating Disorders: Obesity, Anorexia, and the

Person Within. New York: Basic Books, 1973.

151. Rodin GM, Craven J, Littlefield C, Murray M,

Daneman D. Eating disorders and intentional insulin

undertreatment in adolescent females with diabetes.

Psychosomatics 1991;32(2):171–6.

152. Rosmark B, Berne C, Holmgren S, Lago C, Renholm

G, Solberg S. Eating disorders in patients with insulindependent diabetes mellitus. J Clin Psychiatry 1986;

47(11):547–50.

153. Steel JM, Young RJ, Lloyd GG, Clarke BF. Clinically

apparent eating disorders in young diabetic women:

associations with painful neuropathy and other complications. Br Med J (Clin Res Ed) 1987;294(6576):

859–62.

154. Krakoff DB. Eating disorders as a special problem for

persons with IDDM. Nurs Clin North Am 1991;26(3):

707–13.

155. Steel JM. Eating disorders in young diabetic women.

Practical Diabetes, International 1996;13:64–7.
The Adolescent Years

67

156. Steel JM, Young RJ, Lloyd GG, MacIntyre CC.

Abnormal eating attitudes in young insulin-dependent

diabetics. Br J Psychiatry 1989;155:515–21.

157. Peveler RC, Fairburn CG, Boller IB, Dunger D. Eating

disorders in adolescents with IDDM. A controlled study.

Diabetes Care 1992;15(10):1356–60.

158. Pollock M, Kovacs M, Charron-Prochownik D. Eating

disorders and maladaptive dietary/insulin management

among youths with childhood-onset IDDM. J Am Acad

Child Adolesc Psychiatry 1995;34(3):291–6.

159. Garner DM. Pathogenesis of anorexia nervosa. Lancet

1993;341(8861):1631–5.

160. Herzog DB, Sacks NR, Keller MB, Lavori PW, von

Ranson KB, Gray HM. Patterns and predictors of recovery in anorexia nervosa and bulimia nervosa. J Am Acad

Child Adolesc Psychiatry 1993;32(4):835–42.
68

CASE STUDY

Marie is 28 years old and was diagnosed with type 1 diabetes at age 9. She vividly remembers the first

few years after diagnosis when she had to rely on urine testing to monitor her glucose levels and needed

two insulin shots a day. This morning she does the first of six daily finger sticks to check her blood glucose and determine the settings on her insulin pump. She is thankful for the medical advances in caring for her diabetes and the access she has to these important tools, but she still has to psych herself up to

do her finger sticks, change her pump settings, plan her meals and exercise, take care of her family, and

do well at her job, let alone find time for herself. She wants to keep her diabetes under tight control so

she can continue to be a productive wife, mother, and employee.

As she closely watches her 3-year-old daughter dart around the house, Marie is reminded of the keen

interest her parents took in her diabetes and all they did as she grew up to try to protect her from the

dangers of this disease. She realizes that her diabetes was expensive for the family and appreciates that

her father could afford medical care. It is Marie’s husband, Robert, who now shares in the daily challenges of her diabetes. Robert was very concerned about Marie and their baby during her pregnancy. He

is glad that Marie received preconception counseling, had carefully planned the pregnancy, and kept an

especially close watch on her blood glucose levels while she was pregnant. All these efforts were very expensive, however. Robert is a manager of a small company that does not provide insurance coverage for its

employees. Marie now works as a real estate agent, and although she has some medical coverage, she has

to pay a very large premium. Robert worries about the expense of diabetes management, whether their

daughter will also develop diabetes, and if Marie will continue to be healthy and an active part of the

family. Marie and Robert read a lot about diabetes but wish they could take more education programs

to understand how to achieve even better diabetes control.

Marie works hard to keep her blood glucose well managed as she tries to balance her family life and job.

It seems that the stress of her increasingly complicated daily life makes diabetes management more difficult, but her family needs her income. At a recent appointment, her physician told her that she has

some signs of background retinopathy and that her blood pressure is slightly elevated. The physician also

counseled Marie about the advisability of having more children. The doctor put her on an ACE

inhibitor to control her blood pressure and protect her kidneys and told her that the eye problems were

not too serious, but she would continue to closely monitor them. The medicines seem so expensive, but

Marie knows how important it is for her to continue good care. Marie hopes for advances in diabetes

treatment and progress toward a cure so that her child will not lose her mother prematurely or face getting diabetes herself one day.
69

4

THE REPRODUCTIVE YEARS

D.L. Rowley, MD, MPH, I.A. Danel, MD, MPH, C.J. Berg, MD, MPH, F. Vinicor, MD, MPH

This chapter presents a review of the prevalence, incidence, and secular trends of diabetes in women of

reproductive age. The demographic, socioeconomic

(including poverty), sociocultural, and environmental

context within which many women with diabetes in

this age group live, work, and raise their families is

described. The effects of these factors on health behaviors are discussed. Gestational diabetes and its intergenerational effects on the future burden of diabetes

among women, preconception counseling, contraception, and patterns in the use of health services are

described. Available data suggest that increased awareness of the specific needs of this population is needed,

that public policy initiatives be designed to provide

comprehensive and continuous care for women in this

life stage, and that services be delivered to assure the

effective use of these resources. Public health implications of the findings for reproductive-aged women

address the three core functions of public health: assessment, policy development, and assurance.

The reproductive years extend from early adolescence to midlife. However, because more than 95%

of U.S. women who became pregnant between

1976 and 1996 did so between the ages of 18 and

44 years, especially during their twenties,1 this

chapter will generally address issues relevant to

women aged 18–44 years with diabetes.

(Reproductive health and diabetes is also addressed

in Chapter 3: The Adolescent Years.)

From a public health perspective, during this age

span, women’s general health issues include adequate maintenance and protection of good health,

and often attention to reproductive needs. These

are also the years when many women are continuing to develop educationally, entering the workforce, and simultaneously establishing and maintaining their own families. Related challenges during these years may include discontinuous employment, separation and divorce, and consequent loss

of economic security and health care coverage.

These social and economic factors may affect health

directly and may also limit access to, and use of,

health care services.

Further, recent studies indicate that a healthy pregnancy is not only of immediate importance to the

mother and newborn but also may affect the likelihood of each developing diabetes many years in the

future (i.e., there is an intergenerational effect of

pregnancy). Finally, the behaviors of women in this

age category and the consequent risk factors for

future chronic diseases are often established during

women’s reproductive years. Therefore, women in

this age group represent an asymptomatic cohort

with extant chronic disease risk factors but little

current clinical disease. Thus, to address the future

devastation caused by diabetes in women older than

44 years of age, it is important to develop a better

understanding of, and public health programs for,

those with or at risk for diabetes in this age group.

This chapter will emphasize some of the public

health issues faced by women who have or are at

risk for diabetes during their reproductive years,

including during pregnancy, and discuss the public

health implications of associated challenges.
70

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

4.1Prevalence, Incidence, and Trends

Compared with female children and adolescents,

reproductive-aged women have a decreased risk of

developing type 1 diabetes and an increased risk of

developing type 2 diabetes and gestational diabetes

mellitus (GDM).2 Thus, type 2 diabetes accounts

for the majority of cases of diabetes identified during this life stage. 

Prevalence

On the basis of data from the Third National

Health and Nutrition Examination Survey

(NHANES III, 1988–1994) of a representative

sample of the noninstitutionalized population, the

total prevalence (previously diagnosed plus undiagnosed) of diabetes was 1.7% among women aged

20–39 years and 6% among those aged 40–49 years

(Figure 4-1).3 As expected, women of minority

racial and ethnic origins were 2–3 times more likely

than non-Hispanic white women to have diabetes

(Figure 4-2). Among younger women, the total

prevalence was 3.3% for non-Hispanic blacks,

2.7% for Mexican Americans, and 1.3% for nonHispanic whites; among women older than age 39,

estimates were 10.4%, 14.1%, and 4.8%, respectively.

In NHANES III, the prevalence of previously diagnosed diabetes increased fourfold, from 1.1%

among women aged 20–39 years to 4.4% among

those aged 40–49 years (Figure 4-1). Women of

minority racial and ethnic origin were more likely

to have a previous diagnosis of diabetes (Figure 

4-2). At younger ages (less than 40 years), prevalence was 20%–60% higher among non-Hispanic

black (1.6%) and Mexican American (1.2%)

women than among non-Hispanic white women

(0.9%). By age 40, the disparity in diagnosed diabetes increased more than twofold: the prevalence

was 6.7% for non-Hispanic black women, 9.2% for

Mexican American women, and 3.5% for nonHispanic white women. These data from NHANES

III are consistent with the findings from several

other surveys (Table 4-1)4-11 and indicate the early

vulnerability of minority women to diabetes.

Figure 4-1. Prevalence of diagnosed and 

undiagnosed diabetes among 

U.S. adults, by age and sex—

NHANES III,* 1988–94

0

2

4

6

8 Diagnosed

Undiagnosed

Women Men Women Men

Aged 20–39 Years

Percent

Aged 40–49 Years

1.7 1.6

6.9

6.0

*NHANES III = Third National Health and Nutrition Examination

Survey.

Source: Reference 3.

Figure 4-2. Prevalence of diagnosed and 

undiagnosed diabetes among 

U.S. women, by age and race/ 

Hispanic origin—NHANES III,*

1988–94

0

3

6

9

12

15 Diagnosed

Undiagnosed

NHW NHW NHB MA MA NHB

Aged 20–39 Years Aged 40–49 Years

Percent

1.3

3.3 2.7

4.8

10.4

14.1

*NHANES III = Third National Health and Nutrition Examination

Survey; NHW = non-Hispanic white; NHB = non-Hispanic black;

MA = Mexican American.

Source: Reference 3.
Table 4-1. Prevalence of diagnosed diabetes among reproductive-aged women, by race/Hispanic

origin—United States, 1965–97

Population Year Age group (years) Prevalence (%)

Alaska Natives

Alaska Area Native Health Service 1993 15–24 0.9

25–34 1.7

35–44 7.6

American Indians

Navajo

Teec Nos Pos, Arizona 1990 20–44 5.5

Navajo Health and Nutrition Survey 1991–92 20–44 10.4

Pima 1965–75 25–34 14.5

35–44 35.1

Indian Health Service 1996 20–44 3.8

Hispanics

Hispanic Health and Nutrition Examination Survey 1982–84 20–44

Mexican American 2.3

Cuban 1.8

Puerto Rican 2.5

Behavioral Risk Factor Surveillance System 1994–97 18–44 2.7

Sources: References 7–12.

The Reproductive Years

71

Using the diagnostic criteria of the American

Diabetes Association (fasting plasma glucose ≥126

mg/dL ),5 NHANES III also found that 0.6% of

women aged 20–39 years and 1.6% of those aged

40–49 years had diabetes that was undiagnosed

(Figure 4-1).3 Despite their higher prevalence of

diagnosed diabetes, non-Hispanic black and

Mexican American women were also at least 3 times

as likely as non-Hispanic white women to have diabetes that was undiagnosed (Figure 4-2). Among

women aged 20–29 years, undiagnosed diabetes was

present in 1.7% of non-Hispanic blacks, 1.5% of

Mexican Americans, and 0.4% of non-Hispanic

whites; by age 40, prevalence rose to 3.7%, 4.9%,

and 1.6%, respectively.

Thus, among reproductive-aged women with diabetes, about one-third (35.4%) of women younger

than 40 years and about one-quarter (26.7%) of

those aged 40 years or older did not know that they

had the disease. When NHANES III estimates are

applied to the 1995 intercensal population,12 nearly

1.85 million reproductive-aged women have diabetes; in approximately 500,000 of them, the disease is unrecognized. 

Unlike estimates for children and adolescents, estimates of the prevalence of type 1 diabetes among

U.S. adults are not routinely available by sex.13 In

addition, there are no estimates at all for young

adults aged 20–29 years. The very limited data

available for reproductive-aged women are based on

self-reported data from the Second National Health

and Nutrition Examination Survey (NHANES II,

1976–1980).13,14 Persons diagnosed at age 30 or

older were considered to have type 1 diabetes if

they met the following three criteria: duration of at

least 3 years, continuous insulin use since diagnosis,

and current weight at 125% or less of desirable

weight. Among women aged 30–49 years, the

prevalence was 0.1%.
72

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

Incidence

Data from the 1990–1992 National Health

Interview Surveys (NHIS) show that among

women aged 25–44 years, the 3-year average annual

incidence rate of diagnosed diabetes was 2.8 per

1,000.15 When this rate is applied to the 1995 population, approximately 115,000 new cases of diabetes are diagnosed annually in reproductive-aged

women.

Few studies of the incidence of diabetes have been

conducted in minority populations, but regardless

of how diabetes was defined, incidence rates were

consistently higher among minority groups compared with the white population.15-18 In the 16-year

(1971–1987) First National Health and Nutrition

Examination Survey Epidemiologic Follow-Up

Study, the incidence rate of diabetes among black

women aged 25–44 years was about 2–2.5 times

that of their white counterparts.15,16 In the San

Antonio Heart Study, diabetes developed earlier

and the incidence rate was approximately 3 times

higher among Mexican American than nonHispanic white women.17 Among participants

recruited during 1979–1982, the 8-year incidence

rate of diabetes for Mexican American women was

4.5% for those aged 25–34 years and 5.2% for

those aged 35–44 years. Comparable rates for nonHispanic white women were 0% and 1.8%, respectively, or approximately one-fourth and one-third

the rates for Mexican American women.17 Age-specific annual incidence rates for Pima Indian women

were similar to rates for Mexican American women:

45.2 per 1,000 at ages 25–34 (4.5%) and 56.4 per

1,000 at ages 35–44 years (5.6%).18

Incidence of type 1 diabetes peaks around puberty

and decreases sharply in late adolescence;2,19 therefore, many reproductive-aged women with type 1

diabetes enter this life stage with diabetes already

diagnosed. No reliable incidence data are available

for reproductive-aged women.

Trends

The prevalence of diabetes has been increasing in

all demographic groups for several decades.15,20-25

Overall, between 1980 and 1996, the prevalence

among females younger than 45 years of age

remained steady until 1989, then increased by

27%, from 7.3 per 1,000 in 1989 to 9.3 per 1,000

in 1996.20 An approximate 70% increase in diabetes

prevalence among women aged 30–39 years has

been noted between 1990 and 1998.23 Because the

majority of females younger than 45 years with

diagnosed diabetes are aged 20–44 years, these data

primarily reflect the secular trend among reproductive-aged women (unpublished data, CDC,

Diabetes Surveillance).

Aging of the population, increased survival, an

increase in the rate at which new cases develop

(true incidence), and increased or improved identification of cases are factors that may, singly or in

combination, contribute to secular increases in

prevalence. In young adulthood, aging and mortality make relatively little contribution to the secular

trend observed.21,26 However, data from several large

population-based studies indicate that since the

1960s, a rising temporal trend in incidence of type

2 diabetes has been occurring in all age, sex, and

racial/ethnic groups.22,24,25 The steepest rise has

occurred among younger adults. Consequently, at

this stage of life, incidence is making the greatest

contribution to the increasing prevalence observed

among young women.

Overweight,27 weight gain,28 and lack of physical

activity29 are major risk factors for developing diabetes. These factors have become increasingly common among adolescents and young adults since the

1960s, with the greatest increase taking place during the 1980s.30-33 One population-based study of

women aged 18–30 years found that over the 7

years from 1985–1986 to 1992–1993,33 average

daily energy intake increased while physical activity

and physical fitness decreased; these changes

occurred concurrently with increasing body mass.33

Weight gain was strongly associated with decreased

physical fitness.33

The rapid changes in these risk factors among

reproductive-aged women suggest a populationwide
The Reproductive Years

73

impact of social and environmental factors.

Moreover, they also suggest that increasing numbers

of women, especially nonwhite women, are now at

risk of having pregnancies complicated by diabetes.

Gestational Diabetes

As defined by the Fourth International WorkshopConference on Gestational Diabetes Mellitus,

GDM is the presence of carbohydrate intolerance

of varying degrees of severity with onset or first

recognition during pregnancy.34 This definition

includes all diabetes in pregnancy whether or not

the condition was treated with insulin, persisted

after pregnancy, or was provoked by or preceded

the index pregnancy.34

GDM is significant because it is associated with

both immediate and long-term implications for the

health of the woman35-37 and her offspring.38-40

Women with GDM have a 25%–45% higher risk

for recurrence in the next pregnancy37 and a future

risk of nongestational diabetes (primarily type 2)

ranging from 17% to 63% during the 5 to 16 years

following the index pregnancy.36,38

The prevalence of GDM is highly variable within

and between populations throughout the world.41

In the United States, estimates of overall prevalence

of GDM range from 2.5% to 4% of pregnancies

that result in live births.42-44 Generally, prevalence of

GDM is based on data from universal screening of

pregnant women.45-48 Variation in estimates of frequency of GDM may arise from differences in

screening45 and diagnostic34 protocols, case ascertainment criteria,42,43,49,50 distributions of risk

factors,41,46,47 and background level of type 2 diabetes.41

Women are more likely to develop GDM if they

are older; have high prepregnancy weight, high

body mass index, or weight gain in young adulthood; have high parity or a history of a previous

adverse pregnancy; or have preexisting hypertension

or a family history of diabetes.36,38,47,51 Of interest,

these predictive characteristics are also similar to

traditional risk factors for type 2 diabetes.

As with type 2 diabetes, the prevalence of GDM

varies by race and ethnicity.41,43-48 Estimates for all

women who had single live births during

1993–1995 show considerable variation within and

between groups of mothers in the United States.43,44

For example, among Hispanics, the age-adjusted

prevalence of GDM is lowest in Cuban (2.3%),

highest in Puerto Rican (3.9%), and intermediate

for Mexican (2.8%) and South American (2.4%)

mothers (Table 4-2).43 Some groups of American

Indian women have prevalence rates of GDM considerably higher than the national average.49,51

Among Zuni Indian mothers, reported prevalence

is 15.1%; among Navajo Indian women, prevalence

was 7.8% and 10.4% at ages 20–29 and 30–39

years, respectively.

4.2 Sociodemographic Characteristics 

Age, Race, and Ethnicity

In the reproductive years, women with type 1 diabetes are more likely than women with type 2 diabetes to be diagnosed before adulthood (mean ages,

15.7 years versus 29.3 years). The age distributions

of the two groups are therefore very different—8 of

10 women with type 1 diabetes are aged 18–44

years, compared with approximately 1 of 10

women with type 2 diabetes.52

No data are available on the racial and ethnic distribution of women with diabetes in this age group.

However, in the 1989 NHIS, it was observed that

20.2% of persons with diabetes are non-Hispanic

black, 4.8% are Mexican American, and 5.4% are

of other races.52

Marital Status/Living Arrangements

The 1989 NHIS found that women aged 18–44

years with type 2 diabetes were more likely than

their nondiabetic counterparts to report that they

were married, divorced, or separated and less likely

to report that they had never married (Table 4-3).52

These differences in marital status between diabetic

and nondiabetic women were more pronounced

among black than white women. Furthermore,

among women with diabetes, black women were
Table 4-2. Crude and age-adjusted* prevalence† of diabetes during pregnancy, by race/Hispanic

origin—United States, 1993–95

Prevalence (%)

Race or Hispanic origin Number of women Crude Age-adjusted

Non-Hispanic

White 6,996,046 25.3 24.3

Black 1,770,102 22.6 27.5

Hispanic

Mexican 1,331,361 22.8 27.5

Puerto Rican 161,065 31.6 38.7

Cuban 35,148 24.9 22.7

Central/South American 271,639 25.4 24.3

American Indian/Alaska Native 108,982 43.9 52.4

Asian/Pacific Islander

Chinese 77,359 39.1 27.3

Japanese 25,885 26.8 21.6

Hawaiian 16,982 28.9 32.6

Filipino 88,487 39.8 32.0

Asian Indian‡ 31,574 56.1 44.3

Korean‡ 24,918 19.3 16.1

Samoan‡ 4,855 25.7 28.7

Vietnamese‡ 34,140 24.3 19.5

Total 11,384,926 25.3 –

* Per 1,000 singleton live-born infants.

† Standard population = aggregate of all races and Hispanic origin.

‡ Data available for seven states only.

Source: Reference 43.

74

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

less likely than white women to be married (59.9%

versus 70.4%) and more likely to be divorced or

separated (21.8% versus 13.6%). In addition, black

women with diabetes were almost twice as likely as

their white counterparts to live alone (9.3% versus

5.7%) and also more likely to live in larger households (59.2% versus 37.3%). 

Education/Income/Employment

Reproductive-aged women with type 2 diabetes

have fewer years of education, lower incomes, and

are less likely than women without diabetes to be in

the labor force (Table 4-3).52 Among women aged

18–44 years, the percentage of those with diabetes

who reported that they had completed more than

12 years (30.8%) of education was substantially

lower than that of women without diabetes

(45.6%); the percentage who had completed at

least 16 years was about half that of their nondiabetic peers (12.8% versus 20.0%). Second, more

than half (52.9%) of all women with type 2 diabetes reported a family income less than $20,000.

Indeed, for almost half of these women with diabetes, income was less than $10,000. In contrast,

the percentages for women without diabetes were

30.7% and 12.2%, respectively. Third, women with

diabetes (52.1%) were less likely than those without

diabetes (70.8%) to report that they were employed

and more likely to report that they were not in the

labor force (38.9% versus 25.7%). As expected, in

this age group, most women who were not working

reported that keeping house was their usual activity

in the past 12 months. 

These differences were magnified in terms of race

and ethnicity. Regardless of diabetes status, black
Table 4-3. Prevalence (%) of sociodemographic characteristics of women aged 18–44 years with 

and without type 2 diabetes, by race/Hispanic origin—United States, 1989

Non-Hispanic white Non-Hispanic black Total

Characteristic Diabetes No diabetes Diabetes No diabetes Diabetes No diabetes

Marital status

Married 70.4 67.2 59.9 37.0 65.6 62.7

Widowed 1.0 0.6 3.6 1.5 2.1 0.7

Divorced or separated 13.6 10.5 21.8 17.7 19.0 11.4

Never married 15.0 22.2 14.7 43.8 13.2 25.2

Living arrangements

Alone 5.7 8.7 9.3 8.2 6.1 8.3

Nonrelative only 1.4 3.4 2.4 0.9 1.9 2.9

Spouse 69.7 66.7 59.9 35.1 65.3 61.8

Other relative only 23.2 21.2 28.5 55.8 26.8 27.0

Household size (no. of persons)

1 7.0 12.1 11.7 9.2 8.0 11.3

2 24.6 20.8 23.1 20.6 22.4 20.2

3 31.0 24.3 6.1 23.4 25.9 23.9

≥4 37.3 42.8 59.2 46.7 43.8 44.6

Education (years)

<9 2.6 1.8 6.3 3.0 6.9 3.6

9–12 62.9 49.7 63.5 61.3 62.3 50.8

>12 34.6 48.4 30.2 35.7 30.8 45.6

≥16 17.3 22.3 4.8 10.8 12.8 20.0

Annual family income ($thousands)

<10 21.0 8.7 30.5 28.6 25.7 12.2

10 – <20 23.0 16.8 46.9 24.9 27.2 18.5

20 – <40 36.2 37.7 8.6 31.5 29.6 36.5

≥40 19.9 36.8 14.1 15.0 17.5 32.8

Employment status

Employed 56.2 73.3 37.4 65.1 52.1 70.8

Unemployed 8.9 3.0 13.6 6.9 9.0 3.5

Not in labor force 34.9 23.7 49.0 28.0 38.9 25.7

Source: Reference 52.

The Reproductive Years

75

women had fewer years of education, lower

incomes, and were less likely to be employed than

white women (Table 4-3).52 Black diabetic women

were less likely than their white counterparts to

have completed more than 12 years of education

(30.2% versus 34.6%) and even less likely to have

completed 16 or more years (4.8% versus 17.3%).

Among black women with diabetes, more than

three-fourths (77.4%) reported family incomes less

than $20,000, and although approximately 37%

were employed, almost half (49.0%) were not in

the labor force. Comparable percentages for white

women were 44.0%, 56.2%, and 34.9%, respectively. These racial disparities in education, income,

and employment were more pronounced among

women with diabetes than among those without

diabetes.

Reproductive-aged women with diabetes also have

fewer years of education, lower incomes, and are

less likely to be in the labor force than their male

counterparts.52 Further, these sex differences are
76

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

greater among persons with diabetes than in the

nondiabetic population. Education, income, and

employment are commonly used indicators of

socioeconomic status (SES). The findings from the

1989 NHIS suggest that among reproductive-aged

women, diabetes amplifies the racial and sex disparities in SES found in the general population.

Moreover, the gap in SES between women with

and without diabetes appears to have worsened over

time.53 For example, data from the 1979–1981

NHIS showed that 37.1% of women without diabetes were in the highest income group (≥$25,000),

compared with 32.7% of women with diabetes. By

1989, 32.8% of women without diabetes were in

the highest income group (≥$40,000) compared

with only 17.5% of women with diabetes. Further,

whereas the percentage of employed nondiabetic

women increased from 62.7% in 1979–1981 to

70.8% in 1989, the percentage of employed diabetic women increased only slightly, from 49.8% during 1979–1981 to 52.1% in 1989.

Presently, no data on sociodemographic characteristics among women with diabetes of other ethnic

origins are available, nor are they available for

reproductive-aged women with type 1 diabetes.52

4.3. Impact of Diabetes on Health Status

Death Rates

Diabetes mellitus is a leading cause of death among

American women of reproductive age.54 In 1996,

diabetes ranked ninth overall, ninth among white

and Hispanic women, and seventh among black

women aged 25–44 years. However, because diabetes is not recorded anywhere on more than 60%

of the death certificates of decedents with diabetes,55 data derived from death certificates significantly underestimate the actual contribution of diabetes to total mortality in the U.S. population as

well as the mortality risk for people with diabetes.

Many clinical and epidemiologic studies of selected

populations have shown consistently that people

with diabetes have higher mortality rates than those

without diabetes.10,26,55-65 Most of these studies

recruited middle-aged subjects and provided summary age-adjusted measures; consequently, few data

on mortality exist for diabetic women younger than

45 years of age.

The First National Health and Nutrition

Examination Survey (NHANES I, 1971–1975)

included a representative sample of the noninstitutionalized U.S. population aged 25–74 years.

Participants with and without diabetes at baseline

examination were followed through 1992–1993.63

Vital status was ascertained for 97.9% of persons

with diabetes and 96.1% of those without. In all

age, sex, and non-Hispanic racial groups, death

rates were higher for people with diabetes than for

those without diabetes. 

Among those aged 25–44 years, the overall death

rate for women with diabetes was more than 3

times the rate for women without diabetes (9.3 per

1,000 person-years versus 2.9 per 1,000 personyears).63 Excess mortality among women with diabetes was present in both white and black groups,

but the magnitude of the excess in black women

(2.6) was smaller than that in white women (4.0).

Figure 4-3. All-cause mortality rates for U.S. 

adults aged 25–44 years, by 

diabetes status, sex, and race/

Hispanic origin, 1971–93

0

5

10

15

20

25 Diabetes

No diabetes

NHW NHB

Women

NHW NHB

Men

Deaths per 1,000 person-years

8.7

2.2

6.6

17.3

23.9

3.9

17.5

8.0

NHW = non-Hispanic white; NHB = non-Hispanic black.

Source: Reference 63.
The Reproductive Years

77

This racial difference may be due, in part, to the

higher death rates experienced by nondiabetic black

women than by nondiabetic white women (Figure

4-3).

Among women with diabetes, the death rate among

black women was twice the rate of white women

(17.3 per 1,000 person-years versus 8.7 per 1,000

person-years) (Figure 4-3). The sex differential in

mortality seen in the general population is also

found in the diabetic population (i.e., the death

rate among diabetic women is lower than the rate

among diabetic men). However, the NHANES I

Follow-Up Study found that whereas the death rate

among diabetic white reproductive-aged women

was approximately one-third the rate of their male

counterparts (8.7 per 1,000 person-years versus

23.9 per 1,000 person years), in this age group no

sex differential in mortality was seen among diabetic blacks in this age group.63

Data from the NHANES I Follow-Up Study represent the experience of adults primarily with type 2

diabetes; only 49 persons were thought to have type

1 diabetes.63 The Diabetes Epidemiology Research

International (DERI) Mortality Study followed persons in Allegheny County, Pennsylvania, who were

diagnosed with type 1 diabetes before the age of 18

years.64 Estimated death rates for women with diabetes were 2.6 per 1,000 at ages 20–24 years, 7.7

per 1,000 at ages 25–29 years, and 16.6 per 1,000

at 30–39 years. Follow-up data for the period

through 1990 also suggest that the racial disparity

in mortality present in persons with type 2 diabetes

is also present among persons with type 1.65 In the

DERI cohort, black women died at almost 4 times

the rate of white women (15.9 per 1,000 personyears versus 4.0 per 1,000 person-years). Although

the numbers of events were small, the data also suggest that among persons with type 1 diabetes, the

burden of mortality among younger black women

is markedly higher than that among black men of

similar age.65 Of interest, there was no sex difference in mortality among whites in this age group.

Complications

All people with diabetes, including reproductiveaged women, have higher risks of morbidity than

those without diabetes. Common medical complications associated with diabetes include microvascular disease (retinopathy, nephropathy, and neuropathy) that is specific to diabetes and manifestations

of atherosclerotic macrovascular disease (coronary

heart disease, stroke, and peripheral vascular disorders). These complications, especially microvascular

diseases, are strongly related to the duration of

exposure to the altered metabolic state associated

with diabetes. Consequently, most data available for

younger adults are derived from studies of persons

who developed diabetes before adulthood.

Retinopathy. Diabetic retinopathy is caused by alterations in the small blood vessels in the retina in

response to hyperglycemia and hypertension.66

Diabetic retinopathy is classified as either nonproliferative or proliferative diabetic retinopathy

(PDR).

Retinopathy is associated with the duration of diabetes.66 Seven years after the diagnosis of type 1 diabetes, 50% of patients will have some degree of

retinopathy; 20 years after diagnosis, more than

90% are affected. In the Wisconsin Epidemiologic

Study of Diabetic Retinopathy (WESDR), 3 years

after diagnosis among people with the onset of diabetes after age 30 who were not taking insulin,

23% had retinopathy and 2% had PDR. After 20

years, 60% in this group had retinopathy and 5%

had PDR.

In the WESDR, there were no significant differences in the 4- or 10-year incidence or progression

of diabetic retinopathy between the sexes for people

with either younger-onset (less than 30 years of age)

or older-onset diabetes.66 It is therefore important

to realize that women who develop retinopathy

during their reproductive years are most likely to

have been diagnosed before adulthood (i.e., they

probably have type 1 diabetes). In addition, 
78

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

pregnancy is a risk factor for the progression of

retinopathy among women with type 1 diabetes.67

In one case-control study, pregnant women were

twice as likely to progress to PDR as nonpregnant

women (7.3% versus 3.7%). This finding remained

statistically significant even after controlling for glycated hemoglobin (HbA1c).68

Nephropathy. Diabetic nephropathy is the most

common single cause of end-stage renal disease

(ESRD) in the U.S. population (about 40% of new

cases of ESRD are due to diabetes) and is the diabetic complication associated with increased cardiovascular disease morbidity and mortality.69 Among

people with diabetes for 15 or more years,

nephropathy develops in 35%–40% of patients

with type 1 diabetes and less than 20% of those

with type 2 diabetes.70 However, because type 2 diabetes is much more common than type 1, the

majority of cases of ESRD due to diabetes are in

persons with type 2 diabetes.70 In the reproductive

years, diabetic nephropathy may be diagnosed

somewhat earlier in women than men because as

many as 25% of all cases of diabetic nephropathy

among women can be diagnosed during pregnancy.

In early pregnancy, women with preexisting diabetic nephropathy may have a marked increase in protein excretion because of the rise in glomerular filtration rate that normally occurs in pregnancy.70

This phenomenon may increase the likelihood of

earlier detection of diabetic nephropathy.

Pregnancy does not seem to adversely affect the

course of early diabetic renal disease.70,71 However,

pregnancy hastens the onset of end-stage renal disease in women who have more severe impairment

as manifested by hypertension and decreased renal

function.

Cardiovascular disease. Diabetes is a major risk factor for cardiovascular disease (CVD), primarily atherosclerotic coronary heart disease (CHD), and

stroke.72 CHD is the most common cause of mortality and morbidity among people with diabetes.

CHD is also the most costly of the long-term

chronic complications of diabetes because of the

frequency of events and the need for hospitalization

and use of technological devices.73,74 However,

CHD is uncommon before 30 years of age, even

when diabetes is diagnosed in childhood.73 In addition, the data from most population-based studies

are derived from middle-aged participants. Thus,

data are sparse on the frequency of CHD among

reproductive-aged women; the most reliable data

are from studies of persons with type 1 diabetes.

The EURODIAB IDDM complications study of

3,250 adults with type 1 diabetes included men

(51%) and women (49%) with similar mean age

(33 years) and duration of diabetes (14.6 years).75

Among women, the overall prevalence of total

CVD was 10%, including myocardial infarction

(1.5%), angina (1.8%), and stroke (0.9%). There

was no sex difference in prevalence of CVD.

Within the reproductive age range, estimates for the

prevalence of CVD were 6% and 8% for women

aged 15–29 and 30–44 years, respectively. The

prevalence of CVD was associated strongly with

duration of diabetes in both sexes. For duration of

less than 15 years, the prevalence was somewhat

greater among women than men (for 1–7 years, 9%

versus 6%; for 8–14 years, 7% versus 5%, respectively).76 These data suggest that the protection

from CVD found in nondiabetic women is lost in

the presence of diabetes, even at these younger

ages.77

Other population-based studies provide additional

information regarding CVD in reproductive-aged

women with diabetes. According to the 1989

NHIS, among adults aged 18–44 years with diabetes, the overall prevalence of self-reported angina

was 3.9%.73 In this age group, angina was twice as

likely to be reported among those with type 2 diabetes as those with type 1 diabetes (1.9%). Insulin

users were more likely to report angina (4.9%) than

those who did not use insulin (3.8%). Perhaps most

impressively, compared with persons without diabetes, those with diabetes reported a 10-fold higher

prevalence of self-reported ischemic heart disease

(2.7% versus 0.2%).73 Unfortunately, these NHIS

data were not stratified by sex.
The Reproductive Years

79

In the Nurses’ Health Study, a cohort of women

recruited at ages 30–55 years and followed for the

8-year period 1976 to 1984, the risk of developing

CHD and stroke among women with diabetes was

6.7 and 4.1 times that among women without diabetes, respectively.58 Women who were diagnosed

with diabetes before age 30 years had greater incidence of cardiovascular disease: the relative risks

(RR) were at least 10 times those of their nondiabetic counterparts (CHD, RR=12.2; stroke,

RR=10.0).58

Because of 1) the magnitude of the problem of

CVD in persons with diabetes, including

women,77,78 2) evidence of efficacious interventions

involving lipid and blood pressure reduction in diabetic women in this age category,79,80 3) the need to

target high-risk diabetic persons,81 and 4) gaps in

the application of these efficacious prevention programs in actual practice, improved delivery of effective clinical interventions is needed.

However, to maximize efforts to reduce the burden

of diabetes for women at this stage of life (as well as

future generations),82,83 one must move beyond a

clinical view of diabetes.84 For example, reproductive-aged women with diabetes—even in the

absence of clinically apparent diabetes complications—often have risk factors leading to later development of cardiovascular disease, renal disease,

retinopathy, and other chronic conditions.

Reproductive-aged women with diabetes are silently

“cardio-toxic” and poised to display the consequences of these diabetes-associated risk factors.

How should these diabetic women who have yet to

develop typical clinical manifestations of diabetes

be identified? What are the risks and benefits of

such screening programs? Should this large cohort

of reproductive-aged women with diabetes but no

apparent clinical disease be the target of interventions before they develop CVD? If CVD does

develop, what is the impact on the family (since the

woman is most often the family caregiver and manager as well as a contributor to the economic security of the family)? These important public health

issues relevant to reproductive-aged women with

diabetes must be considered.

Intensive Therapy and Its Effects on Quality of Life

In determining the burden of a disease, clinical

medicine and public health have traditionally monitored mortality rates. This singular criterion for

disease burden reflects the dominance of acute,

infectious diseases in the first half of the 20th century. With the emergence of chronic diseases during

the latter half of the 20th century, other indicators—

morbidity, disability, economic impact, and especially health-related quality of life (HRQOL)—have

been used as measures of disease burden. HRQOL

captures aspects of self-perceived well-being affected

by the presence or treatment of disease85,86 and

focuses on outcomes within the context of patient

expectations.86-88 As a result of increasing attention

to “tight diabetes regulation,”89,90 HRQOL measurements are being used. In the Diabetes Control and

Complications Trial (DCCT), multiple indices of

quality of life (one specific to diabetes and two

more general measures) examined the effect of

intensive therapy compared with conventional glucose control for type 1 diabetes.91 Despite the

increased demands of intensive therapy, no deterioration was noted in quality of life except among

patients who experienced repeated, severe hypoglycemic episodes.91 No differences were noted

between sexes. However, these patients had access

to a multidisciplinary team of professionals, and

time, effort, and resources were directed to patients

receiving intensive therapy.92 The United Kingdom

Prospective Diabetes Study, which examined the

impact of improved glucose and blood pressure

control in persons with type 2 diabetes, also measured HRQOL and could detect no significant differences in quality of life measurements between

intensive and control treatment strategies, or

between women and men.93 Indeed, studies suggest

that with improved glycemic—and perhaps blood

pressure—control, perceived quality of life is better

among patients, including reproductive-aged

women.88,94,95
80

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

However, the complexities of HRQOL need greater

study, including analyses of such factors as type of

therapy, sex, education level, cultural factors, race

and ethnicity, and professional or social support

among reproductive-aged women.88,96 Although

measurement of HRQOL for chronic conditions

such as diabetes is a useful indicator of disease burden, present assays still focus almost exclusively on

the individual woman with diabetes. Poor quality

of life due to diabetes or its treatment, however, has

a considerably broader impact on groups of people

and society at large. If the HRQOL of an individual reproductive-aged woman is low, the family,

community, and society also experience a lower

HRQOL. For example, diminished job performance, productivity, and income associated with low

HRQOL of an individual woman with diabetes

also affects the family income and perhaps business

productivity.95 Further, with improved diabetes control, not only does the individual experience a higher HRQOL, but also society at large benefits in

terms of employment and productivity.95 Thus,

even as the diabetes community moves toward

measurements of quality of life as an important

indicator of disease control, a broader societal view

of this dimension should be considered as part of a

public health approach to diabetes among reproductive-aged women.

Hospitalizations

Data on hospitalization rates for women with diabetes are available from the National Hospital

Discharge Survey (NHDS). However, NHDS data

are limited by a lack of personal identifiers and

hence offer no way to distinguish people with multiple annual hospitalizations. Using NHDS data, a

U-shaped trend was noted between 1980 and 1994

in hospital discharge rates among women aged

20–44 years with diabetes as the primary, or firstlisted, diagnosis. These rates decreased from 14 per

10,000 population in 1980 to 8.4 in 1990 and

then increased to 11.2 in 1994.97 Women with diabetes aged 20–44 had higher hospitalization rates

than men in the same age group in the early 1980s,

but these hospitalization rates decreased during the

1990s. White women aged 20–44 with diabetes as

a primary diagnosis had lower hospitalization rates

than all women; however, the same U-shaped trend

curve was noted: rates were 10.9 per 10,000 population in 1980, 5.7 in 1990, and 7.4 in 1994.97

Because of small numbers, no reliable information

is available on hospitalization rates among black

women with diabetes as a first diagnosis.

Among people aged 20–44 years, hospitalization

discharge rates for diabetes as any listed diagnosis

(per 10,000 population) are slightly higher for

women than for men. Between 1980 and 1994,

rates for men showed a tendency to increase from

24.8 to 32.0 discharges per 10,000 population,

while those for women fluctuated between 33 and

42 with no clear trend. Black people had higher

discharge rates for diabetes than white people, and

black women had the highest rates of all, fluctuating between 57 and 74 discharges per 10,000 population. 

Among persons aged 44 years or younger with diabetes, hospitalization rates with diabetes listed as

the primary diagnosis decreased during this time

period from 162 per 1,000 diabetic population to

110.97 Rates were slightly higher for men than for

women but decreased for both sexes. Rates for

white women with diabetes as a primary diagnosis

were lower than for women as a whole, suggesting

that black women with diabetes had a higher discharge rate. However, results were not reported separately for black women. 

Hospital discharge rates among people aged 44

years or younger with diabetes as any listed diagnosis also decreased between 1980 and 1994, from

325 per 1,000 diabetic population to 283. Rates

decreased for both sexes and were slightly higher for

women than for men. Hospitalization rates for

white men and women with diabetes tended to

decrease between 1980 and 1994 but remained

unchanged for black men and women. Between

1990 and 1994, hospitalization rates with diabetes

as any listed diagnosis were 300–360 per 1,000 diabetic population for black women and 195–235 per

1,000 diabetic population for white women.97 The

higher hospital discharge rates for black women
The Reproductive Years

81

with diabetes than for white women with diabetes

suggest that black women may receive less adequate

or appropriate ambulatory care and thus require

more hospitalizations for complications.

Data from the 1994–1997 NHIS are consistent

with the findings presented above. Approximately

21% of women aged 18–44 years with diabetes

reported at least one hospitalization in the previous

year (excluding any hospitalizations for childbirth),

compared with only 6% of women without diabetes. 

Hyperglycemia During Pregnancy

An initial recognition of hyperglycemia occurs in

pregnancy either because of prepregnancy diabetes

or because of GDM. Earlier studies of hyperglycemia during pregnancy focused primarily on

the health of the infant because of higher rates of

perinatal morbidity, particularly when GDM is not

treated or when preexisting diabetes is not well controlled.34,35 Mothers with diabetes or GDM also

deserve attention because they are at greater risk

than nondiabetic pregnant women for pregnancy

complications including preeclampsia, caesarean

section, and infections.34,35,84

However, in addition to these clinical reasons for

attention to hyperglycemia during pregnancy, the

future of the reproductive-aged woman with GDM

as well as the future of her offspring are two important public health issues that are receiving increasing recognition. For women, GDM is a risk factor

for the recurrence of GDM in future pregnancies

and also for the subsequent future development of

type 2 diabetes.35-37 Recurrence rates for progression

to subsequent type 2 diabetes increase with the age

of the mother and for women with other risk factors for developing type 2 diabetes, especially ethnicity, prepregnancy and postpregnancy weight and

weight gain, parity, family history of type 2 diabetes, and level of physical activity after pregnancy.35-37

Several important public health issues require additional study, such as what should be the screening

recommendations for GDM, including cut-off

points as well as evidence to decide whether screening should be routinely performed for all

women.34,98,99 For example, it is possible that considerable harm could occur when a woman is told that

she has GDM in the absence of solid evidence that

adverse outcomes will occur in all women.99 Also,

what should be the clinical practice recommendations for women with either prepregnancy diabetes

or GDM? Should all women with either of these

conditions receive only specialty care? Is overuse of

services (such as universal screenings and Csections100) now occurring, which from a societal

perspective is as harmful as underuse of services for

the individual woman? Finally, considering the evidence documenting the progression of GDM to

type 2 diabetes, especially in minority populations,

what should be the guidelines for follow-up to

detect type 2 diabetes early? Even more importantly, are primary prevention programs, especially

behavioral strategies, likely to either prevent or at

least delay this progression, as has been demonstrated with the use of medication in high-risk populations?101

Recent studies have identified other important consequences of maternal hyperglycemia—the impact

on offspring beyond the immediate peripartum

period. This intergenerational effect of hyperglycemia during pregnancy has long-term effects on

the metabolism and health of the offspring of that

pregnancy. Children of diabetic mothers have up to

a 10-fold increased risk of becoming obese during

childhood and adolescence, as well as developing

glucose intolerance in puberty.39,102-104 Further, it has

been observed that the likelihood of a person developing type 2 diabetes is 70% greater if the mother

has type 2 diabetes than if the father has diabetes,105

suggesting that the intrauterine environment, in

addition to genetics, contributes to the subsequent

development of diabetes in the offspring of diabetic

mothers.

Additional studies have extensive documentation of

the effects of the intrauterine environment on the

subsequent development of many chronic diseases,
82

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

even in the offspring of women without hyperglycemia during pregnancy. Initial studies in the

United Kingdom have indicated that the development of components of the insulin resistance syndrome (IRS)—hypertension, central adiposity, dyslipidemia, insulin resistance, and hyperglycemia—

was inversely correlated with the size of the baby at

birth (i.e., the smaller the baby, the more likely that

newborn will develop components of the IRS

20–40 years later).39,106-110 This relationship, with

some variation (e.g., U-shaped relationship between

fetal/newborn size and subsequent IRS),39 has now

been observed in different populations throughout

the world.110,111 These findings suggest that changes

in the growth and development of the fetus in

utero that are secondary to nutritional disturbances

are associated with permanent metabolic alterations

in the offspring that will result in chronic conditions like impaired glucose tolerance, type 2 diabetes, CVD, and hypertension. Although a specific

pathophysiologic mechanism for the effect of

improper in utero nutrition has yet to be identified,

the concept of “fetal programming” may be relevant.112,113 Impaired beta cell function or peripheral

insulin resistance secondary to impaired fetal maturity associated with maternal hyperglycemia114 may

contribute, along with obesity and inadequate physical activity, to type 2 diabetes in youth.115-117

Several important public health issues emerge from

the preceding metabolic and epidemiologic observations of reproductive-aged women, especially if

hyperglycemia is present. Considering 1) the diabetes epidemic in the United States and throughout

the world,118-120 2) recognition of the importance of

primary prevention (in addition to improved diabetes care) to control the emerging burden of diabetes,121 and 3) initial evidence that the progression

of GDM or impaired glucose tolerance to type 2

diabetes can be reduced,101,122 decisions need to be

made about screening for GDM, as well as offering

effective nutrition and physical activity programs

for those at higher risk of developing diabetes (e.g.,

reproductive-aged women).

4.4 Health-Related Behaviors

Risk Behaviors and Risk Factors

Although several immutable factors are associated

with an increased risk of developing type 2 diabetes

(e.g., genetics, age, race/ethnicity),6,123,124 personal

patterns of behavior also contribute to a greater

incidence of diabetes. Thus, nutritional patterns

that increase the risk for elevated body mass index

(BMI) or weight gain after age 18, lack of physical

activity, and cigarette smoking are behavioral risk

factors associated with the development of type 2

diabetes and its complications.

Obesity. Population-based data from several studies

document an increase in overweight (BMI ≥25

kg/m2

) and obesity (BMI ≥30 kg/m2) in the United

States over the last decade.125,126 A 47% increase in

the percentage of women who were obese among

those aged 18 years or older was noted between

1991 and 1998.126 Overweight, weight gain, and

obesity are associated with consequent impaired

glucose tolerance and type 2 diabetes.27,28,127 For

example, NHANES II data indicate that diabetes is

2.9 times more prevalent among overweight people

than those of normal weight status.28 Thus,

increased obesity in the United States may be contributing to the increase in the prevalence of diabetes. Between the National Health Examination

Survey (NHES, 1963–1965) and NHANES II

(1976–1980), the prevalence of obesity among girls

aged 12 to 17 years increased by 108% among

whites and 151% among blacks.128 Obesity is also

greater among black than white women, and the

percentage of women of both races who are overweight increases with age up to age 70.126 Data from

NHANES II showed that 9% of white women and

24% of black women aged 20–24 years were overweight as were 25% of white women and 41% of

black women aged 35–44 years—a prevalence 65%

higher among black women.28

In recent studies documenting a disturbing increase

in diabetes in the United States,23,120 a statistical

association between weight and increasing 
The Reproductive Years

83

prevalence of diabetes in both black and white

women has been confirmed. Among women aged

30–55 years in the Nurses’ Health Study, the risk

for diagnosed diabetes increased almost exponentially with increases in BMI:27,127 women with a

BMI of 23–23.9 kg/m2 had a risk of developing

diabetes 3.6 times higher than women with a BMI

of less than 22 kg/m2

. The risk of developing diabetes for women with a BMI of 29–30.9 kg/m2 was

20 times higher, and for women with a BMI of 35

kg/m2 or more, it was 61 times higher. A separate

analysis of data from the Nurses’ Health Study

showed that attributable risk for body weight to the

incidence of type 2 diabetes also increased with

BMI. Among women with a BMI of more than 33

kg/m2

, 98% of the diagnoses of diabetes were

attributable to obesity. Further, weight gain after

age 18 years was a major determinant of risk.

Finally, the Nurses’ Health Study found that in

addition to BMI, waist-to-hip ratio (WHR) and

waist circumference were also independent predictors of subsequent development of diabetes,27,127

suggesting that useful, accessible, and simple tools

to determine the risk of developing diabetes are

available. 

The impact of pregnancy on subsequent weight

gain over time and with increasing age is a unique

challenge to women and increases their chances of

developing diabetes.129-132 For example, over a 5-year

period, women who had previously given birth at

least once gained 2 kg–3 kg and had a greater

increase in WHR, independent of weight gain, than

did women who were giving birth for the first

time.129,130 Further, black women had greater

increases in adiposity at each level of parity than

did white women.130 Although not all studies have

confirmed this impact of pregnancy on subsequent

weight gain in reproductive-aged women,131 about

15%–20% of women experience substantial weight

gain after delivery,132 thereby acquiring a greater risk

of developing type 2 diabetes. The interaction of

this weight gain after pregnancy with the presence

of GDM may be a major factor in progression to

type 2 diabetes, especially in women from minority

populations.35,37,46,48

Physical inactivity. The interrelationships between

weight gain and physical inactivity in the development of type 2 diabetes are complex. In a prospective 7-year study of residents of urban areas aged

18–30 years, a strong association between weight

gain and decrease in physical fitness was noted.33,133

Further, the association of weight gain with

decreased physical fitness was greatest among those

who were overweight at baseline. Finally, black

women weighed more and reported significantly

less physical activity at baseline than white women

and had a higher percent increase in overweight.133

Several recent publications have examined relationships between physical activity and the subsequent

development of diabetes in high-risk populations,

including women aged 18–44.29,33,122,134 In general,

women who engage in more physical activity over a

longer period of time have a decreased likelihood of

developing type 2 diabetes. In terms of differences

in amount, type, or duration of physical activity

between women with and without diabetes, among

women aged 18–44 years, rates of physical activity

and exertion of 2,000 kcal/wk or more did not vary

by diabetic status. Although women with diabetes

were more likely than women without this condition to engage in walking, they were less likely to

report other regular physical activity.135

Improving physical activity behaviors among 

reproductive-aged women is clearly a relevant intervention for preventing type 2 diabetes.121,136

Cigarette smoking. The prevalence of cigarette smoking among persons with or at risk for diabetes is

not very different than in persons without diabetes.137 In addition to the likely greater incidence

of diabetes complications in diabetic persons who

smoke,138,139 more recent studies suggest that cigarette consumption is associated with a greater incidence of type 2 diabetes in an independent and

dose-dependent fashion,140,141 perhaps due to

increased insulin resistance in association with cigarette use.142 Thus, an increased risk for the development of diabetes may be another complication of

smoking.
84

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

Health-Promoting Behaviors

Despite the association between four risk factors—

nutrition behaviors (and resultant weight or weight

gain), physical inactivity, smoking, and maternal

health prior to and during pregnancy—and the

subsequent development of type 2 diabetes, is there

also evidence that improving behaviors in each of

these areas will reduce the risk of diabetes to the

woman or her offspring? Further, what are the public health implications of this evidence?

Weight/nutrition. Although longitudinal studies

have established the association between weight,

weight gain, nutrition, and diabetes incidence,33,125-

127,143 few investigations have scientifically examined

the impact of planned changes in behaviors that

affect these factors and diabetes incidence. Further,

few have examined the impact of improved nutrition alone (i.e., separate from concomitant changes

in physical activity). Among overweight persons

with established diabetes, intentional weight loss

was associated with substantial reductions in allcause mortality as well as CVD mortality.144

Preliminary investigations on the impact of intentional weight loss in preventing the onset of diabetes also suggest a clear effect in women, including

reproductive-aged women.145 Finally, in the Da

Qing study, weight control itself resulted in an

approximately one-third decrease in the conversion

of impaired glucose tolerance (IGT) to diabetes in

both women and men.134 Additional information

will soon be forthcoming from two primary prevention trials to provide further support for the benefits of weight management itself in preventing type

2 diabetes.146,147 In the meantime, there is reason for

optimism that weight control can be achieved, particularly in youth,148 and that the onset of type 2

diabetes can be prevented, if not substantially

delayed.

Physical activity. As with weight management, several studies of varied design have linked higher levels

of physical activity with a decreased risk of developing type 2 diabetes in women.29,133,134,148,149 One randomized controlled trial examined the effect of

physical activity alone in reducing the conversion of

IGT to type 2 diabetes, resulting in about a onethird decrease in the incidence of diabetes.134 Other

studies wherein weight control and increased physical activity were combined in a randomized control

study design have demonstrated an approximate

50% reduction in the incidence of diabetes over a

5-year follow-up period.122 While recent investigations in men indicate the beneficial effects of exercise-induced weight loss,149 similar studies in reproductive-aged women are pending. Results from the

important randomized controlled trial—the

Diabetes Prevention Program147—will provide additional support for the benefits of physical activity

(along with weight management) in the efficacy

and cost-effectiveness of preventing type 2 diabetes

in several populations, including reproductive-aged

women. Other benefits of physical activity among

reproductive-aged women with type 2 diabetes

include improved physical and social functioning

and mental health.150 In this regard, physical activity, because of its psychological benefits, may be

especially advantageous to women with diabetes,

whose quality of life scores are lower than those of

men with diabetes.150 At present, given the increasing evidence of the benefits of physical activity for

persons at risk for or with diabetes, many lifestyle

guidelines are available. The challenge will be

increasingly directed toward implementing and sustaining both weight control and physical activity

patterns to prevent several chronic diseases, not to

determine if such programs will work.151

Smoking cessation. For people with established diabetes, smoking cessation for both men and women

is ultimately beneficial in terms of mortality.136

However, the risk for mortality remains higher for

several years in persons with diabetes who once

smoked compared with diabetic persons who never

smoked. Further, the longer duration of smoking

among persons with diabetes significantly lessens

the benefit of quitting smoking.139,140 For persons

without diabetes who smoke, the impact of cigarette use on the incidence of diabetes appears to

decrease over time but may take a decade to return

to nonsmoking levels.140
The Reproductive Years

85

Family planning. Healthy behaviors are very relevant to several aspects of family planning, including

planning for pregnancy, metabolic control prior to

and during pregnancy, and postpregnancy status

and follow-up of the mother and her offspring. 

Because a woman with diabetes can have a normal,

healthy pregnancy and delivery, it is important that

conception and subsequent pregnancies be carefully

planned.152 Should pregnancy not be desired, proper

contraception is an important consideration.153

Diabetes affects the preferred method of contraception. Because intrauterine devices (IUDs) have been

associated with an increased risk for pelvic infection, use among women with diabetes has previously been limited. However, several controlled studies

using newer IUDs have shown them to be safe and

effective in reproductive-aged women with

diabetes.154

Low-dose combination oral contraceptives can also

be used for contraception by women with diabetes.

However, selection of the proper progestin and

estrogen dosages for diabetic women to minimize

potential adverse effects on glucose, lipid, and

blood pressure should be considered.153,154

Preconception care. Previous epidemiologic and clinical studies have confirmed that women with type 1

or 2 diabetes have a higher incidence of spontaneous abortions, maternal complications during

pregnancy, and fetal and neonatal mortality and

morbidity.153,154 These devastating complications are

related to the level of glycemic regulation at the

time of conception and in the first weeks of pregnancy, and with good metabolic control, can be

reduced to rates almost comparable to those of

women without diabetes.155-159 Further, evidence

indicates that these interventions are actually cost

saving.155,160

Given these scientific and economic data, public

health responsibilities are to ensure that the benefits

of this knowledge are applied to all reproductiveaged women so that proper health systems are available and used widely. One approach has been to

establish registries of persons with diabetes, especially of reproductive-aged women, to ensure proper planning, counseling, and care prior to and during pregnancy.161 Further, such registries can also

facilitate careful follow-up of women with GDM to

minimize subsequent conversion to IGT or type 2

diabetes.

Among prepregnancy counseling issues, decisions

about risks for diabetes in offspring should be considered. A parental history of diabetes has been a

major exposure in several epidemiologic investigations of the development of diabetes in offspring.162

Of particular interest is the fact that both the sex of

the parent with diabetes and the type of diabetes

have a differential effect on diabetes developing in

the offspring. Paternal type 1 diabetes is more likely

to “transmit” type 1 diabetes to the offspring than

type 1 diabetes in the mother.163,164 In contrast, the

presence of type 2 diabetes in the mother is associated with a greater likelihood of type 2 diabetes

ultimately developing in the offspring than if the

father has type 2 diabetes.165,166 These observations

regarding maternal transmission of type 2 diabetes

may be a consequence of the environmental impact

of maternal hyperglycemia during pregnancy (i.e., a

component of fetal programming).107,114

Lactation. Women with type 1 diabetes choose to

breast-feed at the same rate as mothers from the

general hospital population;167 however, mothers

with type 1 diabetes are more likely to add formula

supplements within several weeks of delivery.167,168 In

addition, the onset of copious milk production is

delayed among women with type 1 diabetes. The

extent of the delay in lactogenesis correlates directly

with adequacy of maternal glycemic control.169

Once lactation is established, the breast milk of

women with type 1 diabetes does not differ in lactose, protein, lipid, or calcium content, but it may

contain higher levels of glucose and sodium and

lower concentrations of long-chain polyunsaturated

fatty acids. Data on any effects of these qualitative

differences in breast milk are not presently available. 
86

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

An emerging issue that may have an impact on lactation counseling for women with and without diabetes is the possible association of cow’s milk during the newborn period with the subsequent development of type 1 or 2 diabetes.170-176 However,

results of studies and recommendations have been

controversial. A recent study documented high

insulin concentrations in breast milk.177 Thus, with

formula/cow’s milk use, an increased incidence of

type 1 diabetes could reflect an absence of a toleragen, such as maternal insulin, and not the presence

of an immunogenetic substance in cow’s milk.

Better designed studies are presently ongoing that

should provide more definitive information in the

near future.178

Behaviors in the postpartum period may well influence the likelihood of developing subsequent type 2

diabetes in both the mother and the newborn. As

previously discussed, a very high percentage of

reproductive-aged women who have GDM progress

to type 2 diabetes.37 Although an initial study has

demonstrated an impressive effect of an insulinsensitizing agent in reducing the progression from

GDM to diabetes in a high-risk population,101 evidence that weight management by the mother during the postpartum period and beyond reduces the

incidence of type 2 diabetes requires confirmation.

Certainly, results from studies in nonpregnant

women134,136 indicate such activities would be

expected to be beneficial for women with previous

GDM, but confirmation is required. 

Similarly, given the evidence supporting fetal programming107-114 and the additional impact of weight

gain in early youth on the subsequent development

of insulin resistance and type 2 diabetes,148 ensuring

proper nutrition and physical activity in the early

years of life would be a reasonable risk-reduction

strategy, if not yet firmly proven. 

Adherence and Self-Management

Because of the increasing awareness in the diabetes

community that individual and organizational

behaviors can be positive or negative in terms of the

impact of diabetes on reproductive-aged women,

investigations in this important domain of behavior

have become very relevant to a public health perspective on diabetes. Adherence is one term used to

describe the extent to which patients engage in

health-promoting behaviors recommended by

health professionals.179 The results of nonadherence

in terms of adverse health and economic consequences are substantial, whether the condition is

infectious,180 acute,181 chronic,182 or reflective of

appropriate use of health care systems.183,184 Initially,

a lack of adherence was assumed to be due to a lack

of information.185 More recent conceptual frameworks recognize that adherence is influenced by

individual beliefs and attitudes; the influence of

family, community, and other forms of social support; physician characteristics; and the home, work,

and practice care settings.179,185,186 Few studies have

specifically addressed adherence among women

aged 18–44 years; however, women who have multiple family roles that place high demands on them

could experience difficulties with requirements of

diabetes control.179

Studies on compliance and adherence approaches

have been criticized because they imply that problems of patient management are due solely to the

patient’s individual and conscious behavior.179,185,187

These studies confirm both the complexity of

human behavior as well as the need to incorporate

multiple approaches to improving the behaviors of

patients, health care providers, and health systems

alike.188 Certainly, there is ample evidence that scientifically and economically validated diabetes preventive care practices are not used as widely as

desired (i.e., a gap exists between what should be

and what is happening in diabetes care).189,190

Although the factors accounting for this gap are

numerous and complex (e.g., type of diabetes, education level, social support, age, insurance coverage,

employment status191), and although assignment of

the gap to any one of these many factors is

difficult,186,187 the ability of a person with diabetes to

understand, agree to, and follow a diabetes treatment plan is likely to be important. 
The Reproductive Years

87

A framework for understanding choices about daily

diabetes self-management can include two major

domains: 1) knowledge about diabetes as provided

primarily by comprehensive diabetes patient education, and 2) psychosocial skills (discussed in section

4.5) that can significantly influence the success of a

diabetes self-care plan.192

Patient education. From a public health perspective

on diabetes education, four important dimensions

must be recognized. First, validity of the benefits of

diabetes patient education in terms of improved

health outcomes is currently limited yet is necessary

to more broadly ensure the availability of such programs.185,193,194 In large part, this challenge may

reflect an inappropriate evaluation framework for

validating more broadly based population/community-focused interventions.195 Second, frameworks

for more broadly considering how to understand

and improve patient education programs for persons with diabetes, including reproductive-aged

women, have been developed.185,186,195,196 Third, policy decisions by government, as well as legal processes, including not only content but also reimbursement strategies and efforts to ensure that all persons

with diabetes have access to at least some education, can be very influential in making diabetes

education available.84,197-199 Finally, only a few studies

at present have directly examined diabetes patient

education programs for reproductive-aged women,

but these investigations have confirmed the importance of cultural factors in patient adherence.200-202

4.5 Psychosocial Determinants of Health

Behaviors and Health Outcomes

Four aspects of psychosocial determinants, each

with a public health dimension, deserve further discussion: 1) social environment, 2) nondiseaserelated stress, 3) personal disposition, and 

4) relationships with the health care system.185,186

Social Environment 

A chronic disease like diabetes is managed within

an interpersonal milieu.203 A woman’s social environment consists of the network of persons who

provide her with various types of support and the

social context in which this support is provided.185

A major (but not the only) part of a woman’s network is her family. In 1995, approximately 7% of

women aged 20–44 lived alone, 51% lived with a

spouse, 32% lived with other relatives only, and

10% lived with nonrelatives only.204 The family,

defined broadly as a group of people living together

or in close geographic proximity with strong emotional bonds and with a history and future,151 may

provide a helpful context for understanding management challenges of diabetes, especially a complex

medical regimen, over a long period of time.151,203

Within the family construct (and indeed, beyond

the family itself and including such factors as community and work),151 cultural differences among

reproductive-aged women may work synergistically

or independently to influence the family network.205-209 For example, in Hispanic communities

and families, health needs may be viewed as a lower

priority than work; joint family meals may be difficult; and relevancy of education programs can be

problematic.206 Similarly, black women may face

multiple barriers to diabetes management based on

family support, including availability of healthy

food, level of family support, and perceptions of a

healthy body image that may include being overweight.200,207-209 Finally, the importance of extended

family concepts, such as friends and the faith community, are examples of how different cultures may

influence diabetes management of a reproductiveaged woman with diabetes.151 The relevance and

importance of the social environment to the development and management of diabetes among

women in the reproductive years needs further systematic investigation.

During the past several years, there has been

increased recognition of the importance of the

social and cultural environment wherein a person

lives, works, or plays, because it significantly influences the present and future health of that person.210-212 The term “social capital” is typically

defined as “an instantiated informal norm that promotes cooperation between two or more individuals.”213 In essence, social capital is a reflection of the
88

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

degree of cooperative interaction among people and

is based on a sense of trust, common interests, and

willingness to work together.214

Indicators of social capital (e.g., trust, income or

educational disparities, participation in civic organizations) have been studied in terms of defining and

quantifying community or society cooperation.215,216

Further, initial investigations have explored the relationships between various indicators of positive or

negative social capital and clinical health outcomes

such as perceived quality of life and mortality217,218

Although more investigations will be necessary to

both confirm the concepts inherent in social capital

as well as determine if and how social capital can be

intentionally altered,219 initial studies strongly suggest that individual behaviors are largely influenced

by social class, social capital, and the characteristics

of a community. Thus, in considering management

of diabetes among women in their reproductive

years, it is very important to reflect on the social

environment, which can strongly influence individual behaviors and choices, and the importance of

life stress and personal disposition, as discussed in

the following paragraphs.

Life Stress

Women of reproductive age with diabetes face both

biological and behavioral components of stress.220

Studies of biological stress focus on the physiologic

adaptation of the body to life circumstances, whereas behavioral stress research addresses emotional

responses to environmental and various psychosocial situations.221 A limited number of studies have

examined relationships between stress and glycemic

control in diabetic reproductive-aged women.222-224

However, broader views of stress must be incorporated into studies. For example, relationships

between stress and use of health care services by

persons with diabetes deserve additional investigation.225 Other public health perspectives of stress

and diabetes include relationships between environmental experiences (e.g., work, church) and both

biological and behavioral components of stress.225

Personal Disposition

Personal disposition refers to long-standing emotional and psychological characteristics of an individual that may intervene in the pathway from

stress to health outcomes. Personal disposition is

often measured by examining coping styles, perceived control, and mastery/self-efficacy.226 A common measure of perceived control is the use of

locus of control—external versus internal—to

measure ability to control events. Studies using this

approach have yielded contradictory results regarding diabetes control and other diabetes-related

health outcomes.227-229 In contrast, concepts such as

self-efficacy, defined as the belief in one’s ability to

maintain behavior change in the face of situational

challenges, are considered better predictors of

adherence to medical treatment and health-promotion regimens because they are associated with better adherence to complex diabetes regimens.229

Interactions with the Health Care System

Several aspects of women’s interactions with the

health care system deserve attention from the public health community. Reproductive-aged women,

not only during pregnancy (for possible GDM),

may need to be screened for undiagnosed diabetes.

As recently reviewed, however, general screening for

undiagnosed diabetes (except in the case of pregnant women) must be considered within the larger

context of long-term diabetes management and

economics.230 Cost-effective screening for unrecognized diabetes would be better targeted at persons

younger than 45 years of age, including women of

reproductive age, and in those groups (such as

younger women from minority racial and ethnic

groups) with a high incidence of preventable diabetes complications.230

Regarding actual diabetes care and women of reproductive age, convincing clinical and economic evidence suggests that both secondary prevention

(improved glycemic, lipid, and blood pressure control) and tertiary prevention (improved complication detection and treatment) are efficacious and
The Reproductive Years

89

cost-effective.231,232 Public health response to the scientific evidence would focus on two aspects: 

1) ensuring that all people with diabetes receive at

least some benefit, and 2) establishing health systems that both recognize and accommodate the

particular characteristics of reproductive-aged

women with diabetes.

With respect to equity and availability of efficacious

secondary and tertiary care, several factors are disturbing: 1) millions of Americans, including

women in their reproductive years, do not have

health insurance and thus must pay directly if they

are to receive these scientifically justified preventive

programs,233 2) policies often require ideal standards

and objectives, without considering the reality of

limits in terms of financial or health professional

resources or availability (i.e., some people may get

very good care, but others will get nothing),233-235

and 3) scientific data on the benefits of glucose and

blood pressure control demonstrate that any

improvement in metabolic indices results in

improvement in outcomes, and the greatest

absolute benefit is obtained by improvement among

persons with the highest levels of blood glucose and

blood pressure.236-238 Thus, if the public health community has a responsibility of assurance,239 it must

assure that all women of reproductive age have

access to secondary and tertiary care.

In terms of the nature of the interaction between

women who have diabetes in their reproductive

years and the health care system, managed care

organizations are becoming the main source of

health care services for persons with diabetes.240

Although various managed care plans function with

different rules, regulations, and policies, fragmentation of care may be particularly challenging for

women of reproductive age because of the many

other roles and responsibilities they face—such as

work, family, home, children.241,242 In addition to

access to quality care, women with or at risk for

diabetes may also be concerned about the appropriateness or the nature of their interactions with the

health care system. New definitions of comprehensive care, particularly relevant to reproductive-aged

women with diabetes, have been proposed that

include interpersonal care (provider partnershipbuilding behavior and a participatory decisionmaking style) as well as clinical care.243,244 This

movement toward collaborative care may have

important implications for the care of women with

diabetes. The public health challenge in response to

these newer models for diabetes care for reproductive-aged women is to work with the health care

system to facilitate the availability and use of these

models.

4.6 Concurrent Illness as a Determinant of

Health Behaviors and Health Outcomes

Diabetes mellitus does not make an individual

immune to health conditions that are not related to

the metabolic abnormalities of diabetes. These concurrent illnesses, however, may significantly compromise efforts to achieve metabolic control.

Indeed, given the complexities and demands of diabetes, these conditions, especially psychological

conditions, may significantly attenuate the effects

of proper diabetes management.

Eating Disorders

Although the onset of eating disorders among

women with type 1 diabetes usually occurs in adolescence (see chapter 3), persistence of these conditions into adulthood as well as the presence of subclinical eating disorders during the reproductive

years are of concern.245-247 Less information is available on eating disturbances among women with

type 2 diabetes, particularly among women aged

18–44 years. Unlike women with type 1 diabetes,

however, a majority of reproductive-aged women

with type 2 diabetes report that eating disorders

preceded the onset of their diabetes and that binge

eating more accurately describes the nature of their

eating disorder.245,248

Depression 

The prevalence of depression is 3–4 times greater

among people with diabetes (15%–20%) than

among the general population (5%–8%).249 Women
90

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

with diabetes are considered to be at increased risk

for depression because of both their sex and their

disease,250 but very few population-based studies

have examined rates of depression among men and

women with and without diabetes between the ages

of 18 and 44 years.251 The higher prevalence of

depression among women with diabetes remains

unexplained, but the concurrence of these two disorders may have harmful interactions, with resulting poor metabolic control and increased requirements for diabetes regulation.250,252,253 Despite the

increased prevalence among people with diabetes,

depression is diagnosed and treated in fewer than

one-third of patients, perhaps in part because managing diabetes is very time-consuming. Further,

some of the symptoms—fatigue, changes in

appetite, and sleep disturbances—are seen in both

disorders. Thus, diagnosing the coexistence of diabetes and depression is unlikely. Structured psychiatric interviews and validated survey instruments

can distinguish the two disorders, however.250-253

In considering the studies regarding diabetes and

various psychosocial issues (e.g., life stress, associated psychological conditions) among diabetic

women of reproductive age, several caveats are

important: 1) most reports emanate from tertiary

academic institutions, and thus given inevitable

referral bias, issues of generalizability to the entire

population need to be considered, 2) perspectives

on the various psychosocial issues are often limited

to a clinical viewpoint and only consider what is

happening in the person’s life at that moment.

Regarding the former, it is very possible that a

lower social class designation or low social capital

could cause both in the development of diabetes

and impaired psychological function (i.e., depression and diabetes may not be directly related at

all).254

Similarly, recent studies indicate that experiencing

childhood abuse may be associated with not only

impaired psychological function but also a considerably greater likelihood of developing a chronic

disease like diabetes among women of reproductive

age.255 Further, there is reason to consider whether

lower social capital or a lower social class with less

income and education would result in both a

greater number of cases of diabetes among women

of reproductive age, as well as greater difficulty in

diabetes care among these same individuals.256

Public health challenges concerning mental health

disorders in diabetic women of reproductive age are

1) to improve surveillance efforts to more clearly

define the extent and nature of the coexistence of

these conditions, 2) to encourage better etiologic

research including measurement of social capital

and early life events detection to understand the

pathophysiologic reasons for the co-occurrence of

these conditions, 3) to obtain population-based

data on mental health disorders and diabetes, and

4) to ensure health care systems will permit and

facilitate both the identification and appropriate

treatment of the mental disorders commonly seen

in diabetic women of reproductive age.

4.7 Public Health Implications

Surveillance and epidemiologic data presently suggest that the prevalence of diabetes, especially type

2, is increasing most dramatically among reproductive-aged women—an increase most noteworthy in

women from communities of color.

• Better surveillance information is required to

confirm these initial observations and should

focus on minority populations where additional

confirmatory data about the prevalence of diabetes and associated complications among diabetic women of reproductive age would enhance

our ability to target intervention efforts.

• Improved epidemiologic and health services data

are required to understand environmental and

behavioral factors (e.g., weight gain, physical

inactivity, community exercise facilities) and

genetic-environmental interactions that may

account for the increasing trends in incidence of

type 2 diabetes among women in their reproductive years.
The Reproductive Years

91

Population-based studies confirm the intergenerational effects of fetal nutrition status during pregnancy as well as the relationship of early life experiences on subsequent risk for chronic disease in

adulthood. The degree to which this effect contributes to the increase in the prevalence of diabetes

among persons younger than 45 years of age should

be investigated. 

• Improved epidemiologic information is needed

to confirm this intergenerational effect and to

clarify the exact factors that account for its existence. Primary prevention of type 2 diabetes

needs to systematically address pregnancy—not

only to ensure a healthy mother and baby, but

also to decrease the likelihood of subsequent diabetes in the mother and offspring.

• Additional information about GDM is required,

including basic epidemiologic data on screening

policies, possible preventive strategies among

women at risk for GDM, and appropriate treatment strategies once GDM is diagnosed. In

addition, the postpartum period for women

with GDM needs attention both to better document the high rate of progression from GDM to

type 2 diabetes, as well as to identify interventions during the months and years following

delivery that would prevent or delay the onset of

diabetes.

In women of reproductive age with diabetes, it is

necessary to systematically identify the presence of

risk factors for the development of microvascular

and macrovascular complications. Such information

will help in the development of risk reduction programs to reduce the occurrence of these complications in midlife. 

• Various health care systems must be structured

and must function in a manner that will facilitate improved detection of risk factors and,

when appropriate, management of these risk factors so that the appearance of common complications of diabetes will be reduced in women

after age 44 years.

• The interaction between reproductive-aged

women with diabetes and the health care system

needs to be collaborative in nature.

• Policies at the federal, state, and local levels must

ensure that all women with diabetes during the

reproductive years have access to appropriate

preventive strategies for diabetes and associated

conditions, including various mental health disorders.

• Attention to the various and critical environmental factors is needed to move beyond the

important but limiting individual view of health

and behavior. Research is needed to gain insight

into the effects of community-level characteristics, such as social capital and equity, on diabetes

prevention and control.
92

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

References

1. Ventura SJ, Mosher WD, Curtin SC, Abma JC,

Henshaw S. Trends in pregnancies and pregnancy rates

by outcome: estimates for the United States, 1976–96.

Vital Health Stat 2000;21(56):1–47.

2. Harris MI. Classification, diagnostic criteria, and screening for diabetes. In: National Diabetes Data Group, editors. Diabetes in America. 2nd ed. Bethesda, MD:

National Institutes of Health, 1995:15–36. (NIH

Publication No. 95-1468)

3. Harris MI, Flegal KM, Cowie CC, et al. Prevalence of

diabetes, impaired fasting glucose, and impaired glucose

tolerance in U.S. adults. The Third National Health and

Nutrition Examination Survey, 1988–1994. Diabetes

Care 1998;21(4):518–24.

4. Day JC. Population Projections of the United States by

Age, Sex, Race, and Hispanic Origin: 1995 to 2050. U.S.

Bureau of the Census, Current Population Reports, P25-

1130. Washington, DC: U.S. Government Printing

Office, 1996.

5. American Diabetes Association. Report of the Expert

Committee on the Diagnosis and Classification of

Diabetes Mellitus. Diabetes Care 1997;20(7):1183–97.

6. Carter JS, Pugh JA, Monterrosa A. Non–insulindependent diabetes mellitus in minorities in the United

States. Ann Intern Med 1996;125(3):221–32.

7. Ellis JL, Campos-Outcalt D. Cardiovascular disease risk

factors in Native Americans: a literature review. Am J

Prev Med 1994;10(5):295–307.

8. Will JC, Strauss KF, Mendlein JM, Ballew C, White LL,

Peter DG. Diabetes mellitus among Navajo Indians:

findings from the Navajo Health and Nutrition Survey.

J Nutr 1997;127(10 Suppl):2106S–2113S.

9. CDC. Prevalence of diagnosed diabetes among

American Indians/Alaskan Natives—United States,

1996. MMWR 1998;47(42):901–4.

10. Schraer CD, Adler AI, Mayer AM, Halderson KR,

Trimble BA. Diabetes complications and mortality

among Alaska Natives: 8 years of observation. Diabetes

Care 1997;20(3):314–21.

11. Flegal KM, Ezzati TM, Harris MI, et al. Prevalence of

diabetes in Mexican Americans, Cubans, and Puerto

Ricans from the Hispanic Health and Nutrition

Examination Survey, 1982–1984. Diabetes Care

1991;14(Suppl 3):628–38.

12. CDC. Self-reported prevalence of diabetes among

Hispanics—United States, 1994–1997. MMWR

1999;48(1):8–12.

13. LaPorte RE, Matsushima M, Chang Y-F. Prevalence and

incidence of insulin-dependent diabetes. In: National

Diabetes Data Group, editors. Diabetes in America. 2nd

ed. Bethesda, MD: National Institutes of Health,

1995:37–46. (NIH Publication No. 95-1468)

14. Harris MI, Robbins DC. Prevalence of adult-onset

IDDM in the U.S. population. Diabetes Care 1994;

17(11):1337–40.

15. Kenny SJ, Aubert RE, Geiss LS. Prevalence and incidence of non–insulin-dependent diabetes. In: National

Diabetes Data Group, editors. Diabetes in America. 2nd

ed. Bethesda, MD: National Institutes of Health,

1995:47–67. (NIH Publication No. 95-1468)

16. Lipton RB, Liao Y, Cao G, Cooper RS, McGee D.

Determinants of incident non–insulin-dependent diabetes mellitus among blacks and whites in a national

sample. The NHANES I Epidemiologic Follow-up

Study. Am J Epidemiol 1993;138(10):826–39.

17. Haffner SM, Hazuda HP, Mitchell BD, Patterson JK,

Stern MP. Increased incidence of type II diabetes mellitus in Mexican Americans. Diabetes Care 1991;14(2):

102–8.

18. Knowler WC, Bennett PH, Hamman RF, Miller M.

Diabetes incidence and prevalence in Pima Indians: a

19-fold greater incidence than in Rochester, Minnesota.

Am J Epidemiol 1978;108(6):497–505.

19. Libman I, Songer T, LaPorte R. How many people in

the U.S. have IDDM? Diabetes Care 1993;16(5):841–2.

20. CDC. <http://www.cdc.gov/diabetes/statistics/survl99/

2chap2/table10.html>. Last revised March 20, 2000.

21. CDC. Trends in the prevalence and incidence of selfreported diabetes mellitus—United States, 1980–1994.

MMWR 1997;46(43):1014–8.
The Reproductive Years

93

22. Leibson CL, O’Brien PC, Atkinson E, Palumbo PJ,

Melton LJ 3rd. Relative contributions of incidence and

survival to increasing prevalence of adult-onset diabetes

mellitus: a population-based study. Am J Epidemiol

1997;146(1):12–22.

23. Mokdad AH, Ford ES, Bowman BA, et al. Diabetes

trends in the U.S.: 1990–1998. Diabetes Care 2000;

23(9):1278–83. 

24. Burke JP, Williams K, Gaskill SP, Hazuda HP, Haffner

SM, Stern MP. Rapid rise in the incidence of type 2 diabetes from 1987 to 1996: results from the San Antonio

Heart Study. Arch Intern Med 1999;159(13):1450–6.

25. Knowler WC, Saad MF, Pettitt DJ, Nelson RG, Bennett

PH. Determinants of diabetes mellitus in the Pima

Indians. Diabetes Care 1993;16(1):216–27.

26. Gu K, Cowie CC, Harris MI. Diabetes and decline in

heart disease mortality in U.S. adults. JAMA 1999;

281(14):1291–7.

27. Colditz GA, Willett WC, Stampfer MJ, et al. Weight as

a risk factor for clinical diabetes in women. Am J

Epidemiol 1990;132(3):501–13.

28. Ford ES, Williamson DF, Liu S. Weight change and diabetes incidence: findings from a national cohort of U.S.

adults. Am J Epidemiol 1997;146(3):214–22.

29. Manson JE, Rimm EB, Stampfer MJ, et al. Physical

activity and incidence of non–insulin-dependent diabetes mellitus in women. Lancet 1991;338(8770):

774–8.

30. Freedman DS, Srinivasan SR, Valdez RA, Williamson

DF, Berenson GS. Secular increases in relative weight

and adiposity among children over two decades: the

Bogalusa Heart Study. Pediatrics 1997;99(3):420–6.

31. Flegal KM, Carroll MD, Kuczmarski RJ, Johnson CL.

Overweight and obesity in the United States: prevalence

and trends, 1960–1994. Int J Obes Relat Disord 1998;

22(1):39–47.

32. Crespo CJ, Keteyian SJ, Heath GW, Sempos CT.

Leisure-time physical activity among U.S. adults: results

from the Third National Health and Nutrition

Examination Survey. Arch Intern Med 1996;156(1):

93–8.

33. Lewis CE, Smith DE, Wallace DD, Williams OD, Bild

DE, Jacobs DR Jr. Seven-year trends in body weight and

associations with lifestyle and behavioral characteristics

in black and white young adults: the CARDIA Study.

Am J Public Health 1997;87(4):635–42. 

34. Metzger BE, Coustan DR, the Organizing Committee.

Summary and recommendations of the Fourth

International Workshop-Conference on Gestational

Diabetes Mellitus. Diabetes Care 1998;21(Suppl 2):

B161–B167.

35. Kjos SL, Buchanan TA. Gestational diabetes mellitus. 

N Engl J Med 1999;341(23):1749–56.

36. Moses RG. The recurrence rate of gestational diabetes in

subsequent pregnancies. Diabetes Care 1996;19(12):

1348–50.

37. Dornhorst A, Rossi M. Risk and prevention of type 2

diabetes in women with gestational diabetes. Diabetes

Care 1998;21(Suppl 2):B43–B49.

38. Persson B, Hanson U. Neonatal morbidities in gestational diabetes mellitus. Diabetes Care 1998;21(Suppl

2):B79–B84.

39. Pettitt DJ, Knowler WC. Long-term effects of the

intrauterine environment, birth weight, and breast-feeding in Pima Indians. Diabetes Care 1998;21(Suppl

2):B138–B141.

40. Silverman BL, Rizzo TA, Cho NH, Metzger BE. Longterm effects of the intrauterine environment. The

Northwestern University Diabetes in Pregnancy Center.

Diabetes Care 1998;21(Suppl 2):B142–B149.

41. King H. Epidemiology of glucose intolerance and gestational diabetes in women of childbearing age. Diabetes

Care 1998;21(Suppl 2):B9–B13.

42. Engelgau MM, Herman WH, Smith PJ, German RR,

Aubert RE. The epidemiology of diabetes and pregnancy

in the U.S., 1988. Diabetes Care 1995;18(7):1029–33.

43. CDC. Diabetes during pregnancy—United States,

1993–1995. MMWR 1998;47(20):408–14.

44. Kieffer EC, Martin JA, Herman WH. Impact of maternal nativity on the prevalence of diabetes during pregnancy among U.S. ethnic groups. Diabetes Care

1999;22(5):729–35.
94

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

45. Nahum GG, Huffaker BJ. Racial differences in oral glucose screening test results: establishing race-specific criteria for abnormality in pregnancy. Obstet Gynecol 1993;

81(4):517–22.

46. Berkowitz GS, Lapinski RH, Wein R, Lee D. Race/

ethnicity and other risk factors for gestational diabetes.

Am J Epidemiol 1992;135(9):965–73.

47. Green JR, Pawson IG, Schumacher LB, Perry J,

Kretchmer N. Glucose tolerance in pregnancy: ethnic

variation and influence of body habitus. Am J Obstet

Gynecol 1990;163:86–92.

48. Dornhost A, Paterson CM, Nicholls JS, et al. High

prevalence of gestational diabetes in women from ethnic

minority groups. Diabet Med 1992;9(9):820–5.

49. Benjamin E, Winters D, Mayfield J, Gohdes D.

Diabetes in pregnancy in Zuni Indian women.

Prevalence and subsequent development of clinical diabetes after gestational diabetes. Diabetes Care 1993;

16(9):1231–5.

50. Solomon CG, Willett WC, Carey VJ, et al. A prospective study of pregravid determinants of gestational diabetes mellitus. JAMA 1997;278(13):1078–83.

51. Strauss KF, Mokdad A, Ballew C, et al. The health of

Navajo women: findings from the Navajo Health and

Nutrition Survey, 1991–1992. J Nutr 1997;127(10

Suppl):2128S–2133S.

52. Cowie CC, Eberhardt MS. Sociodemographic characteristics of persons with diabetes. In: National Diabetes

Data Group, editors. Diabetes in America. 2nd ed.

Bethesda, MD: National Institutes of Health,

1995:85–116. (NIH Publication No. 95-1468)

53. Drury TF, Danchik KM, Harris MI. Sociodemographic

characteristics of adult diabetics. In: National Diabetes

Data Group, editors. Diabetes in America. 1st ed.

Bethesda, MD: National Institutes of Health; 1985:VII1–VII-37. (NIH Publication No. 85-1468)

54. Peters KD, Kochanek KD, Murphy SL. Deaths: final

data for 1996. Natl Vital Stat Rep 1998;47(9):1–100.

55. Bild DE, Stevenson JM. Frequency of recording of diabetes on U.S. death certificates: analysis of the 1986

National Mortality Followback Survey. J Clin Epidemiol

1992;45(3):275–81.

56. Geiss LS, Herman WH, Smith PJ. Mortality in

non–insulin-dependent diabetes. In: National Diabetes

Data Group, editors. Diabetes in America. 2nd ed.

Bethesda, MD: National Institutes of Health,

1995:233–57. (NIH Publication No. 95-1468)

57. Garcia MJ, McNamara PM, Gordon T, Kannel WB.

Morbidity and mortality in diabetics in the Framingham

population. Sixteen-year follow-up study. Diabetes 1974;

23:105–11.

58. Manson JE, Colditz GA, Stampfer MJ, et al. A prospective study of maturity-onset diabetes mellitus and risk of

coronary heart disease and stroke in women. Arch Intern

Med 1991;151(2):1141–7.

59. Moss SE, Klein R, Klein BE. Cause-specific mortality in

a population-based study of diabetes. Am J Public

Health 1991;81(9):1158–62.

60. Stamler J, Vaccaro O, Neaton JD, Wentworth D.

Diabetes, other risk factors, and 12-yr cardiovascular

mortality for men screened in the Multiple Risk Factor

Intervention Trial. Diabetes Care 1993;16(2):434–44.

61. Sievers ML, Nelson RG, Knowler WC, Bennett PH.

Impact of NIDDM on mortality and causes of death in

Pima Indians. Diabetes Care 1992;15(11):1541–9.

62. Wei M, Gaskill SP, Haffner SM, Stern MP. Effects of

diabetes and level of glycemia on all-cause and cardiovascular mortality. The San Antonio Heart Study.

Diabetes Care 1998;21(7):1167–72.

63. Gu K, Cowie CC, Harris MI. Mortality in adults with

and without diabetes in a national cohort of the U.S.

population, 1971–1993. Diabetes Care 1998;21(7):

1138–45.

64. International analysis of insulin-dependent diabetes mellitus mortality: a preventable mortality perspective. The

Diabetes Epidemiology Research International (DERI)

Study. Am J Epidemiol 1995;142(6):612–8.

65. Tull ES, Barinas E. A twofold excess mortality among

black compared with white IDDM patients in Allegheny

County, Pennsylvania. Pittsburgh DERI Mortality Study

Group. Diabetes Care 1996;19(12):1344–7.

66. Klein R, Klein BE. Vision disorders in diabetes. In:

National Diabetes Data Group, editors. Diabetes in

America. 2nd ed. Bethesda, MD: National Institutes of

Health, 1995:293–338. (NIH Publication No. 95-1468)
The Reproductive Years

95

67. Hemachandra A, Ellis D, Lloyd CE, Orchard TJ. The

influence of pregnancy on IDDM complications.

Diabetes Care 1995;18(7):950–4.

68. Chew EY, Mills JL, Metzger BE, et al. Metabolic control

and progression of retinopathy. The Diabetes in Early

Pregnancy Study. National Institute of Child Health and

Human Development Diabetes in Early Pregnancy

Study. Diabetes Care 1995;18(5):631–7.

69 American Diabetes Association. Diabetic nephropathy.

Diabetes Care 1999;22(Suppl 1):S66–S69.

70. Nelson RG, Knowler WC, Pettitt DJ, Bennett PH.

Kidney diseases in diabetes. In: National Diabetes Data

Group, editors. Diabetes in America. 2nd ed. Bethesda,

MD: National Institutes of Health, 1995:349–400.

(NIH Publication No. 95-1468)

71. Klein BE, Moss SE, Klein R. Effect of pregnancy on

progression of diabetic nephropathy. Diabetes Care

1990;13(1):34–40.

72. Grundy SM, Benjamin IJ, Burke GL, et al. Diabetes and

cardiovascular disease: a statement for health care professionals from the American Heart Association.

Circulation 1999;100(10):1134–46.

73. Wingard DL, Barrett-Connor E. Heart disease and diabetes. In: National Diabetes Data Group, editors.

Diabetes in America. 2nd ed. Bethesda, MD: National

Institutes of Health, 1995:429–48. (NIH Publication

No. 95-1468)

74. Selby JV, Ray GT, Zhang D, Colby CJ. Excess costs of

medical care for patients with diabetes in a managed

care population. Diabetes Care 1997;20(9):1396–1402.

75. Koivisto VA, Stevens LK, Mattock M, et al.

Cardiovascular disease and its risk factors in IDDM in

Europe. EURODIAB IDDM Complications Study

Group. Diabetes Care 1996;19(7):689–97.

76. Lloyd CE, Kuller LH, Ellis D, Becker DJ, Wing RR,

Orchard TJ. Coronary artery disease in IDDM. Gender

differences in risk factors but not risk. Arterioscler

Thromb Vasc Biol 1996;16(6):720–6.

77. Sowers J. Diabetes mellitus and cardiovascular disease in

women. Arch Intern Med 1998;158(6):617–21.

78. American Diabetes Association; National Heart, Lung,

and Blood Institute; Juvenile Diabetes Foundation

International; National Institute of Diabetes and

Digestive and Kidney Disease; American Heart

Association. Diabetes mellitus: a major risk factor for

cardiovascular disease. Circulation 1999;1000:1132–3.

79. Haffner SM. Management of dyslipidemia in adults

with diabetes. Diabetes Care 1998;21(1):160–78.

80. American Diabetes Association. Implications of the

United Kingdom Prospective Diabetes Study. Diabetes

Care 1999;22(Suppl 1):27S–31S.

81. Yudkin JS, Chaturvedi N. Developing risk stratification

charts for diabetic and nondiabetic subjects. Diabet Med

1999;16(3):219–27.

82. Vinicor F. The public health burden of diabetes and the

reality of limits. Diabetes Care 1998;21(Suppl 3):

C15–C18.

83. Glasgow RE, Wagner EH, Kaplan RM, Vinicor F, 

Smith L, Norman J. If diabetes is a public health problem, why not treat it as one? A population-based

approach to chronic illness. Ann Behav Med 1999;

21(2):159–70.

84. Lunt H. Women and diabetes. Diabet Med 1996;13:

1009–16.

85. Glasgow R, Toobert D, Riddle M, Donnelly J, Mitchell

D, Calder D. Diabetes-specific social learning variables

and self-care behaviors among persons with type 2 diabetes. Health Psychol 1989;8(3):285–303.

86. Garay-Sevilla ME, Nava LE, Malacara JM, Huerta R, et

al. Adherence to treatment and social support in patients

with non–insulin-dependent diabetes mellitus. 

J Diabetes Complications 1995;9(2):81–6.

87. Larsson D, Lager I, Nilsson PM. Socioeconomic characteristics and quality of life in diabetes mellitus—relation

to metabolic control. Scand J Public Health 1999;27(2):

101–5.

88. Rubin RR, Peyrot M. Quality of life and diabetes.

Diabetes Metab Res Rev 1999;15(3):205–18.

89. Clark CM Jr. The National Diabetes Education

Program: changing the way diabetes is treated. Ann

Intern Med 1999;130:324–6.
96

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

90. The Diabetes Control and Complications Trial Research

Group. The effect of intensive treatment of diabetes on

the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J

Med 1993;329(14):977–86.

91. Diabetes Control and Complications Trial Research

Group. Influence of intensive diabetes treatment on

quality-of-life outcomes in the Diabetes Control and

Complications Trial. Diabetes Care 1996;19(3):195–203.

92. Diabetes Control and Complications Trial Research

Group. Implementation of treatment protocols in the

Diabetes Control and Complications Trial. Diabetes

Care 1995;18(3):361–76.

93. UK Prospective Diabetes Study (UKPDS) Group.

Quality of life in type 2 diabetic patients is affected by

complications but not by intensive policies to improve

blood glucose or blood pressure control (UKPDS 37).

Diabetes Care 1999;22(7):1125–36.

94. Wikblad K, Leksell J, Wibell L. Health-related quality of

life in relation to metabolic control and late complications in patients with insulin-dependent diabetes mellitus. Qual Life Res 1996;5(1):123–30.

95. Testa MA, Simonson DC. Health economic benefits and

quality of life during improved glycemic control in

patients with type 2 diabetes mellitus: a randomized,

controlled, double-blind trial. JAMA 1998;280(17):

1490–6.

96. Glasgow RE, Ruggiero L, Eakin EG, Dryfoos J,

Chobanian L. Quality of life and associated characteristics in a large national sample of adults with diabetes.

Diabetes Care 1997;20(4):562–7.

97. Centers for Disease Control and Prevention. Diabetes

Surveillance 1997. Atlanta: U.S. Department of Health

and Human Services, 1997.

98. Kerbel D, Glazier R, Holzapfel S, Yeung M, Lofsky S.

Adverse effects of screening for gestational diabetes: a

prospective cohort study in Toronto, Canada. J Med

Screen 1997;4(3):128–32.

99. Dornhorst A, Chan SP. The elusive diagnosis of gestational diabetes. Diabet Med 1998;15(1):7–10.

100. Naylor CD, Sermer M, Chen E, Sykora K. Cesarean

delivery in relation to birth weight and gestational glucose tolerance: pathophysiology or practice style? JAMA

1996;275(15):1165–70.

101. Azen SP, Peters RK, Berkowitz K, Kjos S, Xiang A,

Buchanan TA. TRIPOD (TRoglitazone In the

Prevention Of Diabetes): a randomized, placebocontrolled trial of troglitazone in women with prior gestational diabetes mellitus. Control Clin Trials 1998;

19(2):217–31.

102. Pettitt DJ, Baird HR, Aleck KA, Bennett PH, Knowler

WC. Excessive obesity in offspring of Pima Indian

women with diabetes during pregnancy. N Engl J Med

1983;308(5):242–5.

103. Silverman BL, Rizzo T, Green OC, et al. Long-term

prospective evaluation of offspring of diabetic mothers.

Diabetes 1991;40(Suppl 2):121–5.

104. Pettitt DJ, Aleck KA, Baird HR, Bennett PH, Knowler

WC. Congenital susceptibility to NIDDM. Role of

intrauterine environment. Diabetes 1988;37(5):622–8.

105. Karter AJ, Rowell SE, Ackerson LM, Ferrara A. Excess

maternal transmission of type 2 diabetes across all races:

the Northern California Kaiser Permanente Diabetes

Registry. Diabetes 1998;47(Suppl 2):25A.

106. Reaven G. Insulin resistance and human disease: a short

history. J Basic Clin Physiol Pharmacol 1998;9(2–4):

387–406.

107. Barker DJ. The fetal origins of type 2 diabetes mellitus.

Ann Intern Med 1999;130:322–4.

108. Valdez R, Athens MA, Thompson GH, Bradshaw BS,

Stern MP. Birth-weight and adult health outcomes in a

biethnic population in the USA. Diabetologia 1994;37:

624–31.

109. McCance DR, Pettitt DJ, Hanson RL, Jacobson LT,

Knowler WC, Bennett PH. Birth weight and

non–insulin-dependent diabetes: thrifty genotype,

thrifty phenotype, or surviving small baby genotype?

BMJ 1994;308(6934):942–5.

110. Egeland GM, Skjaerven R, Irgens L. Birth characteristics

of women who develop gestational diabetes: population

based study. BMJ 2000;321(7260):546–7.

111. Rich-Edwards JW, Colditz GA, Stampfer MJ, et al.

Birth-weight and the risk for type 2 diabetes mellitus in

adult women. Ann Intern Med 1999;130:278–84. 

112. Dabelea D, Knowler WC, Pettitt DJ. Effects of diabetes

in pregnancy on offspring: follow-up research in the

Pima Indians. J Matern Fetal Med 2000;9(1):83–8.
The Reproductive Years

97

113. Lucas A, Fewtrell MS, Cole TJ. Fetal origins of adult

disease—the hypothesis revisited. BMJ 1999;319(7204):

245–9.

114. Dabelea D, Hanson RL, Lindsay RS, et al. Intrauterine

exposure to diabetes conveys risks for type 2 diabetes

and obesity: study of discordant sibships. Diabetes

2000;49(12):2208–11.

115. Fagot-Campagna A, Pettitt DJ, Engelgau MM, et al.

Type 2 diabetes among North American children and

adolescents: an epidemiologic review and a public health

perspective. J Pediatr 2000;136(5):664–72.

116. Rosenbloom AL, Young RS, Joe JR, Winter WE.

Emerging epidemic of type 2 diabetes in youth. Diabetes

Care 1999;22(2):345–54.

117. Bavdekar A, Yajnik CS, Fall CH, et al. Insulin resistance

syndrome in 8-year-old Indian children: small at birth,

big at 8 years, or both? Diabetes 1999;48(12):2422–9.

118. Seidell JC. Obesity, insulin resistence, and diabetes—a

worldwide epidemic. Br J Nutr 2000;83(Suppl 1):

S5–S8.

119. International Diabetes Federation. Diabetes Atlas 2000.

Brussels, Belgium: International Diabetes Federation,

2000.

120. King H, Aubert RE, Herman WH. Global burden of

diabetes, 1995–2025: prevalence, numerical estimates,

and projections. Diabetes Care 1998;21(9):1414–31.

121. Mann J. Stemming the tide of diabetes mellitus. Lancet

2000;356(9240):1454–5.

122. Tuomilehto J, Lindstrom J, Ericksson JG, et al.

Prevention of type 2 diabetes mellitus by lifestyle

changes among subjects with impaired glucose tolerance.

N Engl J Med 2001;344(18):1343–50.

123. So WY, Ng MC, Lee SC, Sanke T, Lee HK, Chan JC.

Genetics of type 2 diabetes mellitus. Hong Kong Med J

2000;6:69–76.

124. Black SA, Ray LA, Markides KS. The prevalence and

health burden of self-reported diabetes in older Mexican

Americans: findings from the Hispanic established populations for epidemiologic studies of the elderly. Am J

Public Health 1999;89(4):546–52.

125. Must A, Spadano J, Coakley EH, Field AE, Colditz G,

Dietz WH. The disease burden associated with overweight and obesity. JAMA 1999;282(16):1523–9.

126. Mokdad AH, Serdula MK, Dietz WH, Bowman BA,

Marks JS, Koplan JP. The spread of the obesity epidemic

in the United States, 1991–1998. JAMA 1999;282(16):

1519–22.

127. Colditz GA, Willett WC, Rotnitzky A, Manson JE.

Weight gain as a risk factor for clinical diabetes mellitus

in women. Ann Intern Med 1995;122(7):481–6.

128. CDC. <http://www.cdc.gov/nchs/products/pubs/pubd/

hus/tables/2000/00hus069.pdf> Last accessed March 20,

2001.

129. Smith DE, Lewis CE, Caveny JL, Perkins LL, Burke

GL, Bild DE. Longitudinal changes in adiposity associated with pregnancy. The CARDIA Study. Coronary

Artery Risk Development in Young Adults Study. JAMA

1994;271(22):1747–51.

130. Manson JE, Colditz GA, Stampfer MJ. Parity, ponderosity, and the paradox of a weight-preoccupied society.

JAMA 1994;271(22):1788–90.

131. Williamson DF, Madans J, Pamuk E, Flegal KM,

Kendrick JS, Serdula MK. A prospective study of childbearing and 10-year weight gain in U.S. white women

25 to 45 years of age. Int J Obes Relat Metab Disord

1994;18(8):561–9.

132. Gunderson EP, Abrams B. Epidemiology of gestational

weight gain and body weight changes after pregnancy.

Epidemiol Rev 1999;21(2):261–75.

133. Schmitz KH, Jacobs DR Jr, Leon AS, Schreiner PJ,

Sternfeld B. Physical activity and body weight: associations over ten years in the CARDIA study. Coronary

Artery Risk Development in Young Adults. Int J Obes

Relat Metab Disord 2000;24(11):1475–87.

134. Pan XR, Li GW, Hu YH, et al. Effects of diet and exercise in preventing NIDDM in people with impaired glucose tolerance. The Da Qing IGT and Diabetes Study.

Diabetes Care 1997;20(4):537–44.

135. Ford ES, Herman WH. Leisure-time physical activity

patterns in the U.S. diabetic population. Findings from

the 1990 National Health Interview Survey—Health

Promotion and Disease Prevention Supplement.

Diabetes Care 1995;18(1):27–33.
98

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

136. Harris SB, Zinman B. Primary prevention of type 2 diabetes in high-risk populations. Diabetes Care 2000;

23(7):879–81.

137. Haire-Joshu D, Glasgow RE, Tibbs TL. Smoking and

diabetes. Diabetes Care 1999;22(11):1887–98.

138. Nicholl ID, Bucala R. Advanced glycation endproducts

and cigarette smoking. Cell Mol Biol 1998;44(7):

1025–33.

139. Goldberg RB. Cardiovascular disease in diabetic

patients. Med Clin North Am 2000;84(1):81–93.

140. Rimm EB, Manson JE, Stampfer MJ, et al. Cigarette

smoking and the risk of diabetes in women. Am J Public

Health 1993;83(2):211–4.

141. Will JC, Galuska DA, Ford ES, Mokdad AH, Calle EE.

Cigarette smoking and diabetes mellitus: evidence of a

positive association from a large prospective cohort

study. Int J Epidemiol 2001;30(3):540–6.

142. Targher G, Alberiche M, Zenere MB, Bonadonna RC,

Muggero M, Bonora E. Cigarette smoking and insulin

resistance in patients with non–insulin-dependent diabetes mellitus. J Clin Endocrinol Metab 1997;82(11):

3619–24.

143. Salmeron J, Manson JE, Stampfer MJ, Colditz GA,

Wing AL, Willett WC. Dietary fiber, glycemic load, and

risk of non–insulin-dependent diabetes mellitus in

women. JAMA 1997;277(6):472–7.

144. Williamson DF, Thompson TJ, Thun M, Flanders D,

Pamuk E, Byers T. Intentional weight loss and mortality

among overweight individuals with diabetes. Diabetes

Care 2000;23(10):1499–1504.

145. Will JC, Williamson DF, Ford ES, et al. Averting the

U.S. diabetes epidemic: does weight loss help?

Diabetologia 2000;43(Suppl 1):A4.

146. Chaisson JL, Gomis R, Hanefeld M, Josse RG, Karasik

A, Laakso M. The STOP-NIDDM Trial: an international study on the efficacy of an alpha-glucosidase inhibitor

to prevent type 2 diabetes in a population with impaired

glucose tolerance: rationale, design, and preliminary

screening data. Study to Prevent Non–InsulinDependent Diabetes Mellitus. Diabetes Care 1998;

21(10):1720–5.

147. DPP Study Group. The Diabetes Prevention Program.

Design and methods for a clinical trial in the prevention

of type 2 diabetes. Diabetes Care 1999;22(4):623–34.

148. Baranowski T, Mendlein J, Resnicow K, et al. Physical

activity and nutrition in children and youth: an overview of obesity prevention. Prev Med 2000;

31(Suppl 1):S1–S10.

149. Helmrich SP, Ragland DR, Paffenbarger RS Jr.

Prevention of non–insulin-dependent diabetes mellitus

with physical activity. Med Sci Sports Exerc 1994;

26(7):824–30.

150. Ross R, Dagnone D, Jones PJ, et al. Reduction in obesity and related comorbid conditions after diet-induced

weight loss or exercise-induced weight loss in men. A

randomized, controlled trial. Ann Intern Med 2000;

133(2):92–103.

151. Fisher L, Chesla CA, Bartz RJ, et al. The family and

type 2 diabetes: a framework for intervention. Diabetes

Educ 1998;24(5):599–607.

152. Bennett PH. Primary prevention of NIDDM: a practical

reality. Diabetes Metab Rev 1997;13:(2)105–11.

153. American Diabetes Association. Medical Management of

Pregnancy Complicated by Diabetes. 2nd ed. Alexandria,

VA: American Diabetes Association, 1995.

154. Ryan EA. Pregnancy in diabetes. Med Clin North Am

1998;82(4):823–45.

155. Herman WH, Janz NK, Becker MP, CharronProchownik D. Diabetes and pregnancy. Preconception

care, pregnancy outcomes, resource utilization, and

costs. J Reprod Med 1999;44(1):33–8.

156. McElvy SS, Miodovnik M, Rosenn B, et al. A focused

preconceptional and early pregnancy program in women

with type 1 diabetes reduces perinatal mortality and

malformation rates to general population levels. 

J Matern Fetal Med 2000;9(1):14–20.

157. Wiznitzer A, Reece EA. Assessment and management of

pregnancy complicated by pregestational diabetes mellitus. Pediatr Ann 1999;28(9):605–13.

158. Jovanovic L. Role of diet and insulin treatment of diabetes in pregnancy. Clin Obstet Gynecol 2000;43(1):

46–55.

159. Hadden DR, McCance DR. Advances in management

of type 1 diabetes and pregnancy. Curr Opin Obstet

Gynecol 1999;11(6):557–62.
The Reproductive Years

99

160. Kitzmiller J. Cost analysis of diagnosis and treatment of

gestational diabetes mellitus. Clin Obstet Gynecol

2000;43(1):140–53.

161. Weiss SR, Cooke CE, Bradley LR, Manson JM.

Pharmacist’s guide to pregnancy registry studies. J Am

Pharm Assoc (Wash) 1999;39(6):830–4.

162. Carlsson S, Persson PG, Alvarsson M, et al. Low birth

weight, family history of diabetes, and glucose intolerance in Swedish middle-aged men. Diabetes Care 1999;

22(7):1043–7.

163. El-Hashimy M, Angelico MC, Martin BC, Krolewski

AS, Warram JH. Factors modifying the risk of IDDM in

offspring of an IDDM parent. Diabetes 1995;44(3):

295–9. 

164. Lorenzen T, Pociot F, Stilgren L, et al. Predictors of

IDDM recurrence risk in offspring of Danish IDDM

patients. Danish IDDM Epidemiology and Genetics

Group. Diabetologia 1998;41(6):666–73.

165. Klein BE, Klein R, Moss SE, Cruickshanks KJ. Parental

history of diabetes in a population-based study. Diabetes

Care 1996;19(8):827–30.

166. Groop L, Forsblom C, Lehtovirta M, et al. Metabolic

consequences of a family history of NIDDM (the

Botnia study): evidence for sex-specific parental effects.

Diabetes 1996;45(11):1585–93.

167. Kjos SL. Postpartum care of the woman with diabetes.

Clin Obstet Gynecol 2000;43(1):75–86.

168. Murtaugh MA, Ferris AM, Capacchione CM, Reece EA.

Energy intake and glycemia in lactating women with

type 1 diabetes. J Am Diet Assoc 1998;98(6):642–8.

169. Preparing pregnant women with diabetes for special

breast-feeding challenges. J Am Diet Assoc 1998;98(6):

648.

170. Harrison LC, Honeyman MC. Cow’s milk and type 1

diabetes: the real debate is about mucosal immune function. Diabetes 1999;48(8):1501–7.

171. Scott FW, Norris JM, Kolb H. Milk and type 1 diabetes. Diabetes Care 1996;19(4):379–83.

172. Vaarala O, Knip M, Paronen J, et al. Cow’s milk formula feeding induces primary immunization to insulin in

infants at genetic risk for type 1 diabetes. Diabetes 1999;

48(7):1389–94.

173. Karjalainen J, Martin JM, Knip M, et al. A bovine albumin peptide as a possible trigger of insulin-dependent

diabetes mellitus. N Engl J Med 1992;327(5):302–7.

174. Hammond-McKibben D, Dosch HM. Cow’s milk,

bovine serum albumin, and IDDM: can we settle the

controversies? Diabetes Care 1997;20(5):897–901.

175. Pettitt DJ, Forman MR, Hanson RL, Knowler WC,

Bennett PH. Breastfeeding and incidence of

non–insulin-dependent diabetes mellitus in Pima

Indians. Lancet 1997;350(9072):166–8.

176. Schrezenmeir J, Jagla A. Milk and diabetes. J Am Coll

Nutr 2000;19(Suppl 2):176S–190S.

177. Shedadeh N, Gelertner L, Blazer S, Perlman R,

Solovachik L, Etzioni A. Insulin content in infant diet:

suggestion for a new infant formula. Diabetologia 2001;

43(Suppl 1):A3.

178. Hamalainen AM, Ronkainen MS, Akerblom HK, et al.

Postnatal elimination of transplacentally acquired disease-associated antibodies in infants born to families

with type 1 diabetes. J Clin Endocrinol Metab

2000;85:4249–53.

179. Anderson B, Funnell M, editors. The Art of

Empowerment: Stories and Strategies for Diabetes

Educators. Alexandria, VA: American Diabetes

Association, 2000.

180. Weis SE, Foresman B, Matty KJ, et al. Treatment costs

of directly observed therapy and traditional therapy for

Mycobacterium tuberculosis: a comparative analysis. Int J

Tuberc Lung Dis 1999;3(11):976–84.

181. Leslie WS, Urie A, Hooper J, Morrison CE. Delay in

calling for help during myocardial infarction: reasons for

the delay and subsequent pattern of accessing care.

Heart 2000;84(2):137–41.

182. Rizzo JA, Simons WR. Variations in compliance among

hypertensive patients by drug class: implications for

health care costs. Clin Ther 1997;19(6):1424–5,

1446–57.

183. Fries JF, Koop CE, Sokolov J, Beadle CE, Wright D.

Beyond health promotion: reducing need and demand

for medical care. Health Aff (Millwood) 1998;

17(2):70–84.

184. Horner RD. Patients’ sociodemographics characteristics

and utilization of health care: looking beyond appearances at last. Med Care 1999;37(1):3–4.
100

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

185. Jack L Jr, Liburd L, Vinicor F, Brody G, Murry VM.

Influence of the environmental context on diabetes selfmanagement: a rationale for developing a new research

paradigm in diabetes education. Diabetes Educ

1999;25(5):775–80, 782.

186. Glasgow RE, Fisher EB, Anderson BJ, et al. Behavioral

science in diabetes. Contributions and opportunities.

Diabetes Care 1999; 22(5):832–43.

187. Glasgow RE, Anderson RM. In diabetes care, moving

from compliance to adherence is not enough. Diabetes

Care 1999;22(12):2090–2.

188. Nolan TW. Understanding medical systems. Ann Intern

Med 1998;128(4):293–8.

189. CDC. Levels of diabetes-related preventive-care practices—United States, 1997–1999. MMWR

2000;49(42):954–8.

190. Beckles GLA, Engelgau MM, Narayan KM, Herman

WH, Aubert RE, Williamson DF. Population-based

assessment of the level of care among adults with diabetes in the U.S. Diabetes Care 1998;21(9):1432–8.

191. Narayan KM, Gregg EW, Engelgau MM, et al.

Translation research for chronic disease: the case of diabetes. Diabetes Care 2000;23(12):1794–8.

192. Lutfey KE, Wishner WJ. Beyond “compliance” is

“adherence.” Improving the prospect of diabetes care.

Diabetes Care 1999;22(4):635–9.

193. Brown SA. Studies of educational interventions and outcomes in diabetic adults: a meta-analysis revisited.

Patient Educ Couns 1990;16(3):189–215.

194. Norris SL, Engelgau MM, Narayan KM. Effectiveness of

self-management training in type 2 diabetes: a systematic review of randomized controlled trials. Diabetes Care

2001;24(3):561–87.

195. Glasgow RE, Vogt TM, Boles SM. Evaluating the public

health impact of health promotion interventions: the

RE-AIM framework. Am J Public Health 1999;89(9):

1322–7.

196. American Association of Diabetes Educators. Diabetes

Educational and Behavioral Research Summit. Diabetes

Educ 1999;25(Suppl):1–88.

197. Special considerations for the education and management of older adults with diabetes. American

Association of Diabetes Educators. Diabetes Educ 2000;

26(1):37–9.

198. Mensing C, Boucher J, Cypress M, et al. National standards for diabetes self-management education. Task

Force to Review and Revise the National Standards for

Diabetes Self-Management Education Programs.

Diabetes Care 2000;23(5):682–9.

199. Gostin LO. Public health law in a new century: part II:

public health powers and limits. JAMA 2000;283(22):

2979–84.

200. Anderson RM, Barr PA, Edwards GJ, Funnel MM,

Fitzgerald JT, Wisdom K. Using focus groups to identify

psychosocial issues of urban black individuals with diabetes. Diabetes Educ 1996;22(1):28–33.

201. Anderson JM, Wiggins S, Rajwani R, Holbrook A, Blue

C, Ng M. Living with a chronic illness: ChineseCanadian and Euro-Canadian women with diabetes—

exploring factors that influence management. Soc Sci

Med 1995;41(2):181–95.

202. Glasgow RE, Hampton SE, Strycker LA, Ruggiero L.

Personal-model beliefs and social-environmental barriers

related to diabetes self-management. Diabetes Care

1997;20(4):556–61.

203. Wysocki T, Harris MA, Greco P, et al. Social validity of

support group and behavior therapy interventions for

families of adolescents with insulin-dependent diabetes

mellitus. J Pediatr Psychol 1997;22(5):635–49.

204. U.S. Bureau of the Census. Statistical Abstract of the

United States: 1996. 116th ed. Washington, DC:

Government Printing Office, 1996.

205. Hennessy CH, John R, Anderson LA. Diabetes education needs of family members caring for American

Indian elders. Diabetes Educ 1999;25(5):747–54.

206. Anderson RM, Goddard CE, Garcia R, Guzman JR,

Vazquez F. Using focus groups to identify diabetes care

and education issues for Latinos with diabetes. Diabetes

Educ 1998;24(5):618–25.

207. El-Kebbi IM, Bacha GA, Ziemer DC, et al. Diabetes in

urban African Americans. V. Use of discussion groups to

identify barriers to dietary therapy among low-income

individuals with non–insulin-dependent diabetes mellitus. Diabetes Educ 1996;22(5):488–92.
The Reproductive Years

101

208. Maillet NA, D’Eramo Melkus G, Spollett G. Using

focus groups to characterize the health beliefs and practices of black women with non–insulin-dependent diabetes. Diabetes Educ 1996;22(1):39–46.

209. Liburd LC, Anderson LA, Edgar T, Jack L Jr. Body size

and body shape: perceptions of black women with diabetes. Diabetes Educ 1999;25(3):382–8.

210. Baum FE. Social capital, economic capital and power:

further issues for a public health agenda. J Epidemiol

Community Health 2000;54(6):409–10.

211. Lynch JW, Due P, Muntaner C, Smith GD. Social 

capital—is it a good investment strategy for public

health? J Epidemiol Community Health

2000;54(6):404–8.

212. Baum FE, Bush RA, Modra CC, et al. Epidemiology of

participation: an Australian community study. J

Epidemiol Community Health 2000;54(6):414–23.

213. Fukuyama F. Social capital and civil society. IMF

Institute. Working Paper WP/00/74. International

Monetary Fund, 2000.

214. Leeder S, Dominello A. Social capital and its relevance

to health and family policy. Aust N Z J Public Health

1999;23(4):424–9.

215. Burdine JN, Felix MR, Wallerstein N, et al.

Measurement of social capital. Ann N Y Acad Sci 1999;

896:393–5.

216. Lomas J. Social capital and health: implications for public health and epidemiology. Soc Sci Med 1998;47(9):

1181–8.

217. Lantz PM, Lynch JW, House JS, et al. Socioeconomic

disparities in health change in a longitudinal study of

US adults: the role of health-risk behaviors. Soc Sci Med

2001;53(1):29–40.

218. Kawachi I, Kennedy BP. Income inequality and health:

pathways and mechanisms. Health Serv Res 1999;34:

215–27.

219. Kawachi I. Social capital and community effects on population and individual health. Ann N Y Acad Sci 1999;

896:120-30.

220. Peyrot M, McMurry JF Jr, Kruger DF. A biopsychosocial model of glycemic control in diabetes: stress, coping, and regimen adherence. J Health Soc Behav

1999;40(2):141–58.

221. Lloyd CE, Dyer PH, Lancashire RJ, Harris T, Daniels

JE, Barnett AH. Association between stress and glycemic

control in adults with type 1 (insulin-dependent) diabetes. Diabetes Care 1999;22(8):1278–83.

222. Capes SE, Hunt D, Malmberg K, Gerstein HC. Stress

hyperglycaemia and increased risk of death after myocardial infarction in patients with and without diabetes: a

systematic overview. Lancet 2000;355(9206):773–8.

223. Kelly GS. Insulin resistance: lifestyle and nutritional

interventions. Altern Med Rev 2000;5(2):109–32.

224. Shehadeh N, On A, Kessel I, et al. Stress hyperglycemia

and the risk for the development of type 1 diabetes. J

Pediatr Endocrinol Metab 1997;10(3):283–6.

225. Manning MR, Fusilier MR. The relationship between

stress and health care use: an investigation of the buffering roles of personality, social support, and exercise. 

J Psychosom Res 1999;47(2):159–73.

226. Elder JP, Ayala GX, Harris S. Theories and intervention

approaches to health-behavior change in primary care.

Am J Prev Med 1999;17(4):275–84.

227. Hunt LM, Valenzuela MA, Pugh JA. Porque me toco a

mi? Mexican American diabetes patients’ causal stories

and their relationship to treatment behaviors. Soc Sci

Med 1998;46(8):959–69.

228. Peyrot M, Rubin RR. Structure and correlates of diabetes-specific locus of control. Diabetes Care 1994;17(9):

994–1001.

229. Tillotson LM, Smith MS. Locus of control, social support, and adherence to the diabetes regimen. Diabetes

Educ 1996;22(2):133–9.

230. Engelgau MM, Narayan KM, Herman WH. Screening

for type 2 diabetes. Diabetes Care 2000;23(10):1563–80.

231. Keen H. Therapeutic objectives and their practical

achievement in type 2 diabetes. J Diabetes Complications

2000;14(4):180–4.

232. Dalen JE. Health care in America: the good, the bad,

and the ugly. Arch Intern Med 2000;160(17):2573–6.

233. Mariner WK. Rationing health care and the need for

credible scarcity: why Americans can’t say no. Am J

Public Health 1995;85(10):1439–45.
102

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

234. McKinlay JB, Marceau LD. To boldly go.... Am J Public

Health 2000;90(1):25–33.

235. Ubel PA, Goold SD. “Rationing” health care. Not all

definitions are created equal. Arch Intern Med 1998;

158(3):209–14.

236. Diabetes Control and Complications Trial Study Group.

The absence of a glycemic threshold for the development of long-term complications: the perspective of the

Diabetes Control and Complications Trial. Diabetes

1996;45(10):1289–98.

237. Stratton IM, Adler AI, Neil HA, et al. Association of

glycaemia with macrovascular and microvascular complications of type 2 diabetes (UKPDS 35): prospective

observational study. BMJ 2000;321(7258):405–12.

238. Adler AI, Stratton IM, Neil HA, et al. Association of

systolic blood pressure with macrovascular and microvascular complications of type 2 diabetes (UKPDS 36):

prospective observational study. BMJ 2000;321(7258):

412–19.

239. Brennan TA. The Institute of Medicine report on medical errors—could it do harm? N Engl J Med 2000;

342(15):1123–5.

240. Robinson JC. The future of managed care organizations.

Health Aff 1999;18:7–24.

241. Pavalko EK, Woodbury S. Social roles as process: caregiving careers and women’s health. J Health Soc Behav

2000;41(1):91–105.

242. Khlat M, Sermet C, Le Pape A. Women’s health in relation with their family and work roles: France in the early

1990s. Soc Sci Med 2000;50(12):1807–25.

243. Walowitz PA, Jellen BC, Hanold K, Lee GF, Ropp AL,

Lucas VA. Desperately seeking synergy: the journey to

systems integration of women’s health services. Womens

Health Issues 2000;10(4):161–77.

244. Kirchner JT. Women’s health issues. Introducing a new

series with an underlying emphasis on comprehensive

care. Postgrad Med 2000;107(1):15–16, 19.

245. Herpertz S, Albus C, Wagener R, et al. Comorbidity of

diabetes and eating disorders. Does diabetes control

reflect disturbed eating behavior? Diabetes Care 1998;

21(7):1110–16.

246. Affenito SG, Backstrand JR, Welch GW, Lammi-Keefe

CJ, Rodriguez NR, Adams CH. Subclinical and clinical

eating disorders in IDDM negatively affect metabolic

control. Diabetes Care 1997;20(2):182–4.

247. Affenito SG, Lammi-Keefe CJ, Vogel S, Backstrand JR,

Welch GW, Adams CH. Women with insulindependent diabetes mellitus (IDDM) complicated by

eating disorders are at risk for exacerbated alterations in

lipid metabolism. Eur J Clin Nutr 1997;51(7):462–6.

248. Levine MD, Marcus MD. Women, diabetes, and 

disordered eating. Diabetes Spectrum 1997;10:191–5.

249. Gavard JA, Lustman PJ, Clouse RE. Prevalence of

depression in adults with diabetes. An epidemiological

evaluation. Diabetes Care 1993;16(8):1167–78.

250. Peyrot M, Rubin RR. Persistence of depressive symptoms in diabetic adults. Diabetes Care 1999;22(3):

448–52.

251. Peyrot M, Rubin RR. Levels and risks of depression and

anxiety symptomatology among diabetic adults. Diabetes

Care 1997;20(4):585–90.

252. Lustman PJ, Griffith LS, Gavard JA, Clouse RE.

Depression in adults with diabetes. Diabetes Care

1992;15(11):1631–9.

253. Griffith LS, Lustman PJ. Depression in women with

diabetes. Diabetes Spectrum 1997;10:216–23.

254. Taipale V. Ethics and allocation of health resources—the

influence of poverty on health. Acta Oncol 1999;38(1):

51–5.

255. Fellitti VJ, Anda RF, Nordenberg D, et al. Relationship

of childhood abuse and household dysfunction to many

of the leading causes of death in adults. The Adverse

Childhood Experiences (ACE) Study. Am J Prev Med

1998;14(4):245–58.

256. Lynch JW, Kaplan GA, Salonen JT. Why do poor people behave poorly? Variation in adult health behaviors

and psychosocial characteristics by stages of the socioeconomic lifecourse. Soc Sci Med 1997;44(6):809–19.

104

CASE STUDY

Mrs. Rose Oliver hummed as she got ready for her clinic appointment. She was experiencing some

changes that she knew were related to menopause, including hot flashes and mood swings. She

would discuss how to manage these symptoms with her nurse practitioner. At her last appointment,

they had also agreed to discuss the benefits and concerns of hormone replacement therapy in view of

her medical history. Her blood pressure had increased a couple of points at the last visit, and the

doctor asked about her diet and salt intake. Rose felt confident she and her health care team would

figure out how to keep her healthy and strong for a long time to come. She knew, too, that she would

continue to play the biggest role in her own health.

Straightening her dresser a little as she reached for her appointment slip, she gazed affectionately at

the smiling picture of her youngest child, Jean, now 22 and about to graduate from college. Rose

recalled that some of her beliefs about her own ability to protect her health dated back to the time

of Jean’s birth. Born after a difficult delivery the month of Rose’s 29 th birthday, Jean had weighed

91⁄2 pounds. The obstetrician told Rose that she probably had undetected gestational diabetes during her pregnancy. Fortunately, Rose and Jean were fine, but when Rose took a glucose tolerance test

6 weeks after Jean’s birth, she learned she had type 2 diabetes.

Rose always said she had “gotten a lot of mileage” from the steps she took after her diagnosis, and

she was proud of her dedication in managing her diabetes that had allowed so many years of good

health. Her physician had pointed out then that they had caught the disease early and chances were

good that gradual weight loss, through a healthy diet and exercise, could help control the disease for

years. Having lost a dear aunt to diabetes-related heart disease the previous year, Rose had taken

the physician’s advice seriously. During the year of her diagnosis, she lost 20 pounds (from 156

pounds on her 5’1” frame). Even though she was nursing, Rose kept up her walking regimen. Once

her glucose had consistently dropped to less than 100 mg/dL, Rose had her hemoglobin A1c checked

once a year at the clinic, and it was always within the normal range.

Rose knew there was a chance her glucose readings could go up again, especially if she gained weight.

She was a little bit worried about her blood pressure, but she felt she was an old hand at controlling

her diabetes and that together, she and her health care team could prevent diabetes complications.

She was also grateful that her husband was supportive of her efforts to exercise and to eat properly.

He actually liked some of the recipes from the diabetes cookbook. Rose knew that managing diabetes

by sticking to her diet, exercise, and medication regimens would go a long way to protect her from

heart disease and other diabetes complications.
105

5 

THE MIDDLE YEARS

M. Sabolsi, MD, MPH, C.G. Solomon, MD, MPH, J.E. Manson, MD, DrPH

This chapter presents a review of data for women aged

45–64 years with diabetes. Socioeconomic status, the

epidemiology of the disease in this age group, and the

health behaviors of middle-aged women are described.

The middle years are a time of adjustment for those

who are recently diagnosed, and for many who have

already been diagnosed with diabetes, the emergence

of macrovascular and microvascular complications or

other chronic diseases is a major issue. Coupled with

other personal issues such as aging parents and an

increasing lack of social support, many women in this

age group are concerned about issues related to

improvement in their quality of life. In particular, the

unique vulnerabilities of women with diabetes in this

age group and the differential application of diagnostic and treatment procedures are presented. Epidemiologic evidence indicates that women with diabetes

who have a heart attack are at increased risk for poorer health outcomes and death. The changes associated

with menopause are also discussed. The public health

implications of these findings are framed under the

three core functions of public health: assessment, policy

development, and assurance. Public health practitioners are urged to assure recommended care guidelines

are met and to encourage translational research that

involves women in this age group to improve quality

of care.

Midlife is the period in which chronic diseases

emerge as a major burden on the adult U.S. population. In the mid-1990s, the number of U.S.

women in midlife (aged 45–64 years) was 27 million; by 2010, the number is expected to grow to

41 million.1 Thus, a large number of women are

vulnerable to major chronic diseases such as diabetes.

As women age out of their reproductive years into

their middle years, they experience major shifts in

their social roles. For many women these changes

include the transition from childbearing to childrearing, returning to full participation in the labor

force, and often coping with sole responsibility for

their households. These are also the years in which

women’s health issues include the effects of prolonged exposure to biological and behavioral risk

factors acquired in adolescence and young adulthood. Specifically, factors such as prepregnancy

weight, gestational weight gain and retention, gestational diabetes, and low levels of physical activity

that continue from young adulthood increase

women’s risk of developing diabetes in midlife. This

is also the period of life when some women experience the diminution in their physical and psychological health that may be associated with the

menopause.2 Circumstances such as past discontinuity in employment, separation, divorce, and widowhood may make middle-aged women vulnerable

to low family incomes and inadequate health care

coverage so that they may forego needed services,

including preventive care for serious diseases such

as diabetes.

This review will address some of the issues faced by

women with diabetes and their public health implications. Nearly all persons with diabetes aged 45

years or older have type 2 diabetes, formerly called

non–insulin-dependent diabetes mellitus.

Throughout this chapter, the term “diabetes” will

refer to type 2 diabetes unless otherwise specified.
106

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

5.1. Prevalence, Incidence, and Trends

Prevalence

The prevalence of diabetes increases with age. Data

from the Third National Health and Nutrition

Examination Survey (NHANES III, 1988–1994)

show that, regardless of racial or ethnic origin, the

prevalence of diabetes doubles as women age out of

the reproductive years into the middle years.3

Overall, the total prevalence of diagnosed and undiagnosed diabetes was 12.4% among women aged

50–59 years compared with 6% among those a

decade younger (Figure 5-1). When the NHANES

III estimates are applied to the 1995 population

estimates,4 approximately 2.7 million women aged

40–59 years have diabetes.

For middle-aged women, diabetes is at least twice as

common among nonwhites as among whites

(Figure 5-2). Among women aged 50–59 years, the

total prevalence was 23.0% for non-Hispanic

blacks, 24.0% for Mexican Americans, and 9.7%

for non-Hispanic whites; estimates for women aged

40–49 years were 10.4%, 14.1%, and 4.8%, respectively.

Among non-Hispanic whites and Mexican

Americans, the total prevalence of diabetes is similar in both sexes; however, among non-Hispanic

blacks, the total prevalence of diabetes is higher in

women than in men, notably in those aged 50–59

years (23.0% versus 16.0%).3

In NHANES III, 6.6% of women aged 50–59

years and 4.4% of those aged 40–49 years reported

that they had been diagnosed with diabetes by a

physician (Figure 5-1). The racial difference in total

prevalence noted above was also evident among the

women with diagnosed diabetes, and this difference

widened with aging. Thus, among women aged

50–59 years, non-Hispanic blacks (14.5%) and

Mexican Americans (16.5%) were about 3 times as

likely as non-Hispanic whites (5.3%) to report a

previous diagnosis (Figure 5-2). This racial and ethnic contrast was much less marked among men of

similar age.3

Figure 5-1. Prevalence of diagnosed and 

undiagnosed diabetes among 

U.S. adults, by age and sex—

NHANES III,* 1988–94

0

4

8

12

16

Women Women Men Men

Aged 40–49 Years Aged 50–59 Years

Percent

Diagnosed

Undiagnosed

6.0

6.9

12.4 12.9

*NHANES III = Third National Health and Nutrition Examination

Survey.

Source: Reference 3.

Figure 5-2. Prevalence of diagnosed and 

undiagnosed diabetes among 

U.S. women, by age and race/

Hispanic origin—NHANES III,*

1988–94

Diagnosed

Undiagnosed

Aged 40–49 Years Aged 50–59 Years

Percent

0

5

10

15

20

25

NHW NHB MA NHW NHB MA

4.8

10.4

14.1

9.7

23.0 24.0

*NHANES III = Third National Health and Nutrition Examination

Survey; NHW = non-Hispanic white; NHB = non-Hispanic black;

MA = Mexican American.

Source: Reference 3.
The Middle Years

107

Using the 1997 diagnostic criteria of the American

Diabetes Association (ADA) (fasting plasma glucose

7.0 mmol/L),5 NHANES III also found undiagnosed diabetes in 5.8% of women aged 50–59 years

and 1.6% of those aged 40–49 years (Figure 5-1).

Despite their higher prevalence of diagnosed diabetes, non-Hispanic black and Mexican American

women also had higher rates of undiagnosed diabetes than their non-Hispanic white counterparts,

with rates as much as 3 times higher among those

aged 40–49 years and about 2 times higher among

those aged 50–59 years (Figure 5-2). Among persons aged 50–59 years, undiagnosed diabetes was

more common among women than men (5.8%

versus 3.3%) and accounted for nearly half of the

total prevalence in women compared with about

one-quarter of the prevalence in men (46.8% versus

25.6%). Thus, in late midlife, a considerably larger

number of women than men are at high risk of

developing diabetes complications as a result of

undiagnosed diabetes.

NHANES III estimates for diagnosed diabetes

among women aged 50–59 years (6.6%, 5.3%, and

14.5% for total, non-Hispanic white, and black

women, respectively) are consistent with those for

women aged 45–64 years who participated each

year in the National Health Interview Survey

(NHIS) from 1994 through 1996. For example, in

the 1996 NHIS, the annual prevalence of diabetes

was approximately 6.2% overall, 5.3% among

white women, and about 14% among black

women.6

No national survey data provide stable estimates for

women of other ethnic origins, but evidence from

surveys of selected populations shows consistently

that nonwhite U.S. women in midlife are more vulnerable to diabetes than their white counterparts

(Table 5-1).7-15 In the Strong Heart Study, which

examined American Indian women aged 45–74

years in three different geographic locations, the

prevalence of diabetes in women aged 55–64 years

was 78% in Arizona, 47% in Oklahoma, and 51%

in the Dakotas.9 A 1974–1982 survey found that

approximately 70% of Pima Indian women aged

45–64 years had diabetes as defined by World

Health Organization (WHO) criteria or use of diabetic medications.10 Estimates for Navajo women

participating in the Navajo Health and Nutrition

Survey (1992) were similarly high at 41% among

those aged 45–64 years.11 The wide variation in

prevalence among American Indian women is also

seen among Hispanics.14 Data for middle-aged

Asian Americans, a very rapidly growing segment of

the U.S. population, are sparse. However, among

women aged 45–74 years who participated in the

Seattle Japanese American Community Diabetes

Study, the prevalence of diabetes was 17%.15

Incidence

Based on data from the NHIS, an estimated

135,000 newly diagnosed cases of diabetes were

reported by women aged 45–64 years in 1996, for

an incidence rate of 4.9 per 1,000.16 The incidence

of diabetes was lower among women than men (4.9

per 1,000 versus 7.3 per 1,000).16,17

Data from the few population-based studies conducted show consistently that, regardless of how

diabetes is defined, high-prevalence populations

also have high incidence rates.18-23 For example, in

the San Antonio Heart Study, 8-year cumulative

incidence rates among Mexican American women

were 11.6% at ages 45–54 years and 7.5% at ages

55–64 years; comparable rates for non-Hispanic

white women were 2.3% and 6.8%, respectively.18

In the 16-year (1971–1987) First National Health

and Nutrition Examination Survey (NHANES I)

Epidemiologic Follow-Up Study, incident cases

were identified from self-report, medical records,

and death certificates.19 Among those aged 45–54

and 55–64 years, incidence rates among black

women were about 3 times the rates of their white

counterparts. During 1986–1989, the

Atherosclerosis Risk in Communities (ARIC) Study

recruited probability samples of adults aged 45–64

years. Incident cases of diabetes were identified

using the 1997 ADA diagnostic criteria, current

drug treatment, and self-reported diagnosis. During

9 years of follow-up, the risk of developing diabetes

was higher among African Americans than whites:
Table 5-1. Prevalence (%) of diagnosed and undiagnosed diabetes among adults aged 45–64 

years, by race/Hispanic origin—United States, 1986–97

Age group Diagnosed diabetes (%) Undiagnosed diabetes (%)

Data source Population (years) Women Men Women Men

Navajo Health and Nutrition Navajo 45–64 30.8 20.5 10.7 15.8

Survey (NHANS), 1991–92*

The Strong Heart Study, Arizona† 45–54 56 55 9 7

1988 55–64 69 60 9 12

Oklahoma‡ 45–54 22 23 9 8

55–64 35 12 12 11

South and North 45–54 24 10 10 9

Dakota§ 55–64 41 10 10 11

Indian Health Service Non-Hispanic white 45–64 5.1 5.4 – –

(IHS), 1996 American Indian/ 21.1 16.7 – –

Alaska Native

Behavioral Risk Factor Non-Hispanic white 45–64 5.7 6.2 – –

Surveillance System Hispanic 11.5 12.6 – –

(BRFSS), 1994–97

King County, Washington, Japanese American 45–74 6.7 10.9 10.3 –

1986–88 (Nisei)

*WHO criteria.

†Pima, Maricopa, and Papago.

‡Apache, Caddo, Comanche, Delaware, Kiowa, and Wichita.

§Oglala, Cheyenne River, and Devils Lake Sioux.

Sources: References 9–12, 14, 15.

108

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

among women, incidence rates were 25.1 per 1,000

person-years and 10.4 per 1,000 person-years,

respectively. African American women were about

2.5 times as likely as white women to develop diabetes even after controlling for the confounding

effects of other known risk factors for diabetes.

Unlike among whites, there was no risk differential

by sex among African Americans. The differences in

risk between African Americans and whites were

greater for women compared with men in relative

terms (2.4 versus 1.5, respectively), and in absolute

terms (14.7 per 1,000 person-years versus 7.5 per

1,000 person-years, respectively).

Trends

The prevalence of diabetes has been increasing

steadily in all demographic groups for several

decades.6,7,24,25 Among middle-aged women, prevalence rates for diagnosed diabetes were less than 2%

for women aged 45–54 years and less than 4% for

those aged 55–64 years in the early 1960s; these

rates increased to fairly consistent prevalence rates

of 5%–6% in the 1980s and early 1990s for

women aged 45–64 years. These rates have been

generally comparable to those among men.7

The average annual rate of newly diagnosed cases

for women in midlife increased steadily from the

1960s up to the mid-1980s. After the mid-1980s,

however, the rate of new cases among women

younger than 55 years of age showed no further

change, whereas the rate for women aged 55–64

years decreased.7
The Middle Years

109

Aging of the population, improved identification of

cases, increased survival, and an increase in the rate

at which new cases develop (true incidence) are factors that may, singly or in combination, contribute

to secular changes in prevalence. Aging of the population has been shown to contribute little to the

increasing trends in prevalence,25 and survival of

women with diabetes in midlife was unchanged

from 1971 to 1993.26 The pattern of the national

trend in the annual rate of newly diagnosed cases

may reflect increased case ascertainment. However,

data from several studies of selected populations

indicate that since the 1960s, a rising temporal

trend in true incidence of type 2 diabetes has been

occurring among middle-aged adults in several ethnic groups.20,22-24 The rate of increase has been most

rapid among minority populations.20-23 Overweight,

weight gain, and lack of physical activity—major

risk factors for diabetes in women27-29—have

become increasingly common at all ages, especially

among women and minority groups.30-31 Consequently, despite the constant mortality, it is likely

that increasing true incidence is making the greatest

contribution to the steadily rising burden of diabetes among women in midlife. This increase in

burden is estimated to continue into the middle of

the 21st century.32

5.2. Sociodemographic Characteristics

Age, Sex, Race/Ethnicity

The age, sex, and racial/ethnic structures of the diabetic population vary markedly throughout the

general population, especially among minority

groups. Although sex-specific prevalence is similar,

age-specific data are lacking. Adults aged 18 years

or older with type 2 diabetes are more likely to be

female than male (58.4% versus 41.6%) because

women outnumber men in the U.S. population,

especially in minority groups.33 In the diabetic population, people of nonwhite racial and ethnic origin

are overrepresented and whites are underrepresented

when compared with the nondiabetic population.

Among adults with diabetes, 69.6% are nonHispanic white, 20.2% are non-Hispanic black,

4.8% are Mexican American, and 5.4% are of other

races.33

In contrast, the percentages in the nondiabetic population are 79.3% of non-Hispanic whites, 10.7%

of non-Hispanic blacks, 4.0% of Mexican

Americans, and 6.0% of other races. Although this

pattern was the same in both sexes, it may vary by

age; however, no age-specific data are available.

With the exception of the other races group, the

racial/ethnic composition of the diabetic population

reflects the higher prevalence of type 2 diabetes

among both men and women in nonwhite racial

and ethnic groups when compared with whites.

Marital Status/Living Arrangements

Overall, women aged 45–64 years with type 2 diabetes are less likely than women without diabetes to

be married (58.3% versus 72.2%) and more likely

to be widowed (15.6% versus 9.4%), divorced or

separated (19.3% versus 14.5%), or to have never

married (6.8% versus 3.9%) (Table 5-2). In contrast to women, men with and without diabetes in

this age group do not differ by marital status.33

Among people with diabetes in this age group,

women are more likely than men to be widowed

(15.6% versus 2%) and less likely to be married

(58.3% versus 82.3%).33 In addition, nearly 1 in 5

middle-aged women with diabetes lives alone compared with only about 1 in 10 of their male counterparts.33

Education/Income/Employment

Diabetes imposes an enormous economic burden

on the nation, and out-of-pocket costs for acute

and ambulatory care incurred by persons with diabetes are 2–6 times the costs incurred by persons in

the general population.34,35 However, few data exist

about the impact of diabetes on the socioeconomic

status (SES) of women of any age. Education,

income, and labor force participation, well-validated measures of SES, will be used to describe the

social status of women with diabetes.

Overall, middle-aged women with type 2 diabetes

have less education, have lower income, and are less

likely to be in the labor force than their nondiabetic

counterparts.33 The percentage of all women with

diabetes who reported that they had completed less
110

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

than 9 years of education (22.7%) was twice the

percentage reported by those without diabetes

(9.7%) (Table 5-2); the percentage who reported

that they had completed more than 12 years of

education (16.9%) was half that for women without diabetes (31.7%). More than half of women

with diabetes in this age group have an annual family income less than $20,000, and for 28.5% of

them, such income is less than $10,000 a year,

whereas the percentages for women without diabetes were 30.5% and 11.3%, respectively. The differences between women with and without diabetes

in educational attainment and family income may

reflect the findings among non-Hispanic white

women only; among non-Hispanic black women,

these SES characteristics showed very little variation

with diabetes status (Table 5-2). Finally, nearly 60%

of women with diabetes were not in the labor force

compared with about 40% of those without diabetes (Table 5-2).

Table 5-2. Prevalence (%) of sociodemographic characteristics of women aged 45–64 years with 

and without type 2 diabetes, by race/Hispanic origin—United States, 1989

Non-Hispanic white Non-Hispanic black Total

Characteristic Diabetes No diabetes Diabetes No diabetes Diabetes No diabetes

Marital status

Married 63.0 76.1 44.3 46.9 58.3 72.2

Widowed 5.7 8.2 17.8 20.6 15.6 9.4

Divorced or separated 6.2 12.4 27.7 25.7 19.3 14.5

Never married 5.1 3.3 10.1 6.9 6.8 3.9

Living arrangements

Alone 19.0 13.3 21.8 17.4 18.4 13.4

Nonrelative only 1.6 1.2 0.0 1.2 1.0 1.2

Spouse 63.0 75.7 43.0 44.7 57.6 71.5

Other relative only 16.4 9.9 35.2 36.7 23.0 14.0

Household size (no. of persons)

1 20.6 14.5 21.8 18.6 19.4 14.6

2 44.1 49.7 25.0 31.1 39.0 46.4

3 20.8 20.0 21.3 16.7 20.5 20.0

≥4 14.6 15.8 31.9 33.6 21.0 19.0

Education (years)

<9 13.8 5.6 22.7 21.8 22.7 9.7

9–12 67.7 60.9 59.5 53.6 60.4 58.6

>12 18.5 33.6 17.9 24.7 16.9 31.7

≥16 7.7 14.9 6.6 10.8 6.7 14.5

Annual family income ($thousands)

<10 24.6 8.3 37.8 31.7 28.5 11.3

10 – <20 26.2 17.8 23.3 25.3 26.0 19.2

20 – <40 27.7 34.5 24.9 23.7 26.5 33.5

≥40 21.5 39.4 14.0 19.3 19.0 36.0

Employment status

Employed 41.4 59.2 40.1 59.2 38.3 58.4

Unemployed 1.4 1.9 3.0 2.7 1.8 2.1

Not in labor force 57.2 38.9 56.9 38.2 59.9 39.5

Source: Reference 33.
The Middle Years

111

The low levels of education and family income

among women in midlife with diabetes are even

more striking among black women: 22.7% of black

diabetic women had completed less than 9 years of

education, and 61% lived in families with an annual income less than $20,000; percentages for white

women were 13.8% and 50.8%, respectively (Table

5-2). Age-stratified data were not available for

Mexican American women. However, overall estimates indicate that 69% of Mexican American

women with type 2 diabetes have annual incomes

below $20,000.33

Women with diabetes also have fewer years of education and lower family incomes than men with

diabetes.33 Only 23.6% of diabetic women aged

45–64 years reported at least some college education compared with 40.2% of diabetic men; additionally, more than half of diabetic women reported

a family income less than $20,000, and only onethird of diabetic men reported such income.

These data from the 1989 NHIS suggest that in

midlife, millions of women with diabetes have low

SES. Their low levels of education and income

combine to make them ill-equipped to deal with

the self-management and financial demands of the

disease. These issues are especially compelling for

minority women.

5.3. Impact of Diabetes on Health Status

Death Rates

Diabetes is a leading cause of death among middleaged American women.36 In 1996, diabetes ranked

fifth among white women, fourth among black and

American Indian women, and third among

Hispanic women aged 45–64 years. Death certificate data are subject to bias from underreporting of

diabetes and misclassification of racial and ethnic

categories.37 Consequently, national vital statistics

underestimate the contribution of diabetes to mortality in the total population as well as the magnitude of risk of mortality for people with diabetes.

Several epidemiologic studies of representative samples of the U.S. population and other groups have

shown consistently that diabetes is a major risk factor for all-cause and cardiovascular disease (CVD)

mortality.26,38-47 The First National Health and

Nutrition Examination Survey (NHANES I,

1971–1975) included a representative sample of the

noninstitutionalized U.S. population aged 25–74

years. Participants with and without a medical history of diabetes at baseline examination were followed through 1992–1993.26,46 Vital status was

ascertained for 97.9% of persons with self-reported

diabetes and 96.1% of those without. During the

22-year follow-up, in all age, sex, and racial groups,

all-cause death rates were higher among people with

diabetes than among those without diabetes.

At ages 45–64 years, the death rate among women

with diabetes was almost 3 times the rate of women

without diabetes (33.8 per 1,000 person-years versus 12.6 per 1,000 person-years).26 The strength of

the relationship between diabetes and mortality

among non-Hispanic white women was similar to

that for non-Hispanic black women (age-specific

rate ratios = 2.5 and 2.2, respectively).26 However,

Figure 5-3. All-cause mortality rates for U.S. 

adults aged 45–64 years, by 

diabetes status, sex, and race/

Hispanic origin, 1971–93

0

20

40

60

80

Women

Deaths per 1,000 person-years

Men

NHW NHW NHB NHB

Diabetes

No diabetes

28.9

11.6

44.8

20.2

46.5

23.6

33.6

76.5

NHW = non-Hispanic white; NHB = non-Hispanic black.

Source: Reference 26.
112

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

in both relative and absolute terms, the impact of

diabetes on mortality was greater for non-Hispanic

black women than for their white counterparts

(Figure 5-3). Among women with diabetes, nonHispanic black women had a 60% higher risk for

death than non-Hispanic white women after controlling for CVD risk factors; the excess mortality

attributable to diabetes was 24.6 per 1,000 personyears for non-Hispanic black women compared

with 17.3 per 1,000 person-years for their white

counterparts.

The poorer survival experienced by persons with

diabetes compared with nondiabetic persons was

present throughout the follow-up period. However,

among women, the diabetes-nondiabetes survival

differential became progressively greater with time,

being most apparent for women aged 45–54 years.

Furthermore, the well-known survival advantage of

women over men was much lower in the diabetic

compared with the nondiabetic population, most

markedly at younger ages (Figures 5-4a and 5-4b).

Among persons with diabetes, ischemic heart disease is reported to account for 40% of all deaths,

and other cardiovascular diseases for another 15%

of deaths, making these conditions the leading

causes of diabetes-associated deaths.36 In a recent

study, using data from NHANES I and the

NHANES I Epidemiologic Follow-Up Survey, mortality rates from heart disease among women with

diabetes increased 2% among those aged 55–64

years over an 8-year follow-up period. During the

same period, women without diabetes of similar age

experienced a 20% decrease in heart disease mortality.46

Hospitalizations

Across all age groups, persons with diabetes are

approximately 3 times as likely to be hospitalized as

persons without diabetes.48 Among 1989 NHIS

participants aged 45–64 years, 22.4% of women

with diabetes reported that they had been hospitalized at least once in the past year compared with

8.8% of women without diabetes.48 The prevalence

of self-reported hospitalization did not vary by

race/ethnicity or sex.48

Data from the 1989 NHIS indicated that patients

aged 45–64 years with diabetes also had a longer

Figure 5-4a. Survival of diabetic and 

nondiabetic U.S. adults aged 

45–54 years, by years of followup, 1971–93

Men, No Diabetes

Men, Diabetes

Women, No Diabetes

Women, Diabetes

60

80

100

5 10 15 20

Survival (%)

Years of Follow-Up

90

70

50

0

Source: Reference 26.

Figure 5-4b.Survival of diabetic and 

nondiabetic U.S. adults aged 

55–64 years, by years of followup, 1971–93

Men, No Diabetes

Men, Diabetes

Women, No Diabetes

Women, Diabetes

20

0

40

60

80

100

5 10 15 20

Survival (%)

Years of Follow-Up

Source: Reference 26.
The Middle Years

113

average length of hospital stay (9 days) than

patients without diabetes (6 days).48 However, from

1980 to 1990, the average length of stay decreased

22% among patients with diabetes listed as any

diagnosis. A North Carolina survey found that

women were hospitalized for diabetes-related causes

55% more total days than men and that this sex

difference increased with age; however, average hospital charges were nonetheless higher for men across

all age groups.48

Disabilities

The public health impact and economic costs of

diabetes-related disability are enormous. Data collected by 11 states and the District of Columbia for

the 1998 Behavioral Risk Factor Surveillance

System (BRFSS) disability module indicated that

more women than men reported activity limitations.49 The prevalence of reported activity limitations increased with age.49

Quality of Life

Several characteristics have been shown to affect the

relationship between diabetes and quality of life. In

the San Antonio Heart Study, diabetic patients with

vascular complications had a higher prevalence of

functional impairment (49.5%) than those without

complications (31.8%).50 In addition, among persons with diabetes in this study, increased levels of

impairment were associated with a number of other

factors, including age, duration of diabetes, fasting

glucose level, insulin use, hypertension, and

increased body mass index (BMI).50 Finally, in a

recent evaluation of two measures of quality of life

among persons with diabetes, the investigators

found that quality of life was reduced in persons

who experienced more frequent and severe diabetic

complications (unadjusted for BMI) and that separated and divorced persons experienced a lower

quality of life than their married counterparts.51

Among women aged 50–59 years in this study,

54% of those with diabetic complications had functional impairment, whereas functional impairment

was found in only 30% of diabetic women without

complications and 24% of women without diabetes. Among women aged 60–70 years, corresponding rates of functional impairment were 50%

among diabetic women with complications, 44%

among diabetic women without complications, and

19% among women without diabetes.51

Studies have examined the effect of sex on perceptions of quality of life among persons with diabetes.

Data from the 1989 NHIS showed that women

with diabetes (4.4%) were less likely than men with

diabetes (7.8%) to rate their health status as excellent, although these results were not adjusted for

age. Among persons without diabetes, 31.8% of

women and 38.9% of men rated their health status

as excellent.51 A better understanding is needed of

the effects of gender on quality of life among persons with diabetes.

5.4. Health-Related Behaviors

Risk Behaviors and Risk Factors

A number of lifestyle factors increase a person’s risk

of developing type 2 diabetes and complications of

type 1 or type 2 diabetes. Diet, BMI, and level of

physical activity are closely interrelated and work in

concert to influence a person’s risk for diabetes and

its complications.

An understanding of the impact of these lifestyle

factors on the health of women is critical to the

development of appropriate interventions to prevent diabetes and its complications. Although not

all of these data regarding risk factors are limited

specifically to women aged 45–64 years, these findings appear applicable to a broad population,

including women in this age range.

Diet and obesity. Diet has been associated with both

the development of type 2 diabetes and the onset of

diabetic complications, both through its potential

contribution to hyperglycemia and its relationship

to other risk factors for diabetic complications.

Independent of its influence on weight gain, diet

composition may play an important role in the

development of type 2 diabetes. Recent findings

from the Nurses’ Health Study suggest that women

aged 38–63 years whose diets were rich in whole

grain products had a significantly lower incidence

of diabetes over a 10-year follow-up period.
114

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

Moreover, the relationship was stronger in overweight women (BMI > 25 kg/m2

) and remained

significant after adjustment for intakes of dietary

fiber, magnesium, and vitamin E.52

The importance of dietary therapy in managing

hyperglycemia and hyperlipidemia to prevent both

microvascular and macrovascular complications of

diabetes cannot be overemphasized.53 The goal is to

optimize glycemic control to prevent and treat both

acute hypoglycemic events and chronic diabetes

complications. In the 1989 NHIS, only 64% of all

persons with diabetes reported following a diabetesspecific diet all or most of the time; however, 91%

of persons aged 45–64 years with diabetes reported

that they thought diet was very important for diabetes control.54

The majority of women with type 2 diabetes have

additional risk factors for vascular complications of

diabetes that can be controlled with dietary treatment. Approximately 52% of women aged 45–64

years with diabetes have hypertension, compared

with 26% of nondiabetic women;55 of black women

with diabetes, 91.6% have hypertension compared

with 57.9% of black women without diabetes.

Approximately 30%–40% of women aged 45–64

years with diabetes have elevated LDL cholesterol.55

Because abnormalities in lipid profiles and hypertension are more common among diabetic than

nondiabetic women, a diet low in saturated fat,

cholesterol, and sodium is essential for women with

diabetes.

Among persons aged 45–64 years, BMI is higher

among those with diabetes (mean BMI 28.1 kg/m2

)

than among those without diabetes (mean BMI

25.5 kg/m2

).55 Among persons with diabetes aged

45–64 years, the mean BMI of women exceeds that

of men in all racial and ethnic groups: white

women, 29.2 kg/m2

, and white men, 28.4 kg/m2;

black women, 31.4 kg/m2

, and black men, 28.0

kg/m2

; Mexican American women, 30.5 kg/m2, and

Mexican American men, 26.3 kg/m2

. In NHANES

III, most adult participants with type 2 diabetes

were overweight, and 47% of women with diabetes

were obese (defined as a BMI > 30 kg/m2

) compared with 25% of all women.56 This study included women with diabetes aged 45–64 years, but

results were not stratified by age or sex. In data

from NHANES II and the Hispanic Health and

Nutrition Examination Survey (HHANES,

1982–1984), the prevalence of obesity among

women with diabetes aged 45–64 was estimated to

be 51% among white women, 49% among

Mexican American women, and 70% among black

women.55 The mean BMI for black women with

diabetes exceeded that of white women with diabetes as well. Of white women aged 45–64 years

with type 2 diabetes, approximately 51% had a

BMI greater than 30 kg/m2

, and 40% of those had

a BMI greater than 35 kg/m2

. Among black women

in the same age group with type 2 diabetes, nearly

70% had a BMI 30 kg/m2 or greater; one-fifth had

a BMI 35 kg/m2 or greater.55

Controlling obesity is not only important for

reducing the risk of developing type 2 diabetes but

also for managing diabetes and preventing diabetesassociated complications.57 It has been clearly

shown that hyperglycemia can be controlled with

dietary treatment and modest weight loss in most

patients with type 2 diabetes.58-60 Obesity, especially

abdominal obesity, is also a risk factor for insulin

resistance syndrome61 and for subsequent diabetesrelated macrovascular complications, including

coronary heart disease and hypertension.

In a study of a weight loss intervention among

women with type 2 diabetes, black women lost less

weight overall and regained more weight than white

women.62 These results confirmed the observations

of a previous study of nondiabetic persons that

found smaller weight losses and faster weight regain

among black than white women.63 Because of the

long-term ineffectiveness of weight loss interventions, prevention continues to be the most viable

and effective strategy for decreasing the prevalence

of obesity. Weight gain, especially in persons who

are already overweight, is a strong predictor of diabetes incidence. However, in overweight adults,

even modest weight loss can significantly reduce the

risk of developing diabetes.64 This study included

women aged 45–64 years, but results were not
The Middle Years

115

stratified by age or sex. Clearly, more research is

needed in the area of obesity prevention and weight

reduction, especially for minority women and

women with diabetes.

Physical activity. Physical activity benefits women

and men with diabetes by improving glycemic control and reducing diabetes-related complications.65

Interventions to increase physical activity in this

population may significantly improve glycemic control, particularly in older, physically inactive

women, who are at increased risk of developing diabetes.66 Increased physical activity can also reduce

the risk of coronary heart disease (CHD), the leading cause of death among women with diabetes. A

35%–55% reduction in risk for CHD is associated

with maintaining an active lifestyle,67 although few

data are available concerning the relationship

between physical activity and CHD risk specifically

among women. Compared with 38% of women

without diabetes, only 28% of women with type 2

diabetes participate in regular exercise despite the

benefits of physical activity for weight loss,

glycemic control, and prevention of CHD.68

Efforts to increase levels of physical activity among

women, especially women with diabetes, have great

potential for public health benefits. More research

is needed on the relationship between physical

activity and the development of type 2 diabetes and

diabetes-related complications in women to guide

the development of interventions.

Smoking. Evidence that cigarette smoking may

impair insulin sensitivity and increase the risk for

type 2 diabetes is mounting.69 Among women in

the Nurses’ Health Study (NHS), those who

smoked more than 25 cigarettes a day had a relative

risk for type 2 diabetes of 1.42 (95% CI, 1.18 to

1.72) compared with nonsmokers.70 Despite its

associated risks, smoking has been found to be all

too prevalent among persons with diabetes; according to data from the 1989 NHIS, 27% of men and

22% of women aged 45–64 years with diabetes

were smokers.55

Smoking is also a risk factor for all of the major

complications of diabetes, including CHD and

stroke, that are major causes of death among

women with diabetes. Among women with diabetes, smokers have a greater risk for both fatal and

nonfatal coronary events than nonsmokers. In an

analysis of data from NHS, the attributable risk of

a coronary event among women with diabetes was

162 events per 100,000 person-years for nonsmokers and 387 events per 100,000 person-years for

current smokers.41 In addition to its effect on

CHD, smoking also contributes to diabetic

nephropathy, which is often a precursor of endstage renal disease.71 The risk of respiratory infection is also increased among diabetic patients who

smoke. Because the elimination of smoking can

potentially play a major role in reducing complications among women with diabetes, research is needed to determine whether intervention strategies

need to be tailored specifically to meet the needs of

women with diabetes.

Health-Promoting Behaviors

The four major goals of health-promoting behaviors among women with diabetes are 1) to improve

metabolic control of diabetes itself, 2) to reduce the

frequency and severity of microvascular complications (retinopathy, nephropathy, and neuropathy),

3) to reduce the frequency and severity of

macrovascular complications (including CHD,

stroke, and peripheral vascular disease), and 4) to

improve quality of life. Monitoring blood glucose

levels to eliminate hyperglycemia and reduce the

incidence of hypoglycemia is the key to metabolic

control. The cornerstone of preventing microvascular complications is maintaining serum glucose and

blood pressure at normal or near-normal levels, as

demonstrated among persons with type 1 diabetes

in the Diabetes Control and Complications Trial

(DCCT)72 and among those with type 2 diabetes in

the United Kingdom Prospective Diabetes Study

(UKPDS).73 The role of glycemic control in preventing macrovascular complications is still being

defined; however, data from the UKPDS suggest

that control of concomitant hypertension has a

greater impact than glycemic control on preventing
116

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

macrovascular complications.73,74 The importance of

assessing and managing major cardiovascular risk

factors to prevent macrovascular complications of

diabetes cannot be overemphasized.

Despite the importance of preventive health practices for persons with diabetes, the overall level of

preventive care among patients with diabetes varies

greatly. Among persons aged 25 years or older with

type 2 diabetes who participated in NHANES III,

most (58%) had a hemoglobin A1c (HbA1c) level

greater than 7.0%, about 40% had uncontrolled

hypertension, over one-third had microalbuminuria

or clinical proteinuria, about one-quarter had undiagnosed dyslipidemia, and many had undesirable

lipid levels.56 A study using data from the Colorado

BRFSS found no significant differences between

men and women in levels of preventive care.75

However, preventive care practices tended to

decrease in older age groups and among those with

lower levels of education. Differences were most

striking for the percentage reporting that they had

been monitored for HbA1c: 64.5% of persons aged

30–44 years reported undergoing HbA1c monitoring, compared with only 37.1% of persons aged

45–64 years and 10.6% of persons aged 65 years or

older. In a study using BRFSS data from North

Carolina, knowledge of HbA1c decreased as age

increased.76

In a study of data from the NHIS, only 35% of

persons aged 18 years or older reported having diabetes education at some point during their disease;

among those aged 40–64 years, diabetes education

was reported by 52% of those with insulin-treated

type 2 diabetes and 25% of those with type 2 diabetes not treated with insulin.77 Age-stratified

results were not separated by sex, but overall rates

among women were similar to those among men.

Although this report may have underestimated diabetes education by defining it in terms of participation in a class or program about diabetes, these

studies overall suggest that diabetes education needs

to be improved.

Adherence

Self-management is an important component of

diabetes care.78 Findings from several studies indicate that persons with diabetes are most likely to

comply with their medication regimens and

requirements for self-testing and are least likely to

make lifestyle changes, such as modifying diet and

exercise habits.79,80 However, little information is

presently available regarding the role of sex and age

in influencing physician or patient adherence to

recommendations for prevention or treatment of

diabetes. Development of effective public health

initiatives for women in this age group with diabetes will require further study.

5.5. Psychosocial Determinants of Health

Behaviors and Health Outcomes

Social Environment

Marriage, family, and social support. Most women

aged 45–64 years with diabetes are married.33

However, almost no information is available regarding the impact of the presence of a spouse on the

level or quality of diabetes care, although social

context has an important influence on diabetes care

and prevention goals.81 Similarly, the role of families

in the management of diabetes in adult patients is

largely unexplored, and the studies that have been

done show conflicting results.

A cross-sectional study of 150 insulin-requiring

adults with a median age of 51.3 (34% male and

66% female) that controlled for age, duration of

diabetes, and type of diabetes found that family

environment may not relate to glycemic control but

to psychosocial adaption.82 When family members

were supportive of recommended diabetes care

practices, the person with diabetes was more satisfied with various aspects of his or her care and

adaptation to the illness. Women were also found

to demonstrate a higher level of satisfaction with

various diabetes-related aspects of their lives.

Another model83 suggests that persons with type 1

diabetes exhibit greater psychosocial lability in
The Middle Years

117

glycemic control and are more responsive to psychosocial factors, while those with type 2 are affected more by variations in regimen adherence and

stress. It is clear that additional research must take

into consideration a multitude of factors that affect

glycemic control. One must consider the type of

diabetes, the social and economic environment,

biologic and psychosocial factors, and the synergistic effects of these variables on the disease process in

individuals. 

A study of the determinants of diabetes education

found that widowed patients (39%) were less likely

to receive diabetes education than married patients

(50%); however, this result was not controlled for

age.77 In a review of quality of life indicators, it was

found that persons with diabetes who were not

married were more likely to report symptoms of

depression than those who were married. Men were

also less likely to report symptoms of depression

than women.84 A study of persons with type 2 diabetes in Finland found that those who lived alone

reported lower levels of physical functioning and

psychosocial well-being than those who lived with

others.85

A review of behavioral medicine approaches to

improved diabetes care suggests that enhanced

social support may be a rich resource for diabetes

education and management; however, effects of

gender and age should be considered.86

Self-help groups are one form of social support that

may serve several important functions for persons

with diabetes. Such functions include helping

patients adapt to the diagnosis of diabetes, cope

with complications, and learn to manage diabetes

more effectively.78 In a randomized trial in which

patients with diabetes were assigned to either individual or group instruction, the patients in the

group had greater improvements in diabetes knowledge and attitude toward diabetes than those

instructed individually.79 Community support

groups provide another means of diabetes education

that may be more accessible to some patients than

traditional diabetes education programs. CDC’s

Project DIRECT will be the first community project in the United States to apply community organization approaches to reducing the burden of

diabetes by including interventions at all three levels of prevention. Project DIRECT should yield

valuable information about the applicability of

community organization approaches to diabetes

prevention.87

Socioeconomic factors. On the basis of data from the

1989 NHIS, the proportion of women with diabetes aged 45–64 in the lowest quartile of educational status (fewer than 9 years of education) and

in the lowest quartile of income (annual family

income less than $10,000) exceeds the proportion

of nondiabetic women in these quartiles for every

racial group.33 Among participants in the San

Antonio Heart Study, the prevalence of diabetes

and of other cardiovascular risk factors, including

obesity, hypertriglyceridemia, and low high-density

lipoprotein (HDL) cholesterol, fell with rising

socioeconomic status (SES).88 Previous studies looking at SES and excess prevalence of diabetes showed

no correlation between these two measures.89,90

These studies, however, did not stratify by sex. An

analysis of NHANES III data that examined diabetes prevalence, SES, and other risk factors such as

BMI, physical activity, and smoking among African

American and non-Hispanic white men and

women aged 40–74 years found that economic disadvantage may explain much of the excess prevalence of diabetes in African American women but

not in African American men. The authors suggest

that environmental influences such as poverty,

stress, discrimination, quality of nutrition, and living conditions may affect African American men

and women in different ways.91 A recent analysis of

data on 453,384 persons in the National

Longitudinal Mortality Study (approximately

60,000 were black and white women aged 45–64

years) found that black women had a risk for death

from diabetes nearly twice as high as white women,

and 40% of this excess was explained by SES.92

Such studies provide valuable information on the
118

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

determinants of diabetes in subpopulations. They

do not, however, elucidate the relationships of these

factors to morbidity among persons who have diabetes (i.e., prevalence of diabetes complications or

other comorbidities). Additional studies are needed

to shed more light on this issue. Differences in the

determinants of morbidity and mortality between

women and men would warrant the development

and implementation of appropriate interventions.

In addition to increasing the risk for diabetes and

mortality from diabetes, low SES has been associated with increased levels of cardiovascular risk

among persons with diabetes. In a study of persons

with diabetes in Scotland, the proportion of diabetic patients with three or more cardiovascular risk

factors rose from 8.6% among those in the highest

socioeconomic stratum to 20.2% among those in

the lowest stratum.93 For example, smoking was

most prevalent among persons in the lowest socioeconomic stratum: 33% of persons with diabetes in

the lowest stratum smoked, whereas only 13% in

the most affluent category were smokers. However,

these results were not stratified by sex and age.

Some data suggest that SES may also affect the

functional status of persons with diabetes. Among

9,744 women and men aged 51–64 years sampled

cross-sectionally as part of the 1992 Health and

Retirement Study, SES was a significant predictor

of functional status for persons with diabetes, as

measured by the ability to perform several common

activities of daily living, and differences in SES

appeared to explain much of the worse functional

status of blacks and Hispanics with diabetes compared with whites.94 The relationship between SES

and functional status may stem from the effects of

SES on access to care and on a person’s ability to

alter the environment to improve functional status,

as well as through the association of SES with other

health behaviors, such as smoking and physical

activity, that adversely affect health.94 Much work

remains to be done to clarify the relationships

between sex, race, and SES as they affect diabetes

prevention and control. Uniform definitions of SES

that include household wealth as well as income are

needed to enhance progress in this area. In addition, researchers need to take into account race and

sex as additional variables when considering the

relationship between SES and diabetes.

Social networks. A social network is a set of social

ties that connects an individual with others.

Analysis of social networks examines potential ties

that persons may have apart from traditional

sources of support such as family members or

members of a particular organization such as a

church. Data are lacking on the impact of social

networks on women aged 45–64 years with diabetes. However, data suggesting that lack of a social

network increases all-cause mortality risk among

both women and men in the general population95

indicate that such networks may have an important

effect on disease outcomes. More research is needed

on the effects of larger social units in communities

or social networks on persons with diabetes, including women aged 45–64 years. A better understanding of social networks may be helpful in developing

successful strategies for designing community-based

diabetes interventions.

Community norms and acculturation. Much of

behavioral research in diabetes has focused on individual behavior and family influences. The person

with diabetes, however, lives in a community and

invariably is influenced by the social environment

within which he or she lives. No data are available

on the effects of community norms and acculturation on women aged 45–64 years with diabetes.

However, several studies have found that acculturation to a Western lifestyle increases a person’s risk

for type 2 diabetes.96-99 In the Honolulu Heart

Program, diabetes was less prevalent among

Japanese American men who had retained a more

traditional Japanese lifestyle than among those who

had adapted to a Western lifestyle.96 However, this

study did not include women. In another study of

the effects of acculturation on diabetes risk that

involved both women and men (age range 17–61

years), Pima Indians residing in a rural, semi-isolated area of Mexico were compared with Pima

Indians living on a reservation in Arizona. The
The Middle Years

119

Pima Indians of Mexico were thinner (mean BMI

24.9 kg/m2

) than those of Arizona (mean BMI 33.4

kg/m2

) and had a much lower prevalence of type 2

diabetes.99 Moreover, among both women and men,

mean total cholesterol levels were significantly lower

in the Mexico group than in the Arizona group.

Researchers also noted that the total caloric intake

of the acculturated population was substantially

higher than the presumed caloric intake of Pima

Indians living a traditional lifestyle.100

A cross-sectional study of 1,387 Mexican American

women and 1,404 Mexican American men aged

25–64 years from NHANES III showed that a large

waist circumference (a major risk factor for diabetes) and prevalence of abdominal obesity were

strongly associated with migration and acculturation status.101 Among women, the mean waist circumference was smallest for those born in Mexico

(90.4 cm), intermediate for those who were U.S.-

born English-speaking (93.6 cm), and largest for

those who were U.S.-born Spanish-speaking (96.9

cm). The prevalence of abdominal obesity (waist

circumference ≥ 88 cm) among U.S.-born Spanishspeaking women, U.S.-born English-speaking

women, and Mexico-born women was 68.7%,

58.6%, and 55.6%, respectively. The large differences observed suggest that environmental and cultural factors may be major determinants of the

diabetogenic risk profile of populations. Additional

studies are needed to determine the effect of acculturation on the development of complications related to diabetes.

Acculturation and community norms are also likely

to affect diabetes management in important ways,

although little research has been done in this area.

In a small study using focus groups of Hispanic

men and women over age 40 with type 2 diabetes,

participants stated that the dietary needs of the

family member with diabetes were often subordinated to the dietary preferences of the rest of the

family.102 Exercise and dietary changes were difficult

for members of this community, and most were

unaware that increased exercise and improved diet

could reduce the severity of type 2 diabetes and the

risk for complications. Another important finding

of this study is that all participants reported having

used some type of traditional remedy for type 2

diabetes without informing their health care

providers.

In general, the beliefs of women with diabetes affect

lifestyle and behavior related to nutrition, physical

activity, and diabetes self-management. Acculturation is likely to affect not only a woman’s chance

of developing diabetes but also her way of managing the disease.

Interactions with the Health Care System

Access to care. Data from the 1990 National Health

Interview Survey indicate that physician visits related to diabetes are more frequent among women

than men overall and increase with age. According

to that survey, diabetic women aged 45–64 years

had an average of 16 outpatient physician contacts

each year; this number was similar to that among

men of the same age (16.3 visits annually).103 In

addition, almost all surveyed diabetic women in

this age group had ongoing contact with the medical system: 95% had seen a physician in the last

year, and only 2% had not had physician contact

for 2 years or more; corresponding figures for men

with diabetes were 92% and 2.2%, respectively. In

contrast, only 78% of persons without diabetes

reported a medical contact in the past year.

Nevertheless, some persons with diabetes, including

women in this age group, do not have adequate

access to the health care system, and barriers to

access are associated with increased illness and costs.

For example, in a random sample of English- and

Spanish-speaking adults, perceived access to care

was inversely related to hospitalization rates for diabetes, among other diseases.104 This study included

women aged 45–64 years, but results were not

stratified by age or sex. We are unaware of studies

of the effects of poor access to care on other markers for diabetes severity, such as hemoglobin A1c

levels, among women in this age group. Research

that examines the role of access to care as it relates

to glycemic control and the development of long-
120

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

term complications of diabetes among women

would be valuable in developing strategies to control diabetes and decrease its complications.

Importantly, many women who are integrated into

the health care system may not necessarily be

receiving recommended care for their diabetes. (See

Appendix E.) For example, a national survey found

that although 91% of diabetic men and women

(mean age 62 years) identified one physician who

provided regular care for their diabetes, only 40%

of those not on insulin and 51% of those on

insulin had seen an ophthalmologist in the past

year. In addition, similar low rates were reported for

other recommended services, including seeing a

nutritionist in the past year (reported by 19% not

on insulin and 24% taking insulin) and having feet

checked by a health professional at least twice in

the past 6 months (25% and 39%, respectively).105

Similar findings were reported in a study in

Michigan that examined the frequency with which

persons with diabetes (average age 63 years and

more than half women) accessed three services considered essential for diabetes management: seeing

an ophthalmologist for retinopathy screening, diabetes education, and dietary counseling. Fifteen

percent of the sample reported having never used

any of these services, and only 33% reported having

used all three services at least once in their lifetime.106 Among presumed contributors to these low

rates of accessing appropriate services were the tendency for physicians and patients to minimize the

seriousness of type 2 diabetes, poor understanding

and management of obesity, and the chronic multisystem nature of diabetes, which does not lend

itself well to a health care system built around acute

care.

Data from NHANES III also indicate that

although adults with diabetes have frequent contact

with health care providers, health status and outcomes are far from optimal. Glycemic control was

poor, 58% had a HbA1c level greater than 7%,

many patients were obese (45% had a BMI > 30

kg/m2

), and among 60% of patients with known

hypertension and hyperlipidimia, the blood pressure and lipid levels were not controlled at recommended levels. These adverse health outcomes were

distributed across all patient subgroups, but were

not stratified by age and sex.56

Although it is certainly important to ensure that

persons with diabetes have adequate access to care,

it is also important to ensure that access to care

includes access to preventive services necessary to

optimize the health of persons with diabetes.105

Strategies to meet these goals need to be defined for

women aged 45–64 years.

Resource utilization. Data from the 1990 National

Medical Care Survey indicate that women aged

45–64 years made almost 2.9 million diabetesrelated office visits in 1990. Of all diabetes-related

office visits by women, 35% were made by women

in this age group, compared with 8% among

women aged 25–44 years and 54% among women

aged 65 years or older. These figures are comparable

to those for men.103

A recent estimate of excess health care costs attributable to diabetes comes from the Kaiser

Permanente database. Costs for diabetes-related

treatments among the 85,209 patients with diabetes

were compared with costs among age- and sexmatched controls without diabetes; excess annual

expenditures associated with diabetes were estimated at $3,494 per person, or 2.4 times that of persons without diabetes.107 Of these excess costs, 38%

covered hospitalization and almost 38% covered

long-term complications, primarily coronary heart

disease and end-stage renal disease. Although

women aged 45–64 years comprised only 21% of

the entire study group and results were not stratified by sex, stratification by age indicated that

excess costs for the age group 45–64 years (of

whom almost half were women) were comparable

to the average excess costs (i.e., $3,156 per person

annually).

Because improved glycemic and blood pressure control can significantly reduce microvascular and

macrovascular complications among persons with

diabetes, including women aged 45–64 years,73,74
The Middle Years

121

interventions to improve glycemic and blood pressure control for women with diabetes would be

expected to reduce both morbidity and costs and

thus warrant broad implementation.

Patient/provider relationship. The quality of the relationship between patients with diabetes and their

primary providers of diabetes care might be expected to affect the type and quality of diabetes care

received. Patient/provider communication plays an

important role in adherence to self-care recommendations.108,109 However, few data are available on the

association of patient/physician relationship with

quality of care for women with diabetes aged 45–64

years. In a prospective cohort study of 128 patients

between the ages of 18 and 79 years with diabetes,

it was found that patient perception of support for

autonomy from a health care provider was related

to significant changes in HbA1c levels at 12

months.110 Such patients also perceived more competence in controlling their glucose levels. This

study included women aged 45–64 years, but

results were not stratified by age or sex. A study

involving patients from general practices in

England found no significant relationship between

glycemic control and patient satisfaction with care

received or the perceived willingness of the provider

to discuss diabetes. However, certain provider characteristics did correlate directly with control,

including having a special interest in diabetes and

being a dietitian.111 Only 46% of participants in

this study were female, their age range was not

reported, and the analyses were not stratified by

sex.

Although more information on qualities of the

patient/provider relationship that enhance the level

of diabetes care would be useful in developing recommendations for medical training in diabetes,

policy recommendations have begun to address the

organizational factors that influence the delivery of

diabetes care. Recommendations made at the Fifth

Regenstrief Conference included universal access

and payment for diabetes preventive services,

comanagement of patients with diabetes by primary

and specialty care providers, and special training for

primary care residents in the management of type 2

diabetes.112 These policy recommendations point

out the need for changes in the structure of health

care delivery and the patient/provider relationship

to improve diabetes preventive care for patients

with diabetes.

Personality Characteristics

Self-efficacy. The primary outcomes of effective diabetes education traditionally were improved metabolic control and patient compliance as a result of

having obtained the knowledge and skills necessary

to follow treatment recommendations. No research

has examined the importance of self-efficacy in

controlling diabetes specifically among middle-aged

women. In a nonrandomized study involving 49

men and 14 women aged 32–82 years, measures of

self-efficacy were highly predictive of adherence to

diabetes treatment, even after adjusting for past

adherence;113 adherence was also correlated with

improved glycemic control as measured by HbA1c

levels. A small randomized, controlled trial examined the effects of an intervention to improve selfefficacy among persons with diabetes; the average

age of the study participants was 50 years, and 70%

were women.114 Although results were not stratified

by age or sex, patients who received the intervention scored higher than the control group on all

eight self-efficacy subscales and experienced a significantly greater reduction in HbA1c levels. Thus,

interventions designed to increase self-efficacy and

increase patient empowerment may improve

glycemic control among women with diabetes, but

more research is needed.

Locus of control. Measures of locus of control,

defined as a person’s overriding beliefs about the

causes or origins of significant events, attempt to

assess personal beliefs regarding control over outcomes. In general, locus of control is divided into

internal and external orientations, with two independent dimensions of externality: chance externality and powerful-other externality.115 Several

attempts have been made to develop measures of

locus of control for specific diseases, including diabetes.116,117 Using different instruments to measure
122

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

locus of control, several studies have found that an

internal orientation was associated with better

adjustment to diabetes, better adherence to treatment,118-120 and better glycemic control,118,121,122 but

contradictory findings have also been reported.

These conflicting results may be related to the fact

that locus of control involves more than one construct, each of which may have opposite effects on

diabetes care practices. A recent study involving

women and men separated internal locus of control

into two components, autonomy and self-blame.118

Results indicated that autonomy was generally associated with improved glycemic control and desirable self-care practices, whereas self-blame was

associated with lower levels of diabetes knowledge,

less frequent glucose self-monitoring, and more

binge eating. In addition, high levels of chance

externality were associated with poor glycemic control, low levels of exercise, and poor diabetes knowledge, while “powerful other” (specifically

nonmedical) locus of control was associated with

regular administration of insulin doses and infrequent binge eating. The mean age of the study participants was 47 years, and 42% were women;118

however, results were not stratified by sex and age.

These results suggest that an increased sense of

autonomy and reduced self-blame may be associated with improved diabetes management in this

population, but they also suggest that relying on

others may not negatively affect management.

In a study that examined racial differences in locus

of control among women and men with type 2 diabetes, blacks had higher levels of external locus of

control than whites, as well as higher levels of stress

and lower levels of family functioning, and higher

levels of hemoglobin A1c.

123 However, the study did

not directly correlate psychosocial variables with

glycemic control, and the ages of participants were

not reported.

Further work in the area of locus of control should

consider its interactions with other factors (e.g., sex,

age, race, psychosocial factors) in predicting the

ability of women to manage their own diabetes

care. Findings may be relevant to the design of

effective diabetes education and treatment programs

for diabetic women aged 45–64 years as well as

other persons with diabetes.

Traditional beliefs. Many studies have examined the

relationship between psychosocial factors and successful diabetes self-management, although most of

these studies have methodologic limitations.124-126

Both the patient’s internal (psychological) environment and the external social environment are of

potential importance in diabetes self-management.127-128 Barriers to diabetes self-management

may arise from either the internal or external environment or interactions between the two. Personal

models are part of the patient’s internal environment and include representations of their illness,

disease-related beliefs, diabetes knowledge, and

experiences. These representations guide self-management and adherence to recommendations for

treatment and preventive care.129

For diabetes in particular, personal beliefs about

treatment effectiveness and, to a lesser extent,

beliefs about disease seriousness have been shown to

be predictive of behavior modifications, such as

changes in diet and physical activity, that are recommended for persons with diabetes.130 In a study

that examined the relationship between personal

models and diabetes self-management, the selfmanagement activities that had the highest levels of

adherence—taking diabetes medications and avoiding sweets—were highly linked to widely held traditional beliefs that diabetes management consists

primarily of these two behaviors. Low-fat, low-calorie diets and increased exercise had lower levels of

adherence and were rated lower in perceived effectiveness. In this study, psychosocial and behavioral

factors were much stronger predictors of differences

in self-management than demographic variables. In

particular, personal beliefs regarding treatment

effectiveness (e.g., the effectiveness of exercise in

controlling diabetes and preventing complications)

were highly predictive of treatment adherence.130

This study included women aged 45–64 years, but

results were not stratified by age or sex.
The Middle Years

123

Focus group interviews with southern African

American women aged 45–65 with type 2 diabetes

revealed three consistent themes: 1) spirituality was

an important factor in general health, adjustment,

and coping; 2) general life stress and multiple caregiving responsibilities interfere with daily disease

management; and 3) diabetes led to feelings of food

deprivation and physical and emotional fatigue,

worry, and fear of complications.131 A crosssectional study of African American and white

adults from Detroit, Michigan, who had type 2 diabetes used the Diabetes Care Profile132 to assess psychosocial factors related to diabetes. The

investigators found that attitudes toward diabetes

were similar for both groups, although whites who

use insulin reported fewer positive attitudes and

more negative attitudes toward diabetes. African

Americans were less distinct in these scores. This

finding suggests that insulin use may be a trigger

for changes in attitudes among whites with diabetes.132 This study included women aged 45–64

years, but results were not stratified by age or sex.

Further study is needed to understand these results.

Confidence in outcome. Few data are available on the

relationship between confidence in positive outcome and diabetes self-management and preventive

care practices. In a small study of African American

women with type 2 diabetes, confidence in positive

outcomes was not related to adherence to recommended self-care practices, although self-efficacy

was predictive of self-care behaviors.133 Other studies have shown an association between confidence

in treatment effectiveness and treatment-specific

adherence.130 Finally, a focus group study found that

urban Caribbean Latinos with type 2 diabetes had a

strong sense of fatalism regarding the course of diabetes.102 This attitude, which may reflect an external

locus of control, has been reported in other minority groups134 and may constitute a barrier to the use

of recommended diabetes self-care behaviors.

Confidence in outcome appears to overlap with

locus of control in predicting diabetes selfmanagement.

More research on characteristics such as fatalism,

confidence in outcome, and self-efficacy is needed

to develop diabetes education strategies that are

effective in producing behavioral change. In particular, an analysis of these characteristics among

women and minority populations could increase

our understanding of personal and social barriers to

diabetes control in these vulnerable groups.

5.6. Concurrent Illnesses as Determinants of

Health Behaviors and Health Outcomes

Mental Health

Eating disorders. A number of studies have examined eating disorders among women with diabetes,

although all of these studies have included only

women younger than age 46 with type 1 diabetes

(Chapters 3 and 4). Younger women with clinical

and subclinical eating disorders, as well as women

who withhold insulin for weight control, have significantly worse glycemic control than women with

diabetes who do not practice these behaviors. In

addition, eating disorders are associated with an

increase in retinopathy, as well as increased levels of

serum cholesterol, triglycerides, and total lipids.

Research in this area has not addressed women aged

45–64 years, a group in whom obesity and

attempts at dieting are known to be frequent.

Given the significant risks that may be associated

with disordered eating patterns, studies should

assess the prevalence of these behaviors in middleaged women and their effects on diabetes management outcomes.

Depression. Several studies have found that the

prevalence of depression is greater among men and

women with diabetes than among the general population.135-146 A review of 20 studies reported that

the rate of major depression among persons with

diabetes is at least 3 times greater than that of the

general U.S. adult population.135 Looking specifically at middle-aged women, a population-based study

involving the Rancho Bernardo population found

that among women aged 50–64 years, 14.4% of

those with diagnosed diabetes but only 5.2% of
124

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

those without diabetes had a Beck Depression

Inventory score in the depressed range; corresponding rates in men were 7.1% and 2.0%, respectively.136 Because these studies are cross-sectional in

nature, their results cannot be used to infer a causal

relationship between depression and diabetes. In

fact, the prevailing clinical assumption has been

that diabetes, like other chronic illnesses,137,138 causes

depression through a psychological reaction to the

stress of illness or the threat of death or complications.139-141 However, several studies have failed to

show a correlation between the severity of diabetes

and depressive symptoms.142-144

There is some evidence that depression may be a

risk factor for the development of diabetes, particularly type 2. Research has suggested that diabetes

and depression may have a common neuroendocrine basis, possibly mediated through depression-induced elevations in cortisol.144-146 Results of a

recent prospective 13-year follow-up study that

assessed the prevalence of psychopathology among

3,481 adults suggest that major depressive disorder

may increase the risk of developing type 2 diabetes

(relative risk [RR] 2.2; 95% confidence interval

[CI] 0.90–5.55), although the results were not statistically significant.147 Women aged 45–64 years

comprised only 16% of the group, yet they had the

highest incidence of diabetes of any subgroup. Sex

was not a significant predictor of diabetes in this

study population, and major depression appeared 

predictive of diabetes even after adjusting for age,

sex, and body weight. Major depressive disorder

typically has its onset in the early adult years,148

before the onset of type 2 diabetes, and is characterized by repeated episodes of depression.

No research has addressed the correlation between

the number or severity of depressive episodes and

the development of diabetes or the influence of

antidepressive therapy on the subsequent development of diabetes among women in this age group.

Whether depression represents a modifiable risk

factor for the development of type 2 diabetes in this

population requires further study. Moreover, since

women are at greater risk for the development of

both depression and type 2 diabetes, prospective

studies that address the relationship between diabetes and depression in women and control for

confounding by such factors as obesity and 

socioeconomic status would be of great potential

benefit for treating women with type 2 diabetes. In

addition to the potential role of depression in the

development of diabetes, the public health impact

of depression in persons with diabetes needs to be

assessed.

Physical Disability and Complications

Coronary heart disease. Coronary heart disease

(CHD) is not only the major cause of death but

also an important cause of illness among persons

with diabetes. Because the risks for both type 2 diabetes and CHD are high in the middle years, a

thorough understanding of the interactions between

diabetes and CHD risk factors is critical for health

care providers caring for women in this age group.

As noted earlier, CHD is significantly more prevalent among women with diabetes than among those

without diabetes. For example, in the Nurses’

Health Study, women with diabetes aged 30–55

years at study entry had a 7 times greater risk for

CHD than that of their nondiabetic counterparts.41

This increased risk may be explained in part by the

increased prevalence of other recognized coronary

risk factors, including obesity, hypertension, and

dyslipidemia, among persons with diabetes.149,150

However, even after adjusting for several other recognized coronary risk factors, diabetes remains a

significant risk factor for CHD, with a threefold

increase in risk seen among women in the NHS.41

Furthermore, the renal disease that frequently

accompanies diabetes further increases CHD risk

among persons with diabetes.

Although only a small percentage of persons aged

45–64 years with diabetes have type 1 diabetes, the

strikingly high CHD risk in these patients was

demonstrated in a follow-up study of a Joslin Clinic

cohort of patients with type 1 diabetes, 35% of

whom had died of CHD-related causes by age 55;

an additional 15% of these patients had clinically
The Middle Years

125

evident CHD.151 As with type 2 diabetes, concomitant nephropathy increases the risk for CHD.

Effect of sex on coronary heart disease risk. Diabetes is

a more powerful risk factor for CHD among

women than among men and negates the overall

protective effect of female sex on CHD risk, even

among premenopausal women.152-154 Numerous U.S.

population-based studies have found age-adjusted

mortality rates for CHD that are 3–7 times higher

among women with diabetes, specifically including

those aged 45–64 years, than among women without diabetes, and 2–3 times higher among men

with than without diabetes.41,152-155 Among persons

with diabetes in the Framingham cohort, 7.7% of

CHD among women but only 3.8% of CHD

among men was attributable to diabetes.156 Among

women in the NHS, 13.8% of coronary events

were attributable to diabetes.41 The increased risk

for CHD associated with diabetes in this cohort

was even greater among women with other coronary risk factors such as hypertension, high cholesterol, and obesity, all of which frequently cluster

with diabetes. For middle-aged and older women

with diabetes, the risk posed by CHD is of special

concern because the absolute risk for CHD increases with age.

The mechanisms underlying the greater risk for

CHD among women than among men with diabetes are not completely understood. Contributing

factors may include higher rates of hypertension

and obesity among diabetic women than among

men.155,156 Lipid abnormalities also are likely to contribute to sex differences in CHD risk. Among the

Rancho Bernardo study population of women and

men aged 40–79 years, women with diabetes had

lower HDL cholesterol levels than women without

diabetes, and the difference between diabetic and

nondiabetic HDL levels was greater among women

than among men.157 Furthermore, diabetes may

have a greater adverse effect on LDL particle size in

women than in men.158 Diabetic women are more

likely than diabetic men to have small dense LDL

particles, which are considered more likely to cause

atherosclerotic plaques and coronary vascular disease.159 In all likelihood, the relationship between

sex, diabetes, and CHD risk is probably influenced

by several factors, including hypertension, obesity,

lipid abnormalities, and hormonal (androgen/estrogen) levels.

Major coronary risk factors. The low risk for CHD

among patients with diabetes in countries with low

rates of CHD160,161 supports the hypothesis that diabetes interacts with other cardiovascular risk factors

to promote atherosclerotic lesions.162 Although the

basic biology that underlies the relationship

between diabetes and CHD needs further clarification, the major risk factors likely to play a major

role in the development of CHD in middle-aged

women with diabetes include glycemic control and

hyperinsulinemia, obesity, dyslipidemia, hypertension, and lifestyle factors, including smoking,

weight gain, and physical inactivity. These risk factors are reviewed below.

Glycemic control and hyperinsulinemia. Data are limited on the efficacy of tight glycemic control in

reducing risk for CHD in women with diabetes.

However, available data indicate that poor glycemic

control is associated with an increased risk for

CHD among persons with diabetes. For example,

in a Finnish study of 133 women and men aged

45–64 years with type 2 diabetes, baseline blood

sugar level was a significant predictor of death due

to CHD-related causes throughout 10 years of follow-up.163

Although randomized studies among persons with

both type 1 (DCCT)72 and type 2 (UKPDS)73 diabetes have shown that tight glycemic control can

produce greater reductions in microvascular disease

than conventional treatment, they have failed to

show a correspondingly significant reduction in

macrovascular disease (e.g., stroke, myocardial

infarction, CHD). Nevertheless, these studies were

not completely negative. The DCCT involved a

younger population and therefore did not have sufficient statistical power to assess CHD risk reduction. The UKPDS, which involved patients with a

mean age of 54 years at study entry (39% women),
126

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

reported a 16% reduction in myocardial infarction

(p = 0.052) with tight control. Results did not differ significantly by hypoglycemic agent used

(insulin or different sulfonylureas). In another arm

of the study,164 metformin, a hypoglycemic agent,

produced a greater reduction in CHD risk than

diet modification. As a single agent, metformin

appeared possibly more effective than other hypoglycemic agents in risk reduction, but this observation may have been due simply to analytic design.

This study included women aged 45–64 years, but

results were not stratified by age or sex.

An important observation was the absence of an

adverse impact of hypoglycemic therapy on CHD

risk.73 Studies suggesting that hyperinsulinemia is

an independent risk factor for CHD among men,

although possibly not among women,165 have raised

concerns that both exogenous insulin therapy and

sulfonylureas raise insulin levels. Furthermore, an

earlier study of glycemic control among persons

with diabetes166 reported increased cardiovascular

risk among those treated with sulfonylureas or the

hypoglycemic agent phenformin, a compound

related to metformin. Although the failure of the

UKPDS to confirm these findings is reassuring, the

role of tight glycemic control in reducing cardiovascular risk among women with diabetes in this age

group and among other diabetic patients requires

further study.

Obesity. Obesity is a particularly important CHD

risk factor for women with type 2 diabetes and is

most prevalent among minority women. In

NHANES II, the prevalence of obesity (BMI > 30

kg/m2

) among persons aged 40–64 years with type

2 diabetes was highest among black women (65%)

and was higher among white women (53%) than

among black (25%) or white (17%) men.167 In data

from NHANES II and HHANES, the prevalence

of obesity among Mexican American diabetic

women in this age group was similar to that among

white women, whereas the rate among Puerto

Rican diabetic women in this age group was slightly

higher (55%–60%).55 Among Oklahoman Native

American women with diabetes (women of the

Seven Tribes community, including Apache, Caddo,

Comanche, Delaware, Fort Sill Apache, Kiowa, and

Wichita but not limited to this age group), the

prevalence of obesity was over 70%.168

Obesity is a risk factor of critical importance

because it contributes to the development of type 2

diabetes and is an independent risk factor for cardiovascular disease.169 In the Framingham study,

which involved 2,818 women and 2,252 men aged

28–62 years at study entry, obesity was a significant

predictor of cardiovascular disease throughout 

26 years of follow-up, particularly among women.170

In the Nurses’ Health Study, obese women had a 3

times greater risk for CHD than lean women, and

women who had significant adult weight gain had a

further increase in CHD risk.171 Obesity also

increased CHD risk specifically among the subset

of women with type 2 diabetes.41

Data are lacking on the effects of intentional weight

loss on cardiovascular risk among women aged

45–64 years, particularly women with diabetes,

although this question is being addressed in a major

clinical trial initiated in 2001 by the National

Institutes of Health (NIH). Nonetheless, available

data suggest a clear benefit to avoiding obesity and

weight gain.172 Furthermore, metabolic improvements consistently observed with weight reduction57-60,172,173 support counseling obese patients to

lose weight and maintain weight loss. This issue

warrants further study.

Dyslipidemia. Dyslipidemia is very common among

persons with type 2 diabetes. Among diabetic white

women aged 40–69 years surveyed in NHANES II,

49% had high serum total cholesterol (> 240

mg/dL), 52% had high LDL cholesterol (> 160

mg/dL), 10% had low HDL cholesterol (< 35

mg/dL), and 30% had high serum triglycerides 

(> 250 mg/dL). Corresponding rates among nondiabetic white women were 40%, 34%, 6%, and 6%,

respectively.174 A greater proportion of diabetic

black women in this age group also had low HDL

cholesterol (16%) and high triglyceride concentrations (17%) than nondiabetic black women (2%
The Middle Years

127

for each), but their total cholesterol levels were similar to, and their LDL cholesterol levels lower than,

those of nondiabetic black women.

Overall, compared with persons without diabetes

matched for age and body weight, persons with

type 2 diabetes are likely to have abnormalities in

HDL cholesterol and triglyceride levels, whereas

their levels of total cholesterol and LDL cholesterol

are slightly but not significantly higher.175 However,

in comparing lipid profiles from a large sample of

African Americans with type 2 diabetes who

received care at an urban outpatient diabetes clinic,

investigators reported that more women than men

had high-risk LDL and HDL cholesterol profiles,

but women had a lower likelihood of having a

serum triglyceride concentration above goal.176 This

study included women aged 45–64 years, but

results were not stratified by age or sex. At every

level of total cholesterol, CHD risk is 2–3 times

higher for women with diabetes than for those

without diabetes.150,171 In the Nurses’ Health Study,

diabetic women with self-reported high cholesterol

had almost twice the incidence of CHD than

women with diabetes and a normal cholesterol concentration; these women had a threefold higher

incidence of CHD than nondiabetic women with

high cholesterol, and a 12-fold higher incidence of

CHD than nondiabetic women with normal cholesterol.41 Although data from diabetic women are

limited, low HDL cholesterol and elevated triglyceride concentrations have been shown to be independent determinants of CHD risk in patients with

type 2 diabetes.177

In addition, analyses of subgroups of persons with

diabetes in randomized controlled trials have

demonstrated that pharmacologic therapy can significantly reduce CHD events by reducing total and

LDL cholesterol. In the Scandinavian Simvastatin

Survival Study (4S), which involved 4,446 patients,

treatment with simvastatin was associated with a

42% reduction in total mortality among the 202

persons with diabetes (44 women and 158 men,

mean age 60 years); this reduction was even greater

than the 28% reduction among nondiabetic participants. Furthermore, the participants with diabetes

experienced a 35% reduction in CHD mortality

with the use of simvastatin.178 Similarly, among 586

diabetic patients included in the Cholesterol and

Recurrent Events (CARE) Study, which included

patients with normal total cholesterol levels and a

history of myocardial infarction, pravastatin therapy

resulted in a 25% reduction in CHD events overall,

and an even greater reduction was noted among

women (46%) than among men (20%) with diabetes.179,180

In 1993, the National Cholesterol Education

Program recommended that patients with diabetes

be considered a high-risk group with a target LDL

cholesterol concentration less than 100 mg/dL, the

same level recommended for persons with a history

of CHD.181 This recommendation was also

127

Table 5-3. Prevalence (%) of hypertension among adults aged 45–64 years with and without 

type 2 diabetes, by sex and race/Hispanic origin—United States, 1976–84

Women Men

Race/Hispanic origin Diabetes No diabetes Diabetes No diabetes

Non-Hispanic white 41.0 22.8 46.8 18.3

Non-Hispanic black 91.6 57.9 54.1 38.4

Mexican American 41.3 18.6 26.3 17.7

All 52.0 26.0 47.7 20.0

Source: Reference 55.
128

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

endorsed by the American Diabetes Association.182

Nonpharmacologic interventions, such as diet

changes, smoking cessation, and increased physical

activity, are recommended as initial treatment to

reduce LDL cholesterol; pharmacologic therapy,

optimally using a statin agent, should be initiated if

LDL remains elevated.182 For high triglycerides, the

first-line approach is glycemic control, diet, and

increased physical activity; fibric acid derivatives are

indicated if triglycerides remain elevated. Evidence

from clinical trials is currently insufficient to warrant using drug therapy to modify triglyceride or

HDL cholesterol levels.183 These recommendations

are all applicable to diabetic women aged 45–64

years.

Hypertension. Type 1 and type 2 diabetes and

impaired glucose tolerance are all associated with

hypertension.74,184-188 In the NHANES II data, the

overall prevalence of hypertension among women

aged 45–64 years with a medical history of diabetes

was 52%, compared with a prevalence of 26%

among those with no history of diabetes (Table 

5-3).55 Among women in this age group with diabetes, the prevalence of hypertension among nonHispanic black women (91.6%) was more than

twice that of their white (41.0%) and Mexican

American (41.3%) counterparts. An estimated

35%–75% of diabetic complications result from

hypertension.184 Among women with diabetes in the

Nurses’ Health Study, the risk for CHD was 3

times higher among those with hypertension than

among those without hypertension.41 Hypertension

not only contributes to increased risk for CHD in

diabetic women and men, but also increases the risk

for stroke,188 nephropathy,189 and peripheral arterial

disease.190

Available randomized trial data also demonstrate

that improved blood pressure control reduces CHD

risk among persons with diabetes. Among 1,148

hypertensive women and men (mean age 56 years)

participating in a substudy of the UKPDS, tight

blood pressure control with either atenolol or captopril resulted in a statistically significant 44%

reduction in stroke and a nonsignificant 21%

reduction in myocardial infarction.74

Lifestyle factors. Several lifestyle factors, including

smoking, poor diet and weight gain, and physical

inactivity, independently influence the incidence of

diabetes and the development of complications of

diabetes, including CHD. Healthy lifestyle practices have been shown to confer benefits in a variety

of populations, including women aged 45–64 years.

Cigarette smoking is one of the most powerful

known risk factors for CHD in general populations; among women with diabetes, it has been

shown to increase CHD risk above that conferred

by diabetes alone.41,69 By increasing their HDL cholesterol levels, persons with diabetes in the

Framingham study who quit smoking reduced their

risk for CHD by 50%.156

A healthy diet and weight control are important in

the prevention and management of CHD in persons with diabetes because these factors contribute

to improved glycemic control, decreased adiposity,

changes in lipid levels, and management of hypertension. Even moderate weight loss (less than 10%

of initial body weight) can improve the cardiovascular risk profiles of both diabetic and nondiabetic

obese persons by reducing blood pressure, decreasing plasma LDL cholesterol and triglycerides, and

increasing serum HDL cholesterol.172

Regular physical activity has been associated with

both reduced risk of developing type 2 diabetes and

reduced obesity, both of which are independent risk

factors for CHD.57,65-68,191-193 Physical activity has

been shown to increase levels of HDL cholesterol

and reduce levels of LDL cholesterol, triglycerides,

and fibrinogen in the general population.194-197

Similar changes in patients with diabetes would be

beneficial to treating the dyslipidemia caused by

diabetes and the elevated levels of fibrinogen

observed in women with diabetes.198 Data from

NHANES I indicate that diabetic women and men

aged 40–69 years (72%) who reported being physically active in their leisure time had a reduced risk

of dying of CHD.199 More recent data from the

NHS likewise indicate a reduced risk of CHD

among women with diabetes who engage in regular

physical activity.200
The Middle Years

129

Another lifestyle factor associated with CHD risk

among women with type 2 diabetes is alcohol consumption. In a recent analysis from the NHS, data

from a 14-year follow-up of women (average age

48–49 years at baseline) with diabetes indicated

that moderate alcohol consumption was significantly associated with reduced CHD risk.201

Special interventions to modify CHD risk. For

women aged 45–64 with diabetes, clinical interventions to modify CHD risk include use of aspirin

and hormone replacement therapy. Evidence to

support these interventions follows.

Aspirin treatment. Observed alterations in platelet

and endothelial function among patients with type

1 and type 2 diabetes in the Early Treatment

Diabetic Retinopathy Study (ETDRS), which

involved 3,711 men and women aged 18–70 years,

indicate a potential role for antiplatelet therapy in

persons with diabetes.202 In the ETDRS, the group

randomized to daily aspirin therapy had a 28%

reduction in 5-year risk for myocardial infarction

compared with the group randomized to placebo.

Although the reduction in 5-year risk was greater

among men (26%) than among women (9%), this

difference was not statistically significant.202 Results

of a meta-analysis of controlled trials of aspirin

therapy among women and men with established

CHD indicated that aspirin therapy reduced overall

risk of vascular events by approximately 25%, and

these findings were similar among patients with and

without diabetes and among both women and

men.203

The primary concern regarding the prophylactic use

of aspirin by nondiabetic women is that the 

benefit-to-risk ratio may differ from that observed

in men, because women differ from men in their

risk for myocardial infarction (the primary outcome) but have a comparable risk for stroke, and

aspirin may increase the risk for hemorrhagic

stroke. Healthy women, especially premenopausal

women, have a lower risk for myocardial infarction

than men at almost every age. However, women

with diabetes (especially postmenopausal women)

have a risk for myocardial infarction that is equal to

or greater than that of men in all age groups and

greater risks for stroke and hypertension than diabetic men, resulting in CHD as the leading cause

of death among women with diabetes.

Recent recommendations from the American

Diabetes Association support the use of 81 mg–325

mg of aspirin daily by diabetic women and men

with evidence of macrovascular disease and no contraindications to aspirin use.204 The ADA also recommends considering aspirin therapy for other

diabetic women and men at high risk for CHD,

again in the absence of contraindications.

Nevertheless, estimates from NHANES III indicate

that during 1988–1994, only 20% of persons with

diabetes took aspirin regularly.205

Hormone replacement therapy. Several observational studies have shown that women who use estrogen

replacement therapy (ERT) have a 40%–50% lower

risk for CHD than those who do not.206-209

Presumed contributors to this reduced risk are

favorable changes in LDL and HDL cholesterol,206

possible improvement in insulin sensitivity,207 and

improvement in vascular reactivity.208 Because lipid

abnormalities, hyperinsulinemia, and vascular reactivity all contribute to the increased risk for CHD

among women with diabetes, this group of patients

might well benefit from this therapy. Although

observational studies have found lower rates of

heart disease among postmenopausal women who

take estrogen, the results from randomized clinical

trials have been unable to demonstrate such a benefit. The Heart and Estrogen/progestin Replacement

Study (HERS) was unable to demonstrate lower

rates of heart disease among women who took

estrogen and in fact found higher rates of thromboembolic events among women who took estrogen.210

Indeed, limited observational data have suggested

associations between ERT and reduced CHD risk

among women with diabetes. For example, a recent

case-control study found that postmenopausal

women with diabetes who currently used ERT had
130

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

a nonsignificant 49% reduction in risk for myocardial infarction.209 In addition, data from the Nurses’

Health Study on the effects of hormone replacement therapy (HRT) on the risk for myocardial

infarction have likewise suggested a benefit among

women with diabetes comparable to that among

nondiabetic women.206

Data on HRT as a modifier of CHD risk among

women aged 45–64 years with diabetes are currently insufficient to make recommendations regarding

its use. Results from the Women’s Health Initiative,

an ongoing randomized, controlled trial designed to

assess the potential risks and benefits of hormone

replacement therapy in preventing CHD, should

provide data useful for developing policy recommendations regarding the use of HRT by women

with diabetes.

Cerebrovascular disease. Diabetes is a major cause of

stroke and other cerebrovascular disease. Moreover,

other important risk factors for stroke, including

elevated blood pressure and high levels of LDL cholesterol, occur with increased frequency among

women and men with diabetes, particularly those

with type 2.149,150

Among patients with diabetes, the increased risk for

stroke is greater among women than men, paralleling the greater increase in CHD risk among

women with diabetes. Among women in the

Nurses’ Health Study, the age-adjusted risk for

stroke (fatal and nonfatal) was 4.1-fold greater

(95% CI: 2.8–6.1) among women with diabetes

than among nondiabetic women.171 The relative

risks for fatal and nonfatal strokes from the same

study were 5.0 and 3.8, respectively. In addition,

the risk for stroke among women with diabetes

increases with evidence of other vascular disease.

In the United States, diabetes and hypertension are

both more common among blacks than whites, and

these differences in prevalence contribute to the elevated risk for stroke among black Americans.188

Cigarette smoking also greatly contributes to the

risk for stroke, as do other lifestyle factors that

affect the development of complications from diabetes, including diet, weight gain, and physical

inactivity, primarily through adverse effects on lipid

profiles.

Because of the elevated risk for stroke and CHD

among women with diabetes, the importance of

controlling cardiovascular risk factors among these

patients cannot be overemphasized. Control of

hypertension among diabetic women, especially

black women, is of primary importance in reducing

stroke-related illness and death. Smoking cessation

and improvement of lipid profiles should also be

high priorities for clinicians who treat women with

diabetes. In addition, the increased risk for stroke

among women with diabetes should be considered

before such women, especially those with poorly

controlled hypertension, are prescribed aspirin therapy for the primary and secondary prevention of

myocardial infarction.

Peripheral vascular disease. Diabetes is an important

risk factor for peripheral vascular disease (PVD).

Hypertension, smoking, obesity, and hyperlipidemia are associated with an increased risk for

PVD, as they are for CHD and cerebrovascular disease. Neuropathy and susceptibility to infection

contribute to the progression of PVD, which may

result in foot ulcerations, gangrene, and ultimately,

amputation. Diabetes accounts for approximately

50% of all nontraumatic amputations in the United

States.190

The incidence of PVD is greater among men with

diabetes (12.6–21.3 per 1,000 person-years) than

among women with diabetes (8.4–17.6 per 1,000

person-years),211-213 probably because of the greater

prevalence of smoking among men. The incidence

of PVD also increases with age, and most women

with diabetes are older than age 55.

Primary prevention of PVD for women with diabetes consists of controlling cardiovascular risk factors (especially smoking) and hyperglycemia. Tight

blood pressure control in a substudy of the UKPDS

involving 1,148 women and men (mean age 56

years) was associated with a 49% reduction in

PVD-related amputation and death. However, these
The Middle Years

131

findings represented small numbers of endpoints

and were not statistically significant.74 Among the

entire UKPDS cohort, tight glycemic control was

likewise associated with comparable but not statistically significant reductions in these endpoints.

Because the same risk factors affect all forms of diabetes-associated vascular disease, physicians caring

for women with diabetes should address not only

glycemic control but also, as noted for CHD, other

vascular disease risk factors. In addition, attention

to foot care by physicians and education regarding

self-care have been shown to be insufficient214 and

need to be improved.

Renal disease. Diabetic nephropathy, defined as

increased excretion of urinary protein (principally

albumin) in persons with diabetes who have no

other renal disease, is one of the major complications of both type 1 and type 2 diabetes, which

together account for approximately 35% of all new

cases of end-stage renal disease in the United

States.215 Persons with type 1 (odds ratio, 33.7) and

type 2 (odds ratio, 7.0) diabetes are at significantly

greater risk for end-stage renal disease than persons

without diabetes.

The incidence of end-stage renal disease attributed

to diabetes among white and black women, all per

10 million population, has been reported to be 473

and 2,134 at ages 45–49 years; 730 and 3,708 at

ages 50–54 years; 1,123 and 5,983 at ages 55–59

years; and 1,552 and 7,638 at ages 60–64 years.216

Clearly, the rates for black women are much higher

than those for white women; women and men

appear to be equally affected. Importantly, some of

the same risk factors that affect vascular disease

have also been implicated in the development of

diabetic nephropathy; these include hypertension,

hyperglycemia, and smoking. Persons with type 1

or type 2 diabetes who have renal disease are at

greater risk for CHD than persons with diabetes

who do not have nephropathy.217 In addition, the

cumulative incidence of nephropathy in patients

with a similar duration of diabetes may be at least

as high in persons with type 2 diabetes as in those

with type 1.218

Control of hypertension and hyperglycemia are the

mainstays of the primary prevention of diabetic

nephropathy. Data from the UKPDS showed nonsignificant reductions in renal failure with tight

glycemic control73 and with tight blood pressure

control,74 but few endpoints were available for comparison. Angiotensin converting enzyme (ACE)

inhibitors appear to have a renoprotective effect

that is independent of their effect on blood pressure.219-224 However, these agents may offer less protection for black than for white patients with

diabetes, and they have not been shown to have a

long-term renoprotective benefit for persons with

type 2 diabetes. More research into the role of ACE

inhibitors in preventing the onset of diabetic

nephropathy, especially in persons with type 2 diabetes, is needed. Because nephropathy increases

with the duration of diabetes, clinicians responsible

for the care of women aged 45–64 years with diabetes need to be vigilant in screening for renal complications, especially among patients with type 2,

who may have had clinically silent diabetes for an

undetermined length of time before diagnosis.

5.7. Public Health Implications

Assessment

Specific actions can be taken to assess the needs of

women aged 45–64 years with diabetes. Several

potent and modifiable risk factors for the development of diabetes, especially obesity and physical

inactivity, are highly prevalent among women in

this age group. In addition, many middle-aged

women with diabetes are faced with issues such as

the complications of diabetes, disability, and

decrease in quality of life that complications frequently produce. In general, women of all races

with diabetes are poorer and have less education

than their nondiabetic female counterparts or men

with diabetes. These women are faced with greater

needs and more limited resources than women

without diabetes in their age group. The public

health implications of these conditions for women

in this age group are listed as follows:
132

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

Surveillance and Research

• An intensive effort needs to be made to collect

and report more information on women with

diabetes in this age group. More women with

diabetes need to be included in all types of traditional research, including randomized controlled

trials.

• More creative strategies such as communitybased participatory research and focus groups

should be considered to gather better information on minority women and other underrepresented groups of women with diabetes, such as

immigrants.

• More research is needed to examine the environmental, psychosocial, and economic factors that

contribute to obesity, specifically targeting

women aged 45–64 years with diabetes.

• Additional research to identify effective obesity

treatments is needed. This research should

include sufficient members of persons at high

risk of developing diabetes.

• More data must be gathered on specific dietary

factors that contribute to the development of

diabetes in women to help determine specific

dietary recommendations.

• Because diet, in general, is heavily culturally

determined, more culturally specific and community-based research needs to be done to

explore dietary factors that influence the development and outcomes of diabetes.

• More data are needed to identify the sociocultural and environmental factors that contribute to

low levels of physical activity in women aged

45–64 years, particularly women with diabetes.

• It is important to explore the impact of socioeconomic status on the potential for self-care for

women with diabetes, as well as the interaction

between SES and access to professional diabetes

care.225

• Research into methods for improving the SES of

women with diabetes is needed (e.g., how to

facilitate the health and wellness of women with

diabetes in the labor force).

Tight glycemic control has been shown to reduce

the risk for microvascular disease among persons

with type 2 diabetes. However, its role in reducing

macrovascular disease, specifically CHD, and disability remains less clear and requires further study.

Because CHD is the leading cause of mortality

among women aged 45–64 years with diabetes, specific research should be directed at elucidating its

outcomes as well as other diabetes-related complications. Data are needed on

• Risk factors for CHD among women with diabetes to aid in risk stratification through program development.

• Potential CHD risk-modifying agents specifically among women with diabetes in this age

group, including aspirin and hormone replacement therapy.

• How to better detect precursors of the initial

clinical presentation of myocardial infarction

among women with diabetes.

• Women’s attitudes toward menopause, particularly among minority groups, to assist women

with diabetes in making decisions regarding hormone replacement therapy.

• The amount of disability experienced by women

in this age group and the extent to which complications of diabetes impair functional status

and quality of life. Special attention should be

paid to the interaction between minority status

and the impact of disability in the lives of 

middle-aged women.

Policy Development

It is important to develop policies that increase the

involvement of women with diabetes, including

women aged 45–64 years, in clinical trials of diabetes, CHD, and other diabetes-associated complications. Special attention must be paid to cultural

issues in the development of policies regarding

women with diabetes. In the translation of research

findings into practice, community representatives

should be involved in the development of programs

for minority women with diabetes. They should

also be involved in the assessment of the 
The Middle Years

133

effectiveness of these programs. Intensive outreach

efforts must also be made on behalf of minority

women with diagnosed and undiagnosed diabetes.

Awareness of the risk of diabetes must be increased

at the community level.

The NIH-sponsored Diabetes Prevention

Program,226 a multicenter randomized trial that is

comparing the effectiveness of diet and exercise

with that of pharmacologic (metformin) therapy or

placebo in reducing the risk for type 2 diabetes

among persons at high risk, will provide information critical to the management of patients at risk,

including women aged 45–64 years. The results of

this trial should provide information regarding the

efficacy of specific interventions. More research is

needed to determine the potential role of the community in identifying effective diabetes prevention

strategies.

Other specific policies and guidelines that should

be developed to address the needs of women with

diabetes aged 45–64 include the following:

Diabetes Education

• All women with diabetes should have access to

professional diabetes education services that

teach skills for diabetes self-care. Recent Center

for Medicare and Medicaid Services (CMS) (formerly Health Care Financing Administration

[HCFA]) Medicare regulations are moving us

closer to achieving this goal in elderly populations.

• Creative ways to educate women, using focus

groups or community initiatives, should be

encouraged and evaluated. In addition support

groups should be available for women with diabetes to promote self- and peer education as well

as resource sharing.

Obesity

• Because of the lack of effective therapies for the

treatment of obesity, policies should encourage

increased development of effective interventions

for weight reduction, including strategies to

facilitate diet and exercise adherence and new

pharmacologic therapies.

• Policies should facilitate research that identifies

effective strategies for the primary prevention of

obesity beginning early in life, with a special

focus on minority women.

• Guidelines need to be developed to assist health

professionals in their efforts to educate women

about healthy eating and exercise patterns.

• Policies should encourage providers to spend

time educating women on the benefits of physical activity, and providers should be reimbursed

appropriately.

Socioeconomic Status

Because the low SES of women with diabetes in

this age group may negatively affect women’s access

to care, efforts must be specifically targeted at

decreasing the barriers to care experienced by less

wealthy and less educated women:

• Policies should be developed that ensure access

to quality diabetes care for all women with diabetes regardless of ability to pay or insurance status.

• Policies should be developed to ensure that

women with type 2 diabetes have access to necessary nutrition services and diabetes education

as well as appropriate pharmacologic therapies.

• Programs should be developed and supported to

assist women who have experienced a decrease in

their functional status caused by diabetes complications to return to their previous level of

functioning.

Assurance

Increased awareness must be generated at every

level within the health care and public health systems about the burden of diabetes among minority

women, especially in the middle and older age

groups. Availability of recommended services for

women at risk for diabetes and its complications

needs to be improved. Because a third or more of

all cases of diabetes among women aged 45–64 are

undiagnosed, “opportunistic” glucose screening for

these women should become standard in primary

care practices. Once women are diagnosed with diabetes, they should be assured of all needed care,
134

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

including the availability of and access to a health

care provider and other needed services. Health care

regulatory agencies should be especially vigilant in

ensuring access to all diabetes-related preventive

services including eye exams, foot care, and blood

pressure and lipid screening, as well as counseling

about diet, HRT, and other diabetes preventive

therapies. Mechanisms that may help ensure that

women with diabetes receive appropriate care and

services include

Oversight and Coordination of Care

• Integrated systems of care may facilitate comprehensive management, but provider and patient

education is also needed to assure appropriate

referrals and care.

• To ensure the delivery of quality diabetes care,

delivery systems must continue to implement

strategies to assess whether providers are meeting

recommended care guidelines for diabetes (e.g.,

hemoglobin A1c measurements, eye and foot

care, nutritional counseling) and CHD risk

reduction (e.g., monitoring lipids and blood

pressure, initiating recommended treatment).

• Provider feedback, education, and incentives

may all increase adherence with such guidelines

and optimize diabetes care delivery.

Training

• Improved training on the risks of diabetes and

the importance of preventive care in reducing

diabetes-related complications is essential for

health care professionals.

• A better understanding of the social and cultural

factors that affect access to medical care and the

success of self-care among persons with diabetes

is important in designing effective diabetes interventions. In particular, because so many minority women are affected by diabetes, a greater

awareness of sociocultural issues and the health

effects of diabetes among minority women

should be included in training for health care

professionals.

• Health care professionals need to be trained in

the assessment and documentation of functional

status.

Diet

• Health care organizations should work to ensure

that all women with diabetes receive dietary

counseling. 

• Diet is heavily influenced by culture. Nutritional

data need to be collected separately for minority

women, and dietary counseling should be culturally appropriate.

Physical Activity

• Sociocultural factors may influence physical

activity levels. More opportunities (e.g., at workplaces, churches, schools, community centers)

should be provided to ensure that minority

women receive adequate education regarding the

benefits of physical activity.

• Ensuring safe exercise space, increased availability of conveniently located exercise facilities, and

child care while mothers exercise are important

to the health of all women, and especially of

minority women and women of low socioeconomic status.

Smoking

• Public health agencies should work to ensure

that minority women are included in all smoking prevention and cessation efforts.

• Adequate training in smoking cessation techniques is essential for all health care providers.

Federally funded programs and insurance companies need to increase reimbursement for

patient education.

Disability and Complications

• Federal and state agencies should develop methods to ensure that all women with diabetes who

experience diabetes-related disabilities receive

adequate access to professional diabetes and

rehabilitative care.
The Middle Years

135

References

1. Day JC. Population Projections of the United States by

Age, Sex, Race, and Hispanic Origin: 1995 to 2050. U.S.

Bureau of the Census, Current Population Reports, P25-

1130. Washington, DC: U.S. Government Printing

Office, 1996.

2. Sowers MR, La Pietra MT. Menopause: its epidemiology

and potential association with chronic diseases.

Epidemiol Rev 1995;17(2):287–302.

3. Harris MI, Flegal KM, Cowie CC, et al. Prevalence of

diabetes, impaired fasting glucose, and impaired glucose

tolerance in U.S. adults: the Third National Health and

Nutrition Examination Survey, 1988–1994. Diabetes

Care 1998;21(4):518–24.

4. Deardoff KE, Hollmann FW, Montgomery PM. U.S.

Population Estimates by Age, Sex, Race, and Hispanic

Origin: 1990–1995. Population Paper Listings, No. 41.

Washington, DC: U.S. Bureau of Census, Population

Division, 1996.

5. American Diabetes Association. Report of the expert

committee on the diagnosis and classification of diabetes

mellitus. Diabetes Care 1997;20(7):1183–97.

6. CDC. <http://www.cdc.gov/diabetes/statistics/survl99/

chap2/table10.htm>. Last revised March 2000.

7. Kenny SJ, Aubert RE, Geiss LS. Prevalence and incidence of non–insulin-dependent diabetes. In: National

Diabetes Data Group, editors. Diabetes in America. 2nd

ed. Bethesda, MD: National Institutes of Health, 1995:

47–67. (NIH Publication No. 95-1468)

8. Carter JS, Pugh JA, Monterrosa A. Non–insulin-dependent diabetes mellitus in minorities in the United States.

Ann Intern Med 1996;125(3):221–32.

9. Lee ET, Howard BV, Savage PJ, et al. Diabetes and

impaired glucose tolerance in three American Indian

populations aged 45–74 years: the Strong Heart Study.

Diabetes Care 1995;18(5):599–610.

10. Ellis JL, Campos-Outcalt D. Cardiovascular disease risk

factors in Native Americans: a literature review. Am J

Prev Med 1994;10(5):295–307.

11. Will JC, Strauss KF, Mendlein JM, Ballew C, White LL,

Peter DG. Diabetes mellitus among Navajo Indians:

findings from the Navajo Health and Nutrition Survey.

J Nutr 1997;127(10 Suppl):2106S–2113S.

12. CDC. Prevalence of diagnosed diabetes among

American Indians/Alaskan Natives—United States,

1996. MMWR 1998;47(42):901–4.

13. Schraer CD, Adler AI, Mayer AM, Halderson KR,

Trimble BA. Diabetes complications and mortality

among Alaska natives: 8 years of observation. Diabetes

Care 1997;20(3):314–21.

14. CDC. Self-reported prevalence of diabetes among

Hispanics—United States, 1994–1997. MMWR 1999;

48(1):8–12.

15. Fujimoto WY, Leonetti DL, Bergstrom RW, Kinyoun

JL, Stolov WC, Wahl PW. Glucose intolerance and diabetic complications among Japanese-American women.

Diabetes Res Clin Pract 1991;13(1-2):119–29. Data used

with permission from publisher.

16. CDC. <http://www.cdc.gov/diabetes/statistics/survl99/

chap2/table23.htm>. Last revised March 2000.

17. CDC. <http://www.cdc.gov/diabetes/statistics/survl99/

chap2/table22.htm>. Last revised March 2000.

18. Haffner SM, Hazuda HP, Mitchell BD, Patterson JK,

Stern MP. Increased incidence of type II diabetes mellitus in Mexican Americans. Diabetes Care 1991;14(2):

102–8.

19. Lipton RB, Liao Y, Cao G, Cooper RS, McGee D.

Determinants of incident non–insulin-dependent diabetes mellitus among blacks and whites in a national

sample. Am J Epidemiol 1993;138(10):826–39.

20. Brancati FL, Kao WH, Folsom AR, Watson RL, Szklo

M. Incident type 2 diabetes mellitus in African

American and white adults. The Atherosclerosis Risk in

Communities Study. JAMA 2000;283(17):2253–9.

21. Knowler WC, Pettitt DJ, Saad MF, Bennett PH.

Diabetes mellitus in the Pima Indians: incidence, risk

factors and pathogenesis. Diabetes Metab Rev 1990;
136

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

22. Knowler WC, Saad MF, Pettitt DJ, Nelson RG, Bennett

PH. Determinants of diabetes mellitus in the Pima

Indians. Diabetes Care 1993;16(1):216–27.

23. Burke JP, Williams K, Gaskill SP, Hazuda HP, Haffner

SM, Stern MP. Rapid rise in the incidence of type 2 diabetes from 1987 to 1996: results from the San Antonio

Heart Study. Arch Intern Med 1999;159(13):1450–6.

24. Leibson CL, O’Brien PC, Atkinson E, Palumbo PJ,

Melton LJ 3rd. Relative contributions of incidence and

survival to increasing prevalence of adult-onset diabetes

mellitus: a population-based survey. Am J Epidemiol

1997;146(1):12–22.

25. CDC. Trends in the prevalence and incidence of selfreported diabetes mellitus—United States, 1980–1994.

MMWR 1997;46(43):1014–8.

26. Gu K, Cowie CC, Harris MI. Mortality in adults with

and without diabetes in a national cohort of the U.S.

population, 1971–1993. Diabetes Care 1998;21(7):

1138–45.

27. Colditz GA, Willet WC, Stampfer MJ, et al. Weight as a

risk factor for clinical diabetes in women. Am J

Epidemiol 1990;132(3):501–13.

28. Ford ES, Williamson DF, Liu S. Weight change and diabetes incidence: findings from a national cohort of U.S.

adults. Am J Epidemiol 1997;146(3):214–22.

29. Manson JE, Rimm EB, Stampfer MJ, et al. Physical

activity and incidence of non–insulin-dependent diabetes mellitus in women. Lancet 1991;338(8870):774–8.

30. Flegal KM, Carroll MD, Kuczmarski RJ, Johnson CL.

Overweight and obesity in the United States: prevalence

and trends, 1960–1994. Int J Obes Relat Metab Disord

1998;22(1):39–47.

31. Crespo CJ, Keteyian SJ, Heath GW, Sempos CT.

Leisure-time physical activity among U.S. adults: results

from the Third National Health and Nutrition

Examination Survey. Arch Intern Med 1996;156(1):

93–8.

32. King H, Aubert RE, Herman WH. Global burden of

diabetes, 1995–2025: prevalence, numerical estimates,

and projections. Diabetes Care 1998;21(9):1414–31.

33. Cowie CC, Eberhardt MS. Sociodemographic characteristics of persons with diabetes. In: National Diabetes

Data Group, editors. Diabetes in America. 2nd ed.

Bethesda, MD: National Institutes of Health, 1995:

85–116. (NIH Publication No. 95-1468)

34. American Diabetes Association. Economic consequences

of diabetes mellitus in the U.S. in 1997. American

Diabetes Association. Diabetes Care 1998;21(2):

296–309.

35. Javits JC, Chiang Y-P. Economic impact of diabetes. In:

National Diabetes Data Group, editors. Diabetes in

America. 2nd ed. Bethesda, MD: National Institutes of

Health, 1995:601–11. (NIH Publication No. 95-1468)

36. Peters KD, Kochanek KD, Murphy SL. Deaths: final

data for 1996. Natl Vital Stat Rep 1998;47(9):1–100.

37. Bild DE, Stevenson JM. Frequency of recording of diabetes on U.S. death certificates: analysis of the 1986

National Mortality Followback Survey. J Clin Epidemiol

1992;45(3):275–81.

38. Will JC, Casper M. The contribution of diabetes to

early deaths from ischemic heart disease: U.S. gender

and racial comparisons. Am J Public Health 1996;86(4):

576–9. 

39. Geiss L, Herman WH, Smith PJ. Mortality in

non–insulin-dependent diabetes. In: National Diabetes

Data Group, editors. Diabetes in America. 2nd ed.

Bethesda, MD: National Institutes of Health, 1995:

233–57. (NIH Publication No. 95-1468)

40. Garcia MJ, McNamara PM, Gordon T, Kannel WB.

Morbidity and mortality in diabetics in the Framingham

population. Diabetes 1974;23(2):105–11.

41. Moss SE, Klein R, Klein BE. Cause-specific mortality in

a population-based study of diabetes. Am J Public Health

1991;81(9):1158–62.

42. Manson JE, Colditz GA, Stampfer MJ, et al. A prospective study of maturity-onset diabetes mellitus and risk of

coronary heart disease and stroke in women. Arch Intern

Med 1991;151(6):1141–7.

43. Stamler J, Vaccaro O, Neaton JD, Wentworth D.

Diabetes, other risk factors, and 12-y cardiovascular

mortality for men screened in the Multiple Risk Factor

Intervention Trial. Diabetes Care 1993;16(2):434–44.
The Middle Years

137

44. Sievers ML, Nelson RG, Knowler WC, Bennett PH.

Impact of NIDDM on mortality and causes of death in

Pima Indians. Diabetes Care 1992;15(11):1541–9.

45. Wei M, Gaskill SP, Haffner SM, Stern MP. Effects of

diabetes and level of glycemia on all-cause and cardiovascular mortality. The San Antonio Heart Study. Diabetes

Care 1998;21(7):1167–72.

46. Gu K, Cowie CC, Harris MI. Diabetes and decline in

heart disease mortality in U.S. adults. JAMA 1999;

281(14):1291–7.

47. Folsom AR, Szklo M, Stevens J, Liao F, Smith R,

Eckfeldt JH. A prospective study of coronary heart disease in relation to fasting insulin, glucose, and diabetes:

the Atherosclerosis Risk in Communities (ARIC) Study.

Diabetes Care 1997;20(6):935–42.

48. Aubert RE, Geiss LS, Ballard DJ, et al. Diabetes-related

hospitalization and hospital utilization. In: National

Diabetes Data Group, editors. Diabetes in America. 2nd

ed. Bethesda, MD: National Institutes of Health,

1995:553–70. (NIH Publication No. 95-1468)

49. CDC. State-specific prevalence of disability among

adults—11 states and the District of Columbia, 1998.

MMWR 2000;49(31):711–14.

50. Mitchell BD, Stern MP, Haffner SM, Hazuda HP,

Patterson JK. Functional impairment in Mexican

Americans and non-Hispanic whites with diabetes.

J Clin Epidemiol 1990;43(4):319–27.

51. Jacobson AM, de Groot M, Samson JA. The evaluation

of two measures of quality of life in patients with type I

and type II diabetes. Diabetes Care 1994;17(4):267–74.

52. Liu S, Manson JE, Stampfer MJ, et al. A prospective

study of whole-grain intake and risk of type 2 diabetes

mellitus in U.S. women. Am J Public Health 2000;90(9):

1409–15.

53. American Diabetes Association. Nutrition recommendations and principles for people with diabetes mellitus.

Diabetes Care 2001;24:S44–S47.

54. Fertig BJ, Simmons DA, Martin DB. Therapy for diabetes. In: National Diabetes Data Group, editors.

Diabetes in America. 2nd ed. Bethesda, MD: National

Institutes of Health, 1995:519–40. (NIH Publication

No. 95-1468)

55. Cowie CC, Harris MI. Physical and metabolic characteristics of persons with diabetes. In: National Diabetes

Data Group, editors. Diabetes in America. 2nd ed.

Bethesda, MD: National Institutes of Health,

1995:117–33. (NIH Publication No. 95-1468)

56. Harris MI. Health care and health status and outcomes

for patients with type 2 diabetes. Diabetes Care 2000;

23(6):754–8.

57. Tuomilehto J, Lindstrom J, Johan GE, et al. Prevention

of type 2 diabetes mellitus by changes in lifestyle among

subjects with impaired glucose tolerance. N Engl J Med

2001;344(18):1343–50.

58. Henry RR, Wiest-Kent TA, Scheaffer L, Kolterman OG,

Olefsky JM. Metabolic consequences of very-low-calorie

diet therapy in obese non–insulin-dependent diabetic

and nondiabetic subjects. Diabetes 1986;35(2):155–64.

59. Henry RR, Gumbiner B. Benefits and limitations of

very-low-calorie diet therapy in obese NIDDM. Diabetes

Care 1991;14(9):802–23.

60. Grundy SM. Dietary therapy in diabetes mellitus: is

there a single best diet? Diabetes Care 1991;14(9):

796–801.

61. Okosun IS, Liao Y, Rotimi CN, Prewitt TE, Cooper RS.

Abdominal adiposity and clustering of multiple metabolic syndrome in white, black and Hispanic Americans.

Ann Epidemiol 2000;10(5):263–70.

62. Wing RR, Anglin K. Effectiveness of a behavioral weight

control program for blacks and whites with NIDDM.

Diabetes Care 1996;19(5):409–13.

63. Kumanyaka SK, Obarzanek E, Stevens VJ, Herbert PR,

Whelton PK. Weight-loss experience of black and white

participants in NHLBI-sponsored clinical trials. Am J

Clin Nutr 1991;53(6 Suppl):1631S–1638S.

64. Resnick HE, Valsania P, Halter JB, Lin X. Relation of

weight gain and weight loss on subsequent diabetes risk

in overweight adults. J Epidemiol Community Health

2000;54(8):596–602.

65. American Diabetes Association. Exercise and NIDDM.

Diabetes Care 1990;13(7):785–9.
138

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

66. Wareham NJ, Wong MY, Day NE. Glucose intolerance

and physical inactivity: the relative importance of low

habitual energy expenditure and cardiorespiratory fitness. Am J Epidemiol 2000;152(2):132–9.

67. Paffenbarger RS, Lee IM. Exercise and fitness. In:

Manson JE, Ridker PM, Gaziano JM, Hennekens CH,

editors. Prevention of Myocardial Infarction. New York:

Oxford University Press, 1996:193. 

68. Ford ES, Herman WH. Leisure-time physical activity

patterns in the U.S. diabetic population: findings from

the 1990 National Health Interview Survey—Health

Promotion and Disease Prevention Supplement. Diabetes

Care 1995;18(1):27–33.

69. Haire-Joshu D, Glasgow RE, Tibbs TL. Smoking and

diabetes. Diabetes Care 1999;22(11):1887–98.

70. Rimm EB, Manson JE, Stampfer MJ, et al. A prospective study of cigarette smoking and the risk of diabetes

in women. Am J Public Health 1993;83(2):211–4.

71. Sawicki PT, Didjurgeit U, Muhlhauser I, Bender R,

Heinemann L, Berger M. Smoking is associated with

progression of diabetic nephropathy. Diabetes Care 1994;

17(2):126–31.

72. The Diabetes Control and Complications Trial Research

Group. The effect of intensive treatment of diabetes on

the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J

Med 1993;329(14):977–86.

73. UK Prospective Diabetes Study (UKPDS) Group.

Intensive blood-glucose control with sulphonylureas or

insulin compared with conventional treatment and risk

of complications in patients with type 2 diabetes

(UKPDS 33). Lancet 1998;352(9131):837–53.

74. UK Prospective Diabetes Study (UKPDS) Group. Tight

blood pressure control and risk of macrovascular and

microvascular complications in type 2 diabetes: UKPDS

38. BMJ 1998;317(7160):703–13.

75. CDC. Diabetes-specific preventive-care practices among

adults in a managed care population—Colorado,

Behavioral Risk Factor Surveillance System, 1995.

MMWR 1997;46(43):1018–23.

76. CDC. Preventive-care knowledge and practices among

persons with diabetes mellitus—North Carolina,

Behavioral Risk Factor Surveillance System, 1994–1995.

MMWR 1997;46(43):1023–7.

77. Coonrod BA, Betschart J, Harris MI. Frequency and

determinants of diabetes patient education among adults

in the U.S. population. Diabetes Care 1994;17(8):

852–8. 

78. Anderson RM. Is the problem of compliance all in our

heads? Diabetes Educ 1985;11:31–4.

79. Ruggiero L, Glasgow R, Dryfoos JM, et al. Diabetes selfmanagement: self-reported recommendations and patterns in a large population. Diabetes Care 1997;20(4):

568–76.

80. Glasgow RE, Toobert DJ, Riddle M, Donnelly J,

Mitchell DL, Calder D. Diabetes-specific social learning

variables and self-care behaviors among persons with

type II diabetes. Health Psychol 1989;8(3):285–303.

81. Brody GH, Jack L, McBride-Murray V, Landers-Potts

M, Liburd L. Heuristic model linking conceptual and

contextual processes to self-management and metabolic

control of diabetes type 2 among African American

adults. Diabetes Care 2001. In press.

82. Trief PM, Grant W, Elbert K, Weinstock RS. Family

environment, glycemic control and the psychosocial

adaptation of adults with diabetes. Diabetes Care 1998;

21(2):241–5.

83. Peyrot M, McMurray JF Jr, Kruger DF. A biopsychosocial model of glycemic control in diabetes: stress, coping

and regimen adherence. J Health Soc Behav 1999;40(2):

141–58.

84. Peyrot M, Rubin RR. Levels of risk of depression and

anxiety symptomatology among diabetic adults. Diabetes

Care 1997;20(4):585–90.

85. Hanestad BR. Self-reported quality of life and the effect

of different clinical and demographic characteristics in

people with type 1 diabetes. Diabetes Res Clin Pract

1993;19(2):139–49.

86. Glasgow RE, Toobert DJ, Hampson SE, Wilson W.

Behavioral research on diabetes at the Oregon Research

Institute. Ann Behav Med 1995;17:32–40.
The Middle Years

139

87. Engelgau MM, Narayan KM, Geiss LS, et al. A project

to reduce the burden of diabetes in the African

American Community: Project DIRECT. J Natl Med

Assoc 1998;90(10):605–13.

88. Stern MP, Rosenthal M, Haffner SM, Hazuda HP,

Franco LJ. Sex difference in the effects of sociocultural

status on diabetes and cardiovascular risk factors in

Mexican Americans: the San Antonio Heart Study. Am J

Epidemiol 1984;120(6):834–51.

89. Brancati FL, Whelton PK, Kuller LH, Klag MJ.

Diabetes mellitus, race, and socioeconomic status: a population-based study. Ann Epidemiol 1996;6(1):67–73.

90. Cowie CC, Harris M, Silverman RE, Johnson EW, Rust

KF. Effect of multiple risk factors on differences between

blacks and whites in the prevalence of non–insulindependent diabetes mellitus in the United States. Am J

Epidemiol 1993;137(7):719–32.

91. Robbins JM, Vaccarino V, Zhang H, Kasl SV. Excess

type 2 diabetes in African American women and men

aged 40–74 and socioeconomic status: evidence from the

Third National Health and Nutrition Examination

Survey. J Epidemiol Community Health 2000;54(11):

839–45.

92. Howard G, Anderson RT, Russell G, Howard VJ, Burke

GL. Race, socioeconomic status and cause-specific mortality. Ann Epidemiol 2000;10(4):214–23.

93. Connolly VM, Kesson CM. Socioeconomic status and

clustering of cardiovascular disease risk factors in diabetic patients. Diabetes Care 1996;19(5):419–22.

94. Kington RS, Smith JP. Socioeconomic status and racial

and ethnic differences in functional status associated

with chronic disease. Am J Public Health 1997;87(5):

805–10.

95. Berkman LF, Syme SL. Social networks, host resistance,

and mortality: a 9-year follow-up study of Alameda

County residents. Am J Epidemiol 1979;109:186–204.

96. Huang B, Rodriguez BL, Burchfiel CM, Chyou PH,

Curb JD, Yano K. Acculturation and prevalence of diabetes among Japanese American men in Hawaii. Am J

Epidemiol 1996;144(7):674–81.

97. Wiedman DW. Adiposity or longevity: which factor

accounts for the increase in type II diabetes mellitus

when populations acculturate to an industrial technology? Med Anthropol 1989;11(3):237–53.

98. O’dea K. Westernization, insulin resistance and diabetes

in Australian Aborigines. Med J Aust 1991;155(4):

258–64.

99. Ravussin E, Valencia ME, Esparza J, Bennet PH, Schulz

LO. Effects of a traditional lifestyle on obesity in Pima

Indians. Diabetes Care 1994;17(9):1067–74.

100. Boyce VL, Swinburn BA. The traditional Pima Indian

diet: composition and adaptation for use in a dietary

intervention study. Diabetes Care 1993;16(1):369–71.

101. Sundquist J, Winkleby M. Country of birth, acculturation status, and abdominal obesity in a national sample

of Mexican American women and men. Int J Epidemiol

2000;29(3):470–7.

102. Quatromoni PA, Milbauer M, Posner BM, Carballeira

NP, Brunt M, Chipkin SR. Use of focus groups to

explore nutrition practices and health beliefs of urban

Caribbean Latinos with diabetes. Diabetes Care 1994;

17(8):869–73.

103. Janes GR. Ambulatory medical care for diabetes. In:

National Diabetes Data Group, editors. Diabetes in

America. 2nd ed. Bethesda, MD: National Institutes of

Health, 1995:541–52. (NIH Publication No. 95-1468)

104. Bindman AB, Grumbach K, Osmond D, et al.

Preventable hospitalizations and access to health care.

JAMA 1995;274(4):305–11.

105. Beckles GLA, Engelgau MM, Narayan KM, Herman

WH, Aubert RE, Williamson DF. Population-based

assessment of the level of care among adults with diabetes in the U.S. Diabetes Care 1998;21(9):1432–8.

106. Hiss RG. Barriers to care in non–insulin-dependent diabetes mellitus: the Michigan experience. Ann Intern Med

1996;124:146–8.

107. Selby JV, Ray GT, Zhang D, Colby CJ. Excess costs of

medical care for patients with diabetes in a managed care

population. Diabetes Care 1997;20(9):1396–1402.

108. Eakin EG, Glasgow RE. The physicians role in diabetes

self-management: helping patients to help themselves.

Endocrinologist 1996;6:1–10.

109. Golin CE, DiMatteo MR, Gelberg L. The role of

patient participation in the doctor visit: implications for

adherence to diabetes care. Diabetes Care 1996;19(10):

1153–64.
140

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

110. Williams GC, Freedman ZR, Deci EL. Supporting

autonomy to motivate patients with diabetes for glucose

control. Diabetes Care 1998;21(10):1644–51.

111. Pringle M, Stewart-Evans C, Coupland C, Williams I,

Allison S, Sterland J. Influences on control in diabetes

mellitus: patient, doctor, practice, or delivery of care?

BMJ 1993;306(6878):630–4.

112. Hiss RG, Greenfield S. Forum three: changes in the U.S.

health care system that would facilitate improved care

for non–insulin-dependent diabetes mellitus. Ann Intern

Med 1996;124:180–3.

113. Kavanagh DJ, Gooley S, Wilson PH. Prediction of

adherence and control in diabetes. J Behav Med 1993;

16(5):509–22.

114. Anderson RM, Funnell MM, Butler PM, Arnold MS,

Fitzgerald JT, Feste CC. Patient empowerment: results of

a randomized controlled trial. Diabetes Care 1995;18(7):

943–9.

115. Wallston KA, Wallston BS, DeVellis R. Development of

the multidimensional health locus of control (MHLC)

scales. Health Educ Monogr 1978;6(2):160–70.

116. Bradley C, Brewin CR, Gamsu DS, Moses JL.

Development of scales to measure perceived control of

diabetes mellitus and diabetes-related health beliefs.

Diabet Med 1984;1(3):213–8.

117. Ferraro LA, Price JH, Desmond SM, Roberts SM.

Development of the diabetes locus of control scale.

Psychol Rep 1987;61(3):763–70.

118. Peyrot M, Rubin RR. Structure and correlates of diabetes-specific locus of control. Diabetes Care 1994;17(9):

994–1001.

119. Schlenk EA, Hart KL. Relationship between health locus

of control, health value, and social support and compliance of persons with diabetes. Diabetes Care 1984;7(6):

566–74.

120. Evans CL, Hughes IA. The relationship between diabetic

control and individual and family characteristics. 

J Psychosom Res 1987;31(3):367–74.

121. Dobbins C, Eaddy J. Mood, health behaviors, perceived

life control: excellent predictors of metabolic control.

Diabetes 1986;35(Suppl 1):21A.

122. Peyrot M, McMurry JF Jr. Psychosocial factors in diabetes control: adjustment of insulin-treated adults.

Psychosom Med 1985;47(6):542–57.

123. Bell RA, Summerson JH, Konen JC. Racial differences

in psychosocial variables among adults with

non–insulin-dependent diabetes mellitus. Behav Med

1995;21(2):69–73.

124. Jenkins CD. An integrated behavioral medicine

approach to improving care of patients with diabetes

mellitus (Review). Behav Med 1995;21(2):53–68.

125. Bradley C, editor. Handbook of Psychology and Diabetes.

Berkshire, UK: Harwood Academic, 1994.

126. Glasgow RE, Anderson BJ. Future directions for research

on pediatric chronic disease management: lessons from

diabetes. J Pediatr Psychol 1995;20(4):389–402.

127. Hampson SE, Glasgow RE, Foster LS. Personal models

of diabetes among older adults: relationship to self-management and other variables. Diabetes Educ 1995;21(4):

300–7.

128. Glasgow RE. Social-environmental factors in diabetes:

barriers to diabetes self-care. In: Bradley C, editor.

Handbook of Psychology and Diabetes. Berkshire, UK:

Harwood Academic, 1994.

129. Hampson SE. Illness representations and self-management of diabetes. In: Weinman J, Petrie K, editors.

Perceptions of Illness and Treatment: Current Psychological

Research and Applications. Chur, Switzerland: Harwood

Academic, 1996.

130. Glasgow RE, Hampson SE, Strycker LA, Ruggiero L.

Personal-model beliefs and social-environmental barriers

related to diabetes self-management. Diabetes Care 1997;

20(4):556–61.

131. Samuel-Hodge CD, Headen SW, Skelly AH, et al.

Influences on day-to-day self-management of type 2 diabetes among African American women: spirituality, the

multi-caregiver role, and other social context factors.

Diabetes Care 2000;23(7):928–33.

132. Fitzgerald JT, Gruppen LD, Anderson RM, et al. The

influence of treatment modality and ethnicity on attitudes in type 2 diabetes. Diabetes Care 2000;23(3):

313–8.
The Middle Years

141

133. Skelly AH, Marshall JR, Haughey BP, Davis PJ,

Dunford RG. Self-efficacy and confidence in outcomes

as determinants of self-care practices in inner-city,

African American women with non–insulin-dependent

diabetes. Diabetes Educ 1995;21(1):38–46.

134. Jackson MY, Proulx JM, Pelican S. Obesity prevention.

Am J Clin Nutr 1991;53(6 Suppl):1625S–1630S.

135. Gavard JA, Lustman PJ, Clouse RE. Prevalence of

depression in adults with diabetes: an epidemiological

evaluation. Diabetes Care 1993;16(8):1167–78.

136. Palinkas LA, Barrett-Connor E, Wingard DL. Type 2

diabetes and depressive symptoms in older adults: a population-based study. Diabet Med 1991;8(6):532–9.

137. Rodin G, Voshart K. Depression in the medically ill: an

overview. Am J Psychiatry 1986;143(6):696–705.

138. Moldin SO, Schefner WA, Rice JP, Nelson E, Knesevich

MA, Akiskal H. Association between major depressive

disorder and physical illness. Psychol Med

1993;23(3):755–61.

139. Jacobson A. Depression and diabetes. Diabetes Care

1993;16(12):1621–3.

140. Leedom L, Meehan W, Procci W, Zeidler A. Symptoms

of depression in patients with type II diabetes mellitus.

Psychosomatics 1991;32(3):280–6.

141. Lloyd CE, Matthews KA, Wing RR, Orchard TJ.

Psychosocial factors and complications of IDDM: the

Pittsburgh Epidemiology of Diabetes Complications

Study, VIII. Diabetes Care 1992;15(2):166–72.

142. Murawski BJ, Chazan BI, Balodimos MC, Ryan JR.

Personality patterns in patients with diabetes mellitus of

long duration. Diabetes 1970;19(4):259–63.

143. Lustman PJ, Griffith LS, Clouse RE, Cryer PE.

Psychiatric illness in diabetes mellitus: relationship to

symptoms and glucose control. J Nerv Ment Dis 1986;

174(12):736–42.

144. Geringer ES, Perlmuter LC, Stern TA, Nathan DM.

Depression and diabetic neuropathy: a complex relationship. J Geriatr Psychiatry Neurol 1988;1(1):11–5.

145. Barglow P, Hatcher R, Edinin DV, Sloan-Rossiter D.

Stress and metabolic control in diabetes: psychosomatic

evidence and evaluation of methods. Psychosom Med

1984;46(2):127–44.

146. Geringer E. Affective disorders and diabetes mellitus. In:

Holmes C, editor. Neuropsychological and Behavioral

Aspects of Diabetes. New York: Springer-Verlag, 1990:

167–83.

147. Eaton WW, Armenian H, Gallo J, Pratt L, Ford DE.

Depression and risk for onset of type II diabetes: a

prospective population-based study. Diabetes Care 1996;

19(10):1097–102.

148. Eaton WW, Kramer M, Anthony JC, Dryman A,

Shapiro S, Locke BZ. The incidence of specific

DIS/DSM-III mental disorders: data from the NIMH

Epidemiologic Catchment Area Program. Acta Psychiatr

Scand 1989;79:163–78.

149. Krolewski AS, Warram JH, Christlieb AR. Onset,

course, complications, and prognosis of diabetes mellitus. In: Marble A, Krall LP, Bradley RF, Christlieb AR,

Soeldner JS, editors. Joplin’s Diabetes Mellitus.

Philadelphia: Lea & Febiger, 1985:251–77.

150. Kannel WB. Lipids, diabetes, and coronary heart disease:

insights from the Framingham Study. Am Heart J

1985;110(5):1100–7.

151. Krolewski AS, Kosinski EJ, Warram JH, et al.

Magnitude and determinants of coronary artery disease

in juvenile-onset, insulin-dependent diabetes mellitus.

Am J Cardiol 1987;59(8):750–5.

152. Heyden S, Heiss G, Bartel AG, Hames CG. Sex differences in coronary mortality among diabetics in Evans

County, Georgia. J Chron Dis 1980;33(5):265–73.

153. Barrett-Connor E, Wingard DL. Sex differential in

ischemic heart disease mortality in diabetics: a prospective population-based study. Am J Epidemiol 1983;

118(4):489–96.

154. Pan WH, Cedres LB, Liu K, et al. Relationship of clinical diabetes and asymptomatic hyperglycemia to risk of

coronary heart disease mortality in men and women.

Am J Epidemiol 1986;123(3):504–16.

155. Maggi S, Bush TL, Hale WE. Diabetes and other cardiovascular disease risk factors in an elderly population.

Age Ageing 1990;19(3):173–8.

156. Kannel WB, McGee DL. Diabetes and cardiovascular

risk factors: the Framingham study. Circulation 1979;

59(1):8–13.
142

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

157. Barrett-Connor E, Witzum JL, Holdbrook M. A community study of high-density lipoproteins in adult

non–insulin-dependent diabetics. Am J Epidemiol 1983:

117(2):186–92.

158. Haffner SM, Mykkanen L, Stern MP, Paidi M, Howard

BV. Greater effect of diabetes on LDL size in women

than in men. Diabetes Care 1994;17(10):1164–71.

159. Laakso M, Barrett-Connor E. Asymptomatic hyperglycemia is associated with lipid and lipoprotein changes

favoring atherosclerosis. Arteriosclerosis 1989;9(5):

665–72.

160. West KM, Ahujy MM, Bennett PH, et al. The role of

circulating glucose and triglyceride concentrations and

their interactions with other “risk factors” as determinants of arterial disease in nine diabetic population samples from the WHO multinational study. Diabetes Care

1983;6(4):361–9.

161. The Diabetes Drafting Group. Prevalence of small vessel

and large vessel disease in diabetic patients from 14 centres : the World Health Organization Multinational

Study of Vascular Disease in Diabetes. Diabetologia

1985;28:615–40.

162. Ruderman NB, Haudenschild C. Diabetes as an atherogenic factor. Prog Cardiovasc Dis 1984;26(5):373–412.

163. Laakso M. Glycemic control and the risk for coronary

heart disease in patients with non–insulin-dependent

diabetes mellitus: the Finnish studies. Ann Intern Med

1996;124:127–30.

164. United Kingdom Prospective Diabetes Study (UKPDS)

Group. Effect of intensive blood-glucose control with

metformin in complications in overweight patients with

type 2 diabetes (UKPDS 34). Lancet 1998;352(9131):

854–65.

165. Haffner SM, Miettinen H. Insulin resistance implications for type 2 diabetes mellitus and coronary heart disease. Am J Med 1997;103(2):152–62.

166. Meinert CL, Knatterud GL, Prout TE, Klimt CR. A

study of the effects of hypoglycemic agents on vascular

complications in patients with adult-onset diabetes. II.

Mortality results. Diabetes 1970;19(Suppl):789–830.

167. Harris MI. Summary. In: National Diabetes Data

Group, editors. Diabetes in America. 2nd ed. Bethesda,

MD: National Institutes of Health, 1995:1–13. (NIH

Publication No. 95-1468)

168. Stahn RM, Gohdes D, Valway SE. Diabetes and its

complications among selected tribes in North Dakota,

South Dakota, and Nebraska. Diabetes Care 1993;16(1):

244–7.

169. DeFronzo RA, Ferrannini E, Koivisto V. New concepts

in the pathogenesis and treatment of non–insulindependent diabetes mellitus. Am J Med 1983;74(1A):

52–81.

170. Hubert HB, Feinleib M, McNamara PM, Castelli WP.

Obesity as an independent risk factor for cardiovascular

disease: a 26-year follow-up of participants in the

Framingham Heart Study. Circulation 1983;67(5):

968–77.

171. Manson JE, Colditz GA, Stampfer MJ, et al. A prospective study of obesity and risk of coronary heart disease in

women. N Engl J Med 1990;322(15):882–9.

172. Goldstein DJ. Beneficial effects of modest weight loss.

Int J Obes Relat Metab Discord 1992;16(6):397–415.

173. Hadden DR, Blair AL, Wilson EA, et al. Natural history

of diabetes presenting age 40–69 years: a prospective

study of the influence of intensive dietary therapy. 

Q J Med 1986;59(230):579–98.

174. Cowie CC, Howard BV, Harris MI. Serum lipoproteins

in African Americans and whites with non–insulindependent diabetes in the U.S. population. Circulation

1994;90(3):1185–93.

175. American Diabetes Association. Detection and management of lipid disorders in diabetes. Diabetes Care 1993;

16(5):828–34.

176. Cook CB, Erdman DM, Ryan GJ, et al. The pattern of

dyslipidemia among urban African Americans with type

2 diabetes. Diabetes Care 2000;23(3):319–24.

177. Pyorala K, Laakso M, Uusitupa M. Diabetes and atherosclerosis: an epidemiologic view. Diabetes Metab Rev

1987;3(2):463–524.

178. Pyorala K, Pederson TR, Kjekhus J, Faergeman O,

Olsson AG, Thorgeirsson G. Cholesterol lowering with

simvastatin improves prognosis of diabetic patients with

coronary heart disease. A subgroup analysis of the

Scandinavian Simvastatin Survival Study (4S). Diabetes

Care 1997;20(4):614–20.
The Middle Years

143

179. Fontbonne A, Eschwege E, Cambien F, et al.

Hypertriglyceridaemia as a risk factor of coronary heart

disease mortality in subjects with impaired glucose tolerance or diabetes: results from the 11-year follow-up of

the Paris Prospective Study. Diabetologia 1989;32(5):

300–4.

180. Sacks FM, Pfeffer MA, Moye LA, et al. The effect of

pravastatin on coronary events after myocardial infarction in patients with average cholesterol levels.

Cholesterol and Recurrent Events Trial Investigators. 

N Engl J Med 1996;335(14):1001–9.

181. National Cholesterol Education Program. Summary of

the second report of the National Cholesterol Education

Program (NCEP) expert panel on detection, evaluation,

and treatment of high blood cholesterol in adults (Adult

Treatment Panel II). JAMA 1993;269(23):3015–23.

182. American Diabetes Association. Management of dyslipidemia in adults with diabetes. Diabetes Care 1999;

22(Suppl 1):S56–S59.

183. National Institutes of Health Consensus Conference.

Triglyceride, high-density lipoprotein, and coronary

heart disease. NIH consensus development panel on

triglyceride, high-density lipoprotein, and coronary heart

disease. JAMA 1993;269(4):505–10.

184. Levy D, Kannel WB. Cardiovascular risks: new insights

from Framingham. Am Heart J 1988;116:266–72.

185. Hansson L, Zanchetti A, Carruthers SG, et al. Effects of

intensive blood-pressure lowering and low-dose aspirin

in patients with hypertension: principal results of the

Hypertension Optimal Treatment (HOT) randomized

trial. HOT Study Group. Lancet 1998;351(9118):

1755–62.

186. Alder AI, Stratton IM, Neil HA, et al. Association of

systolic blood pressure with macrovascular and microvascular complications of type 2 diabetes (UKPDS 36):

prospective observational study. BMJ 2000;321(7258):

412–19.

187. Heart Outcomes Prevention Evaluation (HOPE) Study

Investigators. Effects of ramipril on cardiovascular and

microvascular outcomes in people with diabetes mellitus:

results of the HOPE study and MICRO-HOPE substudy. Lancet 2000;355(9200):253–9.

188. Kuller LH. Stroke and diabetes. In: National Diabetes

Data Group, editors. Diabetes in America. 2nd ed.

Bethesda, MD: National Institutes of Health,

1995:449–56. (NIH Publication No. 95-1468)

189. Nelson RL, Knowler WC, Pettitt DJ, Bennett PH.

Kidney diseases in diabetes. In: National Diabetes Data

Group, editors. Diabetes in America. 2nd ed. Bethesda,

MD: National Institutes of Health, 1995:349–400.

(NIH Publication No. 95-1468)

190. Palumbo PJ, Melton LJ. Peripheral vascular disease and

diabetes. In: National Diabetes Data Group, editors.

Diabetes in America. 2nd ed. Bethesda, MD: National

Institutes of Health, 1995:401–8. (NIH Publication No.

95-1468)

191. Wing RR, Epstein LH, Paternostro-Bayles M, Kriska A,

Norwalk MP, Gooding W. Exercise in a behavioral

weight control programme for obese patients with type 2

(non–insulin-dependent) diabetes. Diabetologia 1988;

31(12):902–9.

192. Donahoe CP Jr, Lin DH, Kirschenbaum DS, Keesey

RE. Metabolic consequences of dieting and exercise in

the treatment of obesity. J Consult Clin Psychol 1984;

52(5):827–36.

193. Pavlou KN, Steffee WP, Lerman RH, Burrow BA.

Effects of dieting and exercise on lean body mass, oxygen uptake, and strength. Med Sci Sports Exerc 1985;

17(4):466–71.

194. Haskell WL. Exercise-induced changes in plasma lipids

and lipoproteins. Prev Med 1984;13(1):23–36.

195. Rauramaa R. Relationship of physical activity, glucose

tolerance, and weight management. Prev Med 1984;

13(1):37–46.

196. Gordon DJ, Rifkind BM. High-density lipoprotein—the

clinical implications of recent studies. N Engl J Med

1989;321(19):1311–6.

197. Ernst E. Fibrinogen. BMJ 1991;303(6803):596–7.

198. Kannel WB, D’Agostino RB, Wilson PW, Belanger AJ,

Gagnon DR. Diabetes, fibrinogen, and risk of cardiovascular disease: the Framingham experience. Am Heart J

1990;120(3):672–6.
144

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

199. Ford ES, DeStefano F. Risk factors for mortality from all

causes and from coronary heart disease among persons

with diabetes. Findings from the National Health and

Nutrition Examination Survey I Epidemiologic FollowUp Study. Am J Epidemiol 1991;133(12):1220–30.

200. Hu FB, Hennekens CH, Stampfer MJ, et al. Physical

activity and risk of coronary heart disease among diabetic women. Circulation 1998;98(Suppl 1):I-375, Abstract

No. 1967.

201. Solomon CG, Hu FB, Stampfer MJ. Moderate alcohol

consumption and risk of coronary heart disease among

women with type 2 diabetes mellitus. Circulation

2000;102(5):494–9.

202. Early Treatment of Diabetic Retinopathy Study

Investigators. Aspirin effects on mortality and morbidity

in patients with diabetes mellitus. Early Treatment of

Diabetic Retinopathy Study report 14. ETDRS

Investigators. JAMA 1992;268(10):1292–300.

203. Antiplatelets Trialists’ Collaboration Group. Overall

effect on major vascular events: subgroup issues and

comparison of agents. In: Jarrett RJ, editor. Diabetes and

Heart Disease. New York: Elsevier, 1984:1–41.

204. American Diabetes Association. Aspirin therapy in diabetes. Diabetes Care 2001;22(Suppl 1):S60–1.

205. Rolka DB, Fagot-Campagna AM, Narayan KM. Aspirin

use among adults with diabetes: estimates from the

Third National Health and Nutrition Examination

Survey. Diabetes Care 2001;24(2):197–201.

206. Stampfer MJ, Colditz GA, Willett WC, et al. Postmenopausal estrogen therapy and cardiovascular disease:

ten-year follow-up from the Nurses’ Health Study. N

Engl J Med 1991;325(11):756–62.

207. Barrett-Connor E, Laakso M. Ischemic heart disease

risks in postmenopausal women: effects of estrogen use

on glucose and insulin levels. Arteriosclerosis 1990;10(4):

531–4.

208. Lieberman EH, Gerhard MD, Uehata A, et al. Estrogen

improves endothelium-dependent, flow-mediated

vasodilation in postmenopausal women. Ann Intern Med

1994;121(12):936–41.

209. Kaplan RC, Heckbert SR, Weiss NS, et al.

Postmenopausal estrogens and risk of myocardial infarction in diabetic women. Diabetes Care 1998;21(7):

1117–21.

210. Hulley S, Grady D, Bush T, Furberg C, Herrington D,

Riggs B, Vittinghoff E. Randomized trial of estrogen

plus progestin for secondary prevention of coronary

heart disease in postmenopausal women. Heart and

Estrogen/progestin Replacement Study (HERS)

Research Group. JAMA 1998;280(7):605–13.

211. Ebskov LB. Level of lower limb amputation in relation

to etiology: an epidemiological study. Prosthet Orthot Int

1992;16(3):163–7.

212. Osmundson PJ, O’Fallon WM, Zimmerman BR,

Kasmier FJ, Langworthy AL, Palumbo PJ. Course of

peripheral occlusive arterial disease in diabetes. Vascular

laboratory assessment. Diabetes Care 1990;13(2):

143–52.

213. Kannel WB, Skinner JJ Jr, Schwartz MJ, Shurtleff D.

Intermittent claudication. Incidence in the Framingham

study. Circulation 1970;41(5):875–83.

214. Del Aguila MA, Reiber GE, Koepsell TO. How does

provider and patient awareness of high-risk status for

lower extremity amputation influence foot care practice?

Diabetes Care 1994;17(9):1050–4.

215. Perneger TV, Brancati FL, Whelton PK, Klag MJ. Endstage renal disease attributable to diabetes mellitus. Ann

Intern Med 1994;121(12):912–8.

216. U.S. Renal Data System. USRDS 1994 Annual Data

Report. Bethesda, MD: National Institutes of Health,

National Institute of Diabetes and Digestive and Kidney

Diseases, 1994.

217. Mogensen CE, Christensen CK, Vittinghus E. The

stages of diabetic renal disease, with emphasis on the

stage of incipient diabetic nephropathy. Diabetes 1983;

32(Suppl 2):64–78.

218. Kunzelman CL, Knowler WC, Pettitt DJ, Bennett PH.

Incidence of proteinuria in type 2 diabetes mellitus in

the Pima Indians. Kidney Int 1989;35(2):681–7.
The Middle Years

145

219. Lacourciere Y, Nadeau A, Poirier L, Tancrede G.

Comparing effects of converting enzyme inhibition and

conventional therapy in hypertensive non–insulindependent diabetics with normal renal function. Clin

Invest Med 1991;14(6):652–60.

220. Pedersen MM, Hansen KW, Schmitz A, Sorensen K,

Christensen CK, Mogensen CE. Effects of ACE inhibition supplementary to beta blockers and diuretics in

early diabetic nephropathy. Kidney Int 1992;41(4):

883–90.

221. Bjorck S, Mulec H, Johnsen SA, Norden G, Aurell M.

Renal protective effect of enalpril in diabetic nephropathy. BMJ 1992;304(6823):339–43.

222. Ravid M, Savin H, Jutrin I, Bental T, Katz B, Lishner

M. Long-term stabilizing effect of angiotensin-converting enzyme inhibition on plasma creatinine and on proteinuria in normotensive type II diabetic patients. Ann

Intern Med 1993;118(8):577–81.

223. Morelli E, Loon N, Meyer T, Peters W, Myers BD.

Effects of converting-enzyme inhibition on barrier function in diabetic glomerulopathy. Diabetes 1990;39(1):

76–82.

224. Walker WG, Hermann J, Anderson J. Racial differences

in renal protective effect of enalapril vs hydrochlorothiazide in randomized doubly blinded trial in hypertensive type 2. J Am Soc Nephron 1993;4:310.

225. Roper NA, Bilous RW, Kelly WF, Unwin NC,

Connolly VM. Excess mortality in a population with

diabetes and the impact of material deprivation: longitudinal, population-based study. BMJ 2001;322(7299):

1389–93

226. The Diabetes Prevention Program Research Group.

Design and methods for a clinical trial in the prevention of type 2 diabetes. Diabetes Care 1999;22(4):

623–34.
CHAPTER 3

WOMEN WITH DIABETES: 

ADOLESCENCE YEARS

Case Studies

Type 1 Diabetes:

It’s 5:30 p.m. on a weeknight, Sarah gets off her fourth phone call since coming home from

school after track practice. She squeezed in a snack between and during calls. She and three

girlfriends have made plans to go cosmic bowling late on Friday night—a lot of people from

high school will be there. A friend will drive. Her parents just got home. Now Sarah will have

a quick dinner with her family before leaving to babysit. After returning, she has to complete

her homework and try to get to bed at a reasonable hour. She will start her day at 5:30 a.m.,

making sure she has enough time to look good, before taking the school bus. 

Sarah takes her insulin four to six times a day with meals and snacks, and at bedtime. She

tries very hard to be inconspicuous with her diabetes management, even though she knows

that she must consider her diabetes constantly with every decision and plan that she makes.

This is fairly automatic now, since she was diagnosed with type 1 diabetes at age 4. Sarah

carries around her insulin and glucometer in her backpack. She checks her blood sugar levels

before meals, and periodically, four to seven times a day. She gets tired of pricking her fingers.

Sometimes Sarah is hassled at school for having her syringes, so Sarah asked her doctor at her

appointment today about the possibility of getting an insulin pump. It would be so much more

convenient, and it would probably improve her blood sugar control. Sarah received her DepoProvera shot for birth control today; so she knows that her blood sugars will be more difficult

to control for 1 to 2 weeks. She tries not to overly worry about having blood sugars that may

be too low or too high. Sarah learns continually how to take care of her diabetes and her

health.

146

CHAPTER 3

WOMEN WITH DIABETES: 

ADOLESCENCE YEARS

Case Studies

Type 1 Diabetes:

It’s 5:30 p.m. on a weeknight, Sarah gets off her fourth phone call since coming home from

school after track practice. She squeezed in a snack between and during calls. She and three

girlfriends have made plans to go cosmic bowling late on Friday night—a lot of people from

high school will be there. A friend will drive. Her parents just got home. Now Sarah will have

a quick dinner with her family before leaving to babysit. After returning, she has to complete

her homework and try to get to bed at a reasonable hour. She will start her day at 5:30 a.m.,

making sure she has enough time to look good, before taking the school bus. 

Sarah takes her insulin four to six times a day with meals and snacks, and at bedtime. She

tries very hard to be inconspicuous with her diabetes management, even though she knows

that she must consider her diabetes constantly with every decision and plan that she makes.

This is fairly automatic now, since she was diagnosed with type 1 diabetes at age 4. Sarah

carries around her insulin and glucometer in her backpack. She checks her blood sugar levels

before meals, and periodically, four to seven times a day. She gets tired of pricking her fingers.

Sometimes Sarah is hassled at school for having her syringes, so Sarah asked her doctor at her

appointment today about the possibility of getting an insulin pump. It would be so much more

convenient, and it would probably improve her blood sugar control. Sarah received her DepoProvera shot for birth control today; so she knows that her blood sugars will be more difficult

to control for 1 to 2 weeks. She tries not to overly worry about having blood sugars that may

be too low or too high. Sarah learns continually how to take care of her diabetes and her

health.

CASE STUDY

Maxine carefully opens the “W” compartment on her yellow pill box to take her pills. The yellow box

reminds her to take those pills in the morning; her blue container is for the evening pills. She carefully

places them on the table and counts them, and recounts to be sure. There are seven: three pills to help

control her diabetes, two for her hypertension, one for cholesterol, and one aspirin for her heart condition (she’s been taking it since she had that mild heart attack last year). She used to take two insulin

shots a day to control her diabetes, but her doctor replaced her daily insulin shots with the pills 2 years

ago. When she was diagnosed with diabetes at age 52, she was able to control her diabetes for a few

years by watching her diet and exercising regularly. Can it only be 13 years since frequent urination

and an unquenchable thirst sent Maxine to her doctor in search of an answer? It seems like a much

longer time, especially since she has had so many other health problems.

She feels pretty good this morning, although she’s frustrated that once again she is unable to correctly

operate her blood glucose monitor to check her blood sugar. She tried several times, but her eyes, hands,

and memory are no longer reliable. The strip, approximately 2 inches long, is too thin for her hands

that are weakened by the several small strokes she’s suffered over the past year. A cataract and increasing

retinal damage due to diabetes make the task of putting blood on just the right spot almost impossible

most mornings. And because of the memory problems created by the strokes, she can’t always remember

the steps her daughter showed her to extract the blood from her finger and to correctly use the strip and

monitor. 

Maxine quickly finishes her breakfast and waits. She remembers the many years she spent working as a

secretary and raising her four children. It wasn’t always easy, but she did her best. At the time, she

focused on the priority—“making ends meet.” Who had time for exercising? Sure, she knew she needed

to lose weight and stop smoking. Asthma eventually convinced Maxine not to smoke, but the effort to

lose weight would be unending, especially since the medication to control her asthma and her diabetes

increased her weight gain. 

So quickly the years have passed. Now, widowed and retired, she realizes that she is only 65, but already

she needs her children to care for her. With social security as her only source of income and only Medicare

for her health insurance, what else can a woman her age with such health problems do? She watches the

senior citizen van pull into the driveway of the home she now shares with her youngest daughter. As she

hurries out to start her day at the local senior citizen center, she can’t help wondering why she is the

youngest person among all of her friends at the center.
147

6

THE OLDER YEARS

C.H. Hennessy, DrPH, MA, G.L.A. Beckles, MBBS, MSc

Diabetes prevalence, incidence, and secular trends

associated with elderly adults are presented in this

chapter. Demographic and socioeconomic indicators

for this population are discussed. Of all women with

diabetes, women in this age group are most vulnerable

because of the high prevalence of activity limitations,

other chronic conditions, and poverty. The effects of

income insecurity, lack of social support, and other

psychosocial determinants on health status and health

behavior are presented. Public heath implications call

for surveillance to assess and monitor diabetes and its

complications in this age group, systems-level coordination of community services for the elderly with diabetes, and adequate insurance coverage for medications

and preventive and curative care. The public health

implications of the findings are discussed and framed

by the three core functions of public health: assessment,

policy development, and assurance.

Almost all elderly persons diagnosed with diabetes

have type 2 diabetes mellitus, formerly called

non–insulin-dependent diabetes. In this chapter,

the term “diabetes” will refer to type 2 diabetes and

the term elderly to persons aged 65 years or older

unless otherwise specified.

6.1. Prevalence, Incidence, and Trends

Prevalence and Incidence

Based on the new American Diabetes Association

(ADA) diagnostic criteria of fasting blood glucose

126 mg/dL or greater,1 the Third National Health

and Nutrition Examination Survey (NHANES III,

1988–1994) found that the total prevalence of diabetes (diagnosed and undiagnosed) is 17.8% among

women aged 60–74 years and 17.5% among women aged 75 years or older (Figure 6-1).2 The percentage of older women who report that they have

been diagnosed with diabetes is similar in these two

age groups, 13.8% and 12.8%, respectively. The

percentage with undiagnosed diabetes is 4.5%

among women aged 60–74 years and 4.7% among

those 75 years or older. When these estimates are

applied to the 1995 U.S. population, 4.5 million

women aged 60 years or older have diabetes and

one-quarter of them, 1.2 million, do not know that

they have the disease.

Figure 6-1. Prevalence of diagnosed and 

undiagnosed diabetes among 

U.S. adults, by age and sex—

NHANES III,* 1988–94

*NHANES III = Third National Health and Nutrition Examination

Survey. 

Source: Reference 2.

0

5

10

15

20

25

Women Men Women Men

Aged 60–74 Years

Percent

Aged ≥75 Years 

Diagnosed Undiagnosed

17.5

21.1 20.2

17.8
*NHIS = National Health Interview Survey.

Sources: References 4, 5.

0

50

100

150

200

0

5

10

15

20

Incidence rate

No. of new cases

1980 1982 1984 1986 1988 1990 1992 1994

Year

Incidence (per 1,000)

No. of cases (thousands)

Figure 6-2. Number of new cases and 

incidence rate of diagnosed 

diabetes among women aged 65 

years or older—NHIS,* 1980–94

148

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

Recently, the number of new cases of diabetes diagnosed in the adult population increased significantly.3 Between 1980 and 1994, data from the

National Health Interview Survey (NHIS) indicate

that among women aged 65 years or older, the

number of new cases increased from 97,000 to

181,000 and the annual incidence rate rose 45.7%

from 6.3 per 1,000 to 9.2 per 1,000.4

Temporal Trends

The current level of diabetes in the U.S. population

reflects increasing secular trends in both the number and percentage of adults with diabetes (Figure

6-2), and the largest increase is occurring among

the elderly.3 Data from NHIS show that between

1963 and 1993, the proportion of women aged 65

years or older who reported that they had diabetes

almost doubled from 5.6 per 1,000 to 10.6 per

1,000.4,5 Similarly, the prevalence of diagnosed diabetes among older women was 50% higher in

NHANES III than the prevalence found in the

Second National Health and Nutrition

Examination Survey (NHANES II, 1976–1980).2,4

These trends are not entirely explained by aging of

the population.3 Other factors that might contribute

to increased prevalence of a disease include

improved identification of cases, a true increase in

incidence, and declining death rates. NHIS data are

based on self-reports of cases diagnosed in the previous 12 months, thus national incidence data may

reflect increased case ascertainment rather than a

true increase in incidence. Although, by current

ADA criteria, the proportion of total diabetes that

was undiagnosed did not change during 1976–

1980 and 1988–1994,2 the higher prevalence of

diagnosed diabetes found suggests that case detection increased during this period.5 However, findings from a prospective population-based study of

adults in Rochester, Minnesota, indicate that true

incidence of diabetes has also been increasing.6

Overweight,7 weight gain,8 and lack of physical

activity9 are major risk factors for incidence of diabetes mellitus in women. These factors are very

common among elderly women and increased over

this time period.10,11 Finally, a cohort study of

nationally representative samples of the adult 

population showed that 10-year death rates among

elderly women who had diabetes during 1971–1974

were not statistically different from the rates for

those who had diabetes during 1982–1984.12 Thus,

the increasing prevalence of diabetes among elderly

women can be attributed to the combined effects of

improved case detection and an increase in the incidence of diabetes.

6.2. Sociodemographic Characteristics

Age and Sex

In the general population, the prevalence of diabetes increases with increasing age to about 75 years

of age and then plateaus or decreases somewhat

among persons aged 75 years or older. National

surveys do not report age-specific prevalence estimates for persons older than 75 years. However,

results from the Established Populations for

Epidemiologic Studies in the Elderly (EPESE), a

multisite prospective study of representative samples of community-dwelling adults aged 65 years or

older, show that the percentages of elderly black

and white women with previously diagnosed diabetes remain stable between age 65 and 85 years,

then drop steeply for women aged 85 years or older.13
Figure 6-3. Prevalence of diagnosed and 

undiagnosed diabetes among 

U.S. women, by age and race/

Hispanic origin—NHANES III,*

1988–94

*NHANES III = Third National Health and Nutrition Examination

Survey; NHW = non-Hispanic white; NHB = non-Hispanic black;

MA = Mexican American.

Source: Reference 2.

Diagnosed Undiagnosed

Aged 60–74 Years Aged ≥75 years

Percent

0

5

10

15

20

25

30

35

NHW NHW NHB MA NHB MA

40

16.0

32.4 32.5

16.6

26.6

31.2

The Older Years

149

The lower prevalence among women aged 85 years

or older may result from less aggressive case ascertainment or from a survival effect. In the general

population, diabetic women are older than nondiabetic women; 50% or more of all adult women

with diabetes are aged 65 years or older compared

with only 17.1% of women without diabetes.14

According to NHANES III, age-specific prevalence

estimates for diagnosed diabetes are similar for both

sexes (Figure 6-1). In contrast, undiagnosed diabetes was found much less frequently among elderly

women than elderly men. At ages 60–74 years,

prevalence of undiagnosed diabetes among women

was nearly half that of men (4.5% versus 8.4%); at

age 75 years or older, estimates were 4.7% and

7.3%, respectively. Nevertheless, because women

make up a greater proportion of the elderly population and women with diabetes live longer than their

male counterparts,12 elderly women with diabetes

outnumber elderly men with diabetes (4.5 million

versus 3.7 million in 1995).

Race/Ethnicity

In the United States, type 2 diabetes is at least twice

as prevalent among nonwhites of all ages as among

their white counterparts.2,13,15-21 To facilitate the discussion of comparisons among ethnic and racial groups

throughout this chapter, the terms “white” and

“black” will be used, regardless of Hispanic origin.

Among women aged 60–74 years, 33% of black or

Mexican American women have diabetes (diagnosed and undiagnosed combined) as compared

with 16% of white women; estimates are similar for

women aged 75 years or older: 31%, 27%, and

17%, respectively (Figure 6-3). In each age group,

black (23.9% and 19.0%) and Mexican American

(29.0% and 25.0%) women were twice as likely as

white women (11.7% and 12.3%) to have been

previously diagnosed with diabetes (Figure 6-3).

Information on the prevalence of diagnosed diabetes among older Native American women was

collected in the 1987 Survey of American Indians

and Alaska Natives, in which 31.8% of female

respondents aged 65 years or older reported having

diabetes.22 Additionally, among older blacks,

Mexican Americans, and American Indians, diabetes is more common in women than in men.15-22

Data from NHANES II and the Hispanic Health

and Nutrition Examination Survey (HHANES,

1982–1984)4,21 also suggest that in the period

between each of these surveys and NHANES III,

the prevalence of diagnosed diabetes increased substantially among women aged 65 years or older in

all ethnic and racial groups for whom findings are

reported. The increase was most marked among

older black (10.8% to 23.9%) and Mexican

American women (21.4% to 29.0%).

Despite the higher level of diagnosed diabetes, undiagnosed diabetes is more common among black

and Mexican American women than among white

women.2 However, under 75 years of age, blacks

(8.5%) are twice as likely as Mexican Americans
150

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

(3.5%) and whites (4.3%) to have diabetes that is

undiagnosed (Figure 6-3). At age 75 years or older,

undiagnosed diabetes is present in 7.6% of blacks,

6.2% of Mexican Americans, and 4.3% of whites.

Because of their relatively small numbers, no data

for older women in other ethnic and racial groups

are available from national surveys. However, since

the late 1970s, several surveys of diabetes among

Asian Americans/Pacific Islanders and the total

Hispanic population have confirmed the higher risk

for diabetes among minority women at all ages

compared with their white counterparts.20,21,23

Marital Status/Living Arrangements

Among women aged 65 years or older, women with

diabetes are more likely than those without diabetes

to be widowed (54.8% versus 45.4%) (Table 6-1).14

About 4 of 10 elderly diabetic women live alone,

one-third live with a spouse, and one-fifth live with

some other relative. This pattern reflects the findings in the relatively larger population of white

women and is different for minority women for

whom national data are available. In contrast, older

black women with diabetes were more likely than

those without diabetes to be widowed (61.0% versus 55.8%) and less likely to be divorced or separated (5.6% versus 9.7%). Also, for this group, living

arrangements did not vary by diabetic status (Table

6-1). However, black women are somewhat less

likely than their white counterparts to live alone

(40.0% versus 46.8%) or with a spouse (27.1%

versus 35.4%), and much more likely to live with

some other relative (31.0% versus 17.4%).

Education

It is well known that the level of formal education

attained by older adults in the population is generally lower than that of younger adults, and elderly

women have lower levels of education than elderly

men. Elderly women with diabetes have even less

formal education than do their counterparts without diabetes: they are more likely to have less than

9 years of education (38.0% versus 25.6%) and

they are also less likely to have completed 12 or

more years of education (14.4% versus 21.3%)

(Table 6-1).14 Low levels of education are especially

marked among elderly minority women with diabetes; about one-half (49.9%) of black women have

fewer than 9 years of education compared with

one-third (32.9%) of white women. The implications of lower levels of education among older

women for diabetes management and for the design

of diabetes education and health promotion programs are discussed later in this chapter.

Family Income

By age 65 years, women have half the income of

men and they are twice as likely to live in poverty.24,25 Women with diabetes are even more likely

than women without diabetes to have low family

incomes (Table 6-1).14 Almost half of elderly women with diabetes (47.4%) have an annual family

income less than $10,000, and for more than threequarters (78.8%) of them this income is less than

$20,000; the percentages for women without diabetes are 31.3% and 66%, respectively. The sex differential in income found among all racial and ethnic groups is amplified among persons with type 2

diabetes. Among elderly persons with diabetes,

women are 2.5 times as likely as men to have an

income less than $10,000. As in the general population, low income levels are considerably more

common among minority women: more than 60%

of elderly black women with diabetes have family

incomes less than $10,000, and about 90% of them

have incomes less than $20,000. Although the

national data available for Mexican Americans are

not specific to women aged 65 years or older,

Mexican American women with diabetes are almost

twice as likely as those without diabetes to have an

income below $10,000.

6.3. Impact of Diabetes on Illness and Death

Risk of Death 

Diabetes ranks as one of the leading underlying

causes of death among women aged 65 years or

older.5 In this age group, diabetes ranks higher as an

underlying cause of death among women aged

65–74 years than among those aged 75 years or

older; however, the death rate for diabetes continues

to increase with age. In 1992, the number of deaths
Table 6-1. Prevalence (%) of sociodemographic characteristics of women aged 65 years or older 

with and without type 2 diabetes, by race/Hispanic origin—United States, 1989

Non-Hispanic white Non-Hispanic black Total

Characteristic Diabetes No diabetes Diabetes No diabetes Diabetes No diabetes

Marital status

Married 36.6 45.0 27.4 27.9 35.2 43.2

Widowed 54.5 44.7 61.0 55.8 54.8 45.4

Divorced or separated 4.3 5.6 5.6 9.7 5.1 6.3

Never married 4.6 4.7 6.0 6.6 4.9 5.1

Living arrangements

Alone 46.8 42.0 40.0 40.0 44.8 41.9

Nonrelative only 0.4 1.0 1.9 0.6 0.8 0.9

Spouse 35.4 44.3 27.1 26.6 34.1 42.4

Other relative only 17.4 12.8 31.0 32.7 20.3 14.8

Household size (no. of persons)

1 47.2 43.0 41.9 41.0 45.6 43.0

2 40.0 47.7 28.3 36.2 37.1 46.3

3 7.1 5.8 15.9 16.0 9.4 6.8

≥4 5.7 3.4 13.9 6.9 7.9 3.9

Education (years) 

<9 32.9 22.1 49.9 52.6 38.0 25.6

9–12 51.0 55.3 39.3 37.1 47.7 53.1

>12 16.1 22.6 10.8 10.3 14.4 21.3

Annual family income ($thousands)

<10 44.4 29.1 61.4 51.6 47.4 31.3

10 – <20 32.4 34.9 28.2 35.9 31.4 34.7

20 – <40 18.9 24.4 9.3 10.4 17.3 23.4

≥40 4.2 11.6 1.1 2.2 3.9 10.5

Employment status

Employed 5.5 10.2 9.2 9.5 6.1 10.1

Unemployed 0.0 0.3 0.0 0.7 0.0 0.3

Not in labor force 94.5 89.5 90.8 89.7 93.9 89.6

Source: Reference 14.

The Older Years

151

among women aged 65 years or older with diabetes

was 4.6 times the number of deaths among women

aged 45–64 years with diabetes.5 (See Figure 5-3.)

The case fatality rate of 12 per 1,000 for these elderly women was 3.4 times the rate for diabetic

women in midlife. However, death rates based on

diabetes as an underlying cause of death are known

to markedly underestimate the impact of diabetes

on mortality.26

In the 22-year mortality follow-up study of participants in the First National Health and Nutrition

Examination Survey, diabetes status was ascertained

at baseline.12,27 The data show that among persons

aged 65–74 years, the overall risk of death was

higher for persons with diabetes than for those

without diabetes (Figure 6-4), but the effect of diabetes (rate ratio = 1.6) was less than that seen at

younger ages (3.2 and 2.7 for age groups 25–34

and 45–64, respectively).12

Further, unlike younger women, no racial/ethnic

difference in mortality was present among elderly

women with diabetes (Figure 6-4). However, one
Figure 6-4. All-cause mortality rates for U.S. 

adults aged 65–74 years, by 

diabetes status, sex, and race/

Hispanic origin—1971–93

0

30

60

90

120

150

Women

Deaths per 1,000 person-years

Men

NHW NHW NHB NHB

Diabetes

No diabetes

79.7

47.4

80.6

57.9

103.8

73.8

83.1

120.2

NHW = non-Hispanic white; NHB = non-Hispanic black.

Source: Reference 12.

152

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

study in San Antonio, Texas, found that the death

rate for diabetes was almost 4 times greater among

elderly Mexican American women than among 

elderly white women.28

Hospitalizations

Data from the 1989 NHIS indicate that women

aged 65 years or older with diabetes were almost

twice as likely as nondiabetic elderly women to

report having been hospitalized in the past year

(28% versus 15%).29 At all ages, the proportion of

women with diabetes who reported being hospitalized in the past year exceeded that of diabetic men,

but this sex differential narrowed with age. By 65

years of age, 28% of women and 24% of men with

diabetes reported a hospital stay within the past year.

National findings on hospitalization rates for older

minority women with diabetes are only available for

blacks.29 In 1990, the hospitalization rate for elderly

black women with diabetes (747.3 per 10,000) was

1.7 times the rate of their white counterparts

(450.0 per 10,000).

Diabetes-Related Illnesses

Although elderly persons are subject to the same

complications of diabetes as persons of any other

age, the decreased function of major organ systems

and the possible organ impairment from concurrent

conditions put elderly persons at particular risk for

diabetes-related illnesses.30 Thus, in addition to

being at greater risk for death from diabetes, elderly

persons are also more susceptible to the complications of diabetes. Chronological age also interacts

with diabetes to accelerate the chronic complications of diabetes: retinopathy, nephropathy, and

neuropathy occur almost twice as quickly among

elderly diabetic persons as among their younger

counterparts.31 In addition, these complications are

more severe when they first occur in advanced old

age.32 Elderly women with diabetes are particularly

at risk for cardiovascular disease and visual problems and may also be at greater risk for metabolic

disorders and depression.

Cardiovascular and peripheral vascular diseases are

the most prevalent complications among elderly

diabetic women, as they are among all persons with

diabetes. Arthrosclerotic disease, the prevalence of

which increases with age, is believed to interact

with diabetes to accelerate changes in major blood

vessels.33 Epidemiologic evidence indicates that the

prevalence of these macrovascular complications is

greater among elderly women with diabetes than

among elderly men who have the disease. For

example, findings from EPESE indicated that

prevalence ratios describing the association between

diabetes and cardiovascular conditions (i.e.,

myocardial infarction, stroke, hypertension, and

angina) were generally greater among elderly

women than among elderly men.14 Moreover,

results from the National Hospital Discharge

Survey (1979–1987) demonstrated that among

patients aged 65 years or older who were discharged

from the hospital with acute myocardial infarction

listed as the primary diagnosis, 21.8% of women

compared with 16.1% of men also had diabetes

listed as a diagnosis.34

Most studies that have examined lower extremity

arterial disease (LEAD) among elderly persons with
The Older Years

153

diabetes do not present findings for elderly women

specifically. However, unless otherwise noted, the

findings from these are assumed to hold true for

both sexes. LEAD increases with age among all persons, and among persons with diabetes, LEAD

increases with the duration of the disease.35 Diabetic

neuropathy is also related to the duration of diabetes,

and it may develop more rapidly in persons with

diabetes diagnosed at older ages than in those with

diabetes diagnosed before age 40.36 Neuropathy and

susceptibility to infection compound LEAD in persons with diabetes and contribute to LEAD progressing to foot ulcers, gangrene, and ultimately

amputation.35 The prevalence of foot ulcers increases with age, occurring in 7% of diabetic persons

older than 60 years and in 14% of those aged 80

years or older.37,38 Amputation rates also increase

with age; most (64%) amputations in persons with

diabetes take place in those older than age 65

years.38 Although many of these complications associated with LEAD occur more frequently in older

men than in older women,35 the projected growth

of the population of older women with diabetes39

implies an increase in the total number of women

experiencing these adverse outcomes.

Elderly persons with diabetes are also subject to

metabolic complications resulting from problems

with blood glucose control (e.g., hypoglycemia,

hyperosmolar coma) and other clinical syndromes.31

For example, diabetes can result in hypothermia,

which is of particular concern to elderly women

with diabetes as evidenced by their increased risk of

being hospitalized for hypothermia compared with

their male counterparts.40

Visual problems such as cataracts and glaucoma

that are common among elderly persons are more

prevalent among those who have diabetes.41 Data

from the Wisconsin Epidemiologic Study of

Diabetic Retinopathy (WESDR), which examined

the prevalence of ocular problems among persons

with diabetes diagnosed at an older age (mean age

at diagnosis, 65.4 years), showed that poorer visual

acuity was associated with increasing duration of

diabetes but also that rates of legal blindness

increased significantly after age 70, regardless of the

duration of diabetes. In addition, a greater proportion of older women than older men had some

degree of visual impairment (13.3% compared with

9.9%) and legal blindness (1.7% compared with

1.4%).

The relationship between diabetes and cognitive

impairment has been equivocal in the few population-based studies of older adults that have been

conducted.42,43 However, studies of elderly patients

from clinical populations with higher glycemic levels who typically have had the disease for a relatively long duration report a positive association

between diabetes and cognitive dysfunction.44,45 In

these studies, elderly persons with diabetes were

shown to have a greater degree of cognitive problems than did their nondiabetic age peers matched

for other concurrent diseases. The effect of diabetes

on cognition seems to be primarily on the ability to

retain new information, and persons with diabetes

may be less likely to remember changes in medication than are persons with other diseases.

Among adults, diabetes is associated with an

increased risk for depression,45 especially for those

with more diabetes-related complications, and as in

the general population, depression has been shown

to be more common among women than men with

the disease.46,47 In persons aged 65 years or older,

the incidence of depression is estimated to be about

50% greater among women than among men.48

Thus, elderly women with diabetes may be at greater

risk for depression than their male counterparts.

National estimates of diabetes-related illnesses

among elderly women are not generally available

for minorities. Findings from EPESE indicated

stronger associations between diabetes and stroke

among elderly black women than elderly white

women.14 HHANES is the only study that has

examined the health and functional status of

Hispanic women with diabetes, but the data are

aggregated for middle-aged and elderly women
154

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

(aged 45–74 years).22 Results from this study showed

that the prevalence of hypertension, kidney problems, and vision problems (i.e., cataracts, retinopathy, and glaucoma) was higher among Mexican

American women with diabetes than among those

without diabetes.

Disabilities 

Almost one-fourth of elderly Americans have difficulty in carrying out the activities of daily living;

one-fourth of women aged 65–74 years but more

than half of those aged 85 years or older experience

this difficulty.49 Findings from EPESE indicated

that elderly women reporting a history of diabetes

were more likely than those without the disease to

report a major disability (i.e., impairment in activities of daily living and physical mobility), urinary

incontinence, and impairments in vision or

hearing.14 In addition, these elderly diabetic women

were less likely to perceive their overall health status

as excellent or good than were those without diabetes. Among a group of 2,021 participants in the

Framingham Heart Study, none of whom had cardiovascular disease, diabetes was associated with

physical disability in women (particularly those

older than age 75) but not in men.50 A study of

self-rated health and functioning among persons

with diabetes of long duration (>15 years) in the

WESDR also demonstrated significantly poorer ratings of health and functional status among women

than among men.51

As with diabetes-related illnesses, national data on

disabilities associated with diabetes among elderly

women are extremely limited for minority groups.

In the 1989 NHIS, overall, black women with diabetes had a higher prevalence of activity limitations

than did white women with diabetes, and this 

pattern may hold true for elderly women.52 Data

from HHANES indicated that Mexican American

women aged 45–74 years with diabetes had a higher prevalence of activity limitation than did those

without the disease.53 These data also indicated that

activity limitation among Mexican American

women with diabetes increased with the duration of

the disease. Likewise, a higher proportion of these

diabetic women than nondiabetic women had a

health status rated as poor by both self-evaluation

and by physician assessment.

6.4. Health-Related Behaviors

Physical Inactivity

The role of health-related behaviors in the development of diabetes and its complications is wellestablished, and a number of these behaviors are

particularly relevant to elderly women. One of the

major risk factors for diabetes and its complications

is physical inactivity, which increases with age

among the general U.S. population.54 In addition,

contemporary elderly women tend to be less physically active than their male counterparts because

they were often discouraged from active participation in exercise in their youth for a variety of cultural reasons.55 In the 1991 NHIS, NHANES III

(1988–1994), and the 1992 Behavioral Risk Factor

Surveillance System, the percentages of elderly

women who reported no leisure-time physical activity ranged from 32.8% to 43.4%.56 Results from all

three surveys indicate that this risk factor for diabetes and its complications is more frequent among

older women than among older men.

Obesity

Total body adiposity, another recognized risk factor

for diabetes and its complications, increases with

age-associated decreases in metabolism. The rate of

overweight among elderly women exceeds that

among elderly men. Among persons aged 65 years

or older with diabetes, 70.4% of women but only

38.2% of men are 20% over their desirable

weight.57 One-fourth of elderly women with diabetes, but only 5.7% of their male counterparts, are

extremely obese (50% over their desirable weight).

The risk of being overweight also differentially

affects older women by race and ethnicity. Among

women aged 65 years or older, the prevalence of

being at least 20% over the desirable body weight is

1.7 times greater among blacks (43.8%) and 1.3
The Older Years

155

times greater among Hispanics (35.5%) than among

whites (25.3%).54 Comparable national data on

overweight among elderly diabetic women of other

ethnic and racial groups are not available. 

Smoking

Smoking is another documented risk factor for diabetes and its complications. The smoking rate

among women declines with age, from 30.2%

among those aged 55–64 years, to 21.5% among

those aged 65–74 years, and to 8.5% among

women aged 75 years or older.58 This decline with

age may be due to decreased survivorship of smokers and to rates of smoking initiation in adolescence

and young adulthood becoming increasingly lower

among contemporary women as age increases.

Smoking rates are considerably lower among the

current cohort of elderly women than among elderly men, at least in part because of social norms

against smoking by women in the early 1900s.

Because current younger smokers include a greater

proportion of women, this risk factor for diabetes

and its complications could increase significantly

among elderly women in the future.

Preventive Self-Care

Effective management of diabetes depends on modifying behavioral risks and on learning appropriate

diabetes management techniques and skills. Thus,

the first line of therapy involves diet modification,

weight control, exercise, self-monitoring of urine

and blood glucose levels, and patient education.59

Pharmacologic treatment is considered if these

measures fail to produce adequate glycemic control.

Although there is little information about the

prevalence of preventive self-care practices among

elderly women with diabetes, more is known about

preventive self-care practices for those aged 60 years

or older. Among all persons who have diabetes,

those aged 60 years or older have been shown to be

most likely to comply with diet modifications but

least likely to exercise or to test their urine for glucose levels.60 Among persons with diabetes aged 60

years or older, women report lower levels of exercise

than do men, and those who take insulin are more

likely to test their glucose levels than those who do

not take insulin.61 Barriers to and motivations for

practicing preventive self-care are covered in more

detail in section 6.5.62,63

6.5. Psychosocial Determinants of Health

Behaviors and Health Outcomes

Social Environment

Social support. Social support consists of both emotional links and task-oriented assistance provided by

the community, family, friends, or significant others.64 This support, whether emotional or practical,

can mitigate the negative effects of stress, including

those engendered by coping with a chronic disease,

and can promote healthy behaviors and self-care

among older persons.65 The type, structure, quality,

and availability of social support among elderly

women with diabetes will therefore affect the psychosocial resources they possess to cope with the

disease.

Research on the effects of social support provided

to elderly women with diabetes is negligible, and

studies of adults of various ages with diabetes have

had mixed findings regarding the relationship of

social support, compliance with self-care practices,

and glycemic control.66,67 The most recent study

investigated the role of family members in the management of diabetes in persons aged 70 years or

older.68 The types and extent of assistance provided

with daily diabetes-related care tasks and participation in visits with health care providers were examined. Not unexpectedly, family involvement in the

patient’s diabetes care regimen increased as the

patient’s functional impairment increased, and

patients receiving more assistance were more likely

to report that they adhered to their recommended

medications and diet. A modest association was also

found between family assistance and glycemic control. Thus, the investigators concluded that taskoriented support provided by family members to

older diabetic persons positively influences adherence to diabetes care regimens and possibly blood

glucose levels.
156

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

Socioeconomic factors. As discussed above, socioeconomic factors, including income and educational

attainment, have a demonstrated relationship with

the prevalence of type 2 diabetes.69 These factors

influence risk factors for the development of diabetes and a person’s capacity to manage this chronic

disease. Evidence suggests that a high socioeconomic status is positively related to understanding a disease and negatively related to anxiety over disease

symptoms and their misinterpretation.70 The low

level of education among older women thus has

major implications for the design of diabetes education and health promotion programs. In addition,

the economic situation of elderly women described

above suggests that a high proportion of older

women with diabetes may have limited access to

appropriate care because their disposable income

may be so low as to impose constraints on their

ability, or desire, to comply with prescribed drug

and diet regimens because they are unable to meet

out-of-pocket costs.

Interactions with the Health Care System

Health insurance. The ability to pay for health care

strongly influences an older person’s use of services.71 Older women with diabetes who have no

health insurance may delay seeking medical attention for symptoms or routine preventive care.

Although no research has examined the influence of

health insurance on health outcomes among elderly

women with diabetes, a study of adults aged 18–64

years with diabetes found that health insurance 

had several positive effects: persons with health 

insurance reported less frequent hyperglycemia and

glycosuria, more frequent medical care, and more

preventive self-care practices than did those who

were not insured.72

Health care services for elderly U.S. citizens are

covered by Medicare, a public health insurance program. As of 1996, 98.5% of elderly Americans had

this coverage.73,74 Medicare coverage is limited, however, to curative services; it does not pay for any

primary nor for most secondary preventive services,

such as periodic screening and prevention measures

for hearing, dental, podiatry, and eye problems.

Medicare also does not cover prescription drugs.

Many elderly Americans purchase private insurance

to cover the out-of-pocket expenses and copayments not reimbursed by Medicare. However,

the proportion of elderly persons who have private

insurance is lower among those who have diabetes

(69.2%) than among those who do not (79.9%).72

Medicaid is an entitlement program for lowincome, disabled, and blind persons. Among persons aged 65 years or older, coverage through

Medicaid is more common among those who have

diabetes (15.4%) than among those who do not

(6.0%). Regardless of the health insurance they

have, only 52.6% of elderly Americans who have

diabetes have coverage for prescription drugs.72

Coverage for diabetes outpatient education programs is inconsistent and is shifting throughout the

private and public health insurance sectors but is

generally increasing.75 In a growing number of

states, Medicare reimburses patients for participation in such education programs, but local Medicare

intermediaries determine which programs meet

reimbursement criteria, no self-referrals are allowed,

and individual patient claims may be denied.

Medicaid coverage for these programs is at the discretion of each state and is dependent on their

demonstrated cost-effectiveness; currently 35 states

offer this benefit.76 Private insurance provides the

most comprehensive coverage for this preventive

care service for those who can afford this benefit.

Use of services. Elderly women with diabetes use

health care services—both hospital care and ambulatory care—more intensively than elderly men

with diabetes. According to data from the National

Ambulatory Medical Care Surveys of 1991 and

1992, the average annual number of office-based

physician visits in which diabetes was listed as a

diagnosis was 1.5 times higher for women aged 65

years or older (7.4 million visits) than for their

male counterparts (5.0 million visits).77 Elderly

women also had a higher number of physician visits

specifically for diabetic complaints (4.5 million visits versus 3.2 million visits). Although these differences in use of health care services may reflect the

greater propensity of women than men to report
Table 6-2. Percentage of beneficiaries 

with diabetes who received 

recommended preventive and 

monitoring services in fee-forservice Medicare, by sex—United 

States, 1994

Recommended service Women Men

Physician visit, ≥2 per year 94.5 92.0

Dilated eye exam, ≥1 per year 43.6 39.5

Glycohemoglobin test

≥2 per year 20.5 21.3

≥1 per year 37.5 38.7

Urinalysis, 1 per year 53.2 53.0

Serum cholesterol test, 1 per year 70.4 68.7

Influenza vaccination, 1 per fall season* 42.4 46.6

* The flu shot may be underreported in Medicare claims because

people may obtain it in nonmedical settings.

Source: Reference 82.

The Older Years

157

disease symptoms, the disparities may also mirror

the greater burden of diabetes on elderly women

than on elderly men.

Published national findings on the use of ambulatory care services by minority elders with diabetes are

limited to blacks and are not sex-specific. Among

elderly persons who are in poor health or who have

diabetes, blacks have fewer physician contacts than

do whites.77,78 These data suggest that even though

the prevalence and impact of diabetes are greater

among elderly black women than among elderly

white women, the former are less intensive users of

ambulatory care services. Because elderly minority

women are at increased risk for many diabetic complications, further characterization of their access to

and use of primary medical care services is essential.

Provision of services. Because elderly persons with

diabetes are more likely to have concurrent illnesses,

sensory and functional deficits, and physical and

financial limitations in their ability to adhere to

treatment regimens, they may require more careful

attention and explanation from health care

providers than do younger diabetic patients.

However, at least one study has found that older

patients generally have shorter medical visits than

do middle-aged patients despite the more impaired

health status and greater number of medical problems of older patients.79 Thus, elderly patients with

diabetes may receive no more contact time with

health care providers than do younger diabetic

patients.

Elderly patients with diabetes may also receive less

aggressive care than do their younger counterparts.

In a study of adaptation to diabetes by persons in

four different age groups, the oldest adults (mean

age, 72 years) reported that they received the least

amount of diabetes instruction.80 In another study

of persons with type 2 diabetes, those aged 65 years

or older reported having been told to follow a diet,

exercise, and protect and inspect their feet less often

than did persons aged 45–64 years. This differential

may be due in part to clinicians being less concerned

about possible long-term complications among

older patients.81 However, because elderly women

have an excess risk for many of the short- and longterm complications of diabetes, active management

of their diabetes is very important.

A recent national survey examined the level of preventive and monitoring services received in 1994 by

fee-for-service Medicare beneficiaries (91% of

whom were aged 65 years or older) who had diabetes.82 Only 10.8% of the women received all the

services recommended by the American Diabetes

Association, and 10.9% received none of the preventive services recommended (Table 6-2).82,83 (Also

see Appendix E.) Receipt of preventive and monitoring services was similar among women and men,

but because women account for 60% of elderly persons who have diabetes, much larger numbers of

elderly women than men are likely to receive suboptimal diabetes care.
158

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

Barriers to and Motivations for Practicing Preventive

Self-Care

Among persons who have diabetes, noncompliance

with preventive self-care is highest among elderly

patients.32 Noncompliance may be due to deficits in

vision or hearing, arthritis, dementia, overly complicated medication regimens, lack of support from

other persons, inadequate income, or the patient’s

beliefs and attitudes concerning the disease and 

the likely effects of self-care behaviors. Of the few

studies that have examined the barriers to or motivations for practicing preventive self-care among

elderly persons with diabetes, none present findings

for elderly women specifically. However, unless otherwise noted, the findings from these are assumed

to hold true for both sexes.

Although no studies have addressed exercise initiation and adherence specifically among elderly persons with diabetes, research has demonstrated that

sources of motivation to exercise among the elderly

include access, enjoyment, social interaction, and

personal experience of the benefits, such as

improved health and quality of life.84 Tapping 

these motivations to exercise will be important in

convincing elderly women who have diabetes to

modify their existing physical activity patterns—

many of which are embedded in cultural and social

patterns that have been reinforced over a lifetime.84-88

Another study examined whether preventive selfcare affected the perceived quality of life of diabetic

persons aged 60–79 years who were monitoring their

blood glucose.89 The subjects did not find blood

glucose monitoring to be burdensome. They also

reported that modifying their diet negatively affected their quality of life more than did monitoring

their blood glucose or taking diabetes medications.

The Health Belief Model, an approach to understanding the barriers to and motivations for preventive self-care, was applied in a study of diabetic persons in four age groups, including a group aged 66

years or older.80 The study results indicated that the

perceived seriousness of diabetes increased with age,

yet the oldest persons were least concerned with the

potential health problems caused by the disease and

were least likely to perceive the benefits of exercise

and medication in controlling diabetes. Participants

aged 66 years or older were most likely to try to

take care of their health, try to follow medical

advice as closely as possible, and feel guilty when

they did things they knew were contrary to good

health. However, compared with persons in other

age groups, the eldest participants were not very

likely to worry about their own health.

Another study expanded on the Health Belief

Model to examine the associations between self-care

practices and the personal constructs (i.e., beliefs

about treatment effectiveness, the seriousness of the

disease and its impact, and the cause of the disease)

of persons aged 60 years or older with diabetes.90

The results showed that healthy diet and physical

activity among these participants were related not

only to sociodemographic and medical history variables but also to personal constructs about diabetes.

Belief in treatment effectiveness was the personal

construct most strongly related to healthy diet. In

addition, self-blame for diabetes was more likely to

negatively affect adherence to diet among women

than among men. Belief in treatment effectiveness

was the strongest predictor of physical activity and

had a stronger influence among women than

among men. Feeling personally responsible for

causing diabetes was also positively, but less strongly, related to physical activity among both sexes.

In addition to personal constructs, personality characteristics may influence a diabetic person’s adherence to self-care practices. A study of adults aged

65–80 years with diabetes found that hardiness

(defined as an adaptive personality style including

the qualities of control, commitment, and challenge) was significantly associated with adherence

to 24 self-care behaviors, including eating a healthy

diet, regularly exercising, practicing good personal

hygiene, and managing disease complications.91

Several researchers have investigated how elderly

persons with diabetes can be motivated to practice

preventive self-care. One such study examined the
The Older Years

159

effects of a 4-week telephone follow-up intervention

on the self-care knowledge, behaviors, and metabolic

control of a group of persons aged 65 years or older

who had completed an inpatient diabetes education

program.92 No significant differences in knowledge

or blood glucose levels were found between participants who received the intervention and those who

did not, but the former reported significantly more

self-care behaviors, such as self-monitoring blood

glucose and keeping records, modifying physical

activities, reporting symptoms, and seeking assistance from health care professionals.

Another study examined the effect of diabetes education and peer support on weight reduction and

glycemic control among older adults (mean age, 68.2

years) with diabetes.93 Study participants received diabetes education only, diabetes education and peer

support, or neither. Education focused on diabetes

and its nutritional aspects and was presented in eight

weekly sessions and follow-up sessions at 12 and 16

weeks. Participants who also received peer support

took part in group discussions led by a trained peer

support facilitator. Study participants who received

diabetes education and peer support had significantly

greater weight loss and glycemic control at 12 weeks

than participants who received education only or no

intervention. These findings suggest that diabetes

education programs that are accompanied by additional support may be most effective in helping elderly women comply with preventive self-care practices.

Although there is evidence that the information

and peer support provided through diabetes education programs can encourage preventive self-care,

some studies indicate that older adults with diabetes may not participate in such programs as frequently as younger persons with diabetes.62,63 Sex,

duration of diabetes, type of medication, and previous experience with diabetes education programs

did not affect participation rates. Apart from age,

the strongest predictor of participation was how

participants were recruited: those who decided

independently to join the program were twice as

likely to participate as those recruited by health care

providers, relatives, or friends.

These studies examined factors associated with 

elderly adults’ participation in diabetes education

programs, but they do not reveal the participants’

subjective perceptions of the features and processes

of such programs (e.g., format, relevance of the

information presented). Understanding how these

perceptions translate into barriers or motivations

for participation in diabetes education programs is

essential to maximizing participation by and benefit

to elderly women.

Traditional Beliefs

Traditional beliefs about disease causation and the

nature of control over health, along with folk medical practices associated with these beliefs, may be

important determinants of diabetes self-care practices among elderly women, particularly among

those who live in ethnic or rural communities or

who have limited access to conventional medical

care. Such culturally grounded religious beliefs

influence notions about the causes and care of diabetes. For example, one study of Hispanic adults

with diabetes found that 78% of participants stated

that they had diabetes because it was God’s will,

81% said that God controlled their diabetes, and

55% said that their priests helped them control

their disease.94 Six percent of the participants—all

of them older women—initially turned to God to

address a diabetic problem. Other prevalent traditional beliefs among the study participants were

that diabetes is caused by physiological imbalances

and can be treated with herbs.94

In contrast, a study of the influence of age on the

self-care practices of blacks with diabetes found that

those aged 60–77 years were more reliant on the

advice of physicians and other health professionals

and less interested in alternative methods of healing

than were those aged 45–59 years.95 The older study

participants used only biomedicine to control their

diabetes; none supplemented standard medical care

with traditional treatment, as the middle-aged persons did. The researchers speculated that this difference may be due to the greater prevalence of multiple chronic disease conditions and the perceived

seriousness of these diseases among the older study
Table 6-3. Age-associated factors affecting 

diabetes management in older 

women

Sensory changes

Decreased vision, hearing, smell

Altered taste perception

Difficulties in food preparation and consumption

Impaired manual dexterity 

Impaired mobility

Poor dentition

Alterations in gastrointestinal function

Effects of other chronic diseases

Increased frailty

Increased burden of medications management

Decreased exercise and mobility 

Cognitive and psychological problems

Depression

Cognitive impairment and dementia

Source: Reference 81.

160

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

participants. Nevertheless, many of these older

blacks expressed traditional beliefs about the causes

and management of diabetes, describing changes in

blood sugar levels as “raising” and “lowering” the

blood. The findings may thus also reflect the fact

that the study participants were drawn from an

urban diabetes clinic and thus had access to conventional medical care.

Public health practitioners need to be alert to such

beliefs and practices and acknowledge their potential to influence health-related behaviors as they

develop interventions and diabetes control programs targeted at older women.

6.6. Concurrent Illnesses as Determinants of

Health Behaviors and Health Outcomes

Management of diabetes in elderly women is affected by changes in sensory, physical, and psychological functioning related to aging and by impairments

resulting from diabetes complications (Table 6-3).

These alterations directly affect the ability of elderly

women who have diabetes to care for themselves.

Visual impairment can affect a person’s ability to

adequately inspect the feet, read markings on a

syringe, or administer an insulin injection.96 Indeed,

diabetic persons who have some degree of visual

impairment may have up to a 20% error rate in

drawing up their insulin.97 In addition, uncompensated hearing deficits among elderly persons can

prevent patient comprehension of and interaction

with health care providers who want to discuss selfcare with the diabetic patient.

The ability to intervene in the diet of elderly

women who have diabetes may be affected by several factors including altered perceptions of taste and

smell (which may result in changes in food preferences and diet) and poor dentition. One-quarter of

elderly American women are totally edentulous,98

and many have poorly fitting partial or complete

dentures that make chewing uncomfortable.99 In

addition, the decrease with age in the efficiency of

peristalsis can lead to problems with digestion,

absorption, and elimination that may be exacerbated in diabetic persons by autonomic neuropathy

involving the gastrointestinal tract.100 Thus, elderly

diabetic women who are edentulous or who have

gastrointestinal problems may substitute foods that

are easily chewed and digested for those appropriate

to a diabetic diet. Meal preparation (and other selfcare activities necessary for diabetes management)

can also be affected by chronic conditions that limit

manual dexterity and mobility, such as arthritis.101

All of these factors can put elderly persons at risk

for nutritional deficiencies; frail, anorectic elderly

persons who also try to follow extensive dietary

restrictions for diabetes may put themselves at further risk for nutritional deficiencies.101,102

Self-care by elderly women who have diabetes may

be affected by other comorbid conditions as well.

In particular, among elderly persons with diabetes,

the need to manage multiple medications for other

chronic conditions is a major cause of noncompliance with preventive self-care for diabetes and its

complications.32 In addition, elderly diabetic persons who have multiple chronic conditions are at
The Older Years

161

risk for problems associated with polypharmacy and

for adverse drug interactions.81

Acute and subacute problems related to hyperglycemia can exacerbate existing chronic

conditions.30 For example, high levels of blood glucose cause increased secretion of urine and excesive

urination at night, which can aggravate preexisting

urinary incontinence. The estimated prevalence of

urinary incontinence among noninstitutionalized

adults aged 60 years or over ranges from 15% to

30%; women are twice as likely as men to have this

problem.103 Incontinence can adversely affect the

quality of life for elderly women, as it is associated

with pressure sores among persons who have limited mobility, urinary tract infections, and use of

indwelling catheters, and it can create embarrassment and social isolation. This condition is also frequently a factor in the decision to institutionalize

an elderly person. Thus, the interaction of diabetes

with other commonly occurring chronic conditions

can affect a woman’s ability to manage diabetes as

well as her physical and psychosocial functioning.

Cognitive and psychological disorders can also

affect a person’s ability to manage diabetes.

Memory losses associated with cognitive impairment can result in overmedication or undermedication and in skipped meals,81 and persons who are

unable to retain new information may not adhere

to changed medications or self-care practices.30

Because persons with dementia may not sense

hunger or thirst, they may lose weight and become

dehydrated if they are not closely monitored.81

Depression can also produce self-neglect and irregular eating patterns. Through such alterations in

behavior, these cognitive and psychological disorders compromise the management and control of

diabetes and its complications.

6.7. Public Health Implications

Over the next 10 years, there will be a considerable

increase in the number of women aged 65 years or

older among the various racial/ethnic groups.

Because of the greater proportion of women in this

age group, there will be significantly more women

with diabetes than men. Better data and information are needed to fully assess the burden of disease

in this group. Family members, friends, and community-based organizations should be involved in

the process of collecting information on the elderly

population because they usually play a major role in

providing care and support. 

Assessment

The tremendous growth projected in the number of

women aged 65 years or older in the United States

over the next several decades—from 19.9 million in

1990 to 29.6 million in 2020—indicates a need to

collect, analyze, and disseminate timely and accurate information on elderly women. In particular,

data are needed

• To better characterize diabetes among women

aged 85 years or older.

• To estimate the prevalence and incidence of diabetes and its complications.

• To understand and monitor trends in racial and

ethnic populations.

• To measure health-related quality of life.

• To track diabetes-related behavioral risk factors,

knowledge, attitudes, and self-care practices

among elderly women with diabetes.

• To evaluate the range, patterns, and adequacy of

services available to elderly women, including

the patient’s functional and cognitive status,

concurrent illnesses, the number and type of

medications being used, and financial and social

situation; patterns of service use, including

ambulatory and inpatient care; and the views of

elderly women on the adequacy and accessibility

of existing programs and services.

Addressing the needs of elderly women with diabetes will help maximize the years of healthy life of
162

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

older Americans by achieving a number of national

health objectives for elderly adults. Achieving these

objectives can substantially improve diabetes care

for older women.

Policy Development

Population-based policies for elderly persons with

diabetes are needed to ensure and promote

• Reimbursement for diabetes education and supplies.

• Greater coordination of services in the broader

community, particularly because an increasing

number of elderly women with diabetes are at

risk for poverty and are more likely to live alone.

• Diabetes care that includes formal, multidimensional assessments of physical, emotional, and

social functioning of each patient to determine

whether barriers to self-care exist.

Assurance

Access to appropriate diabetes care and services

must be assured for elderly women with diabetes.

Transportation problems, insurance coverage for

preventive care, and language and cultural barriers

need to be considered. Diabetes care and education

should be tailored to the holistic needs of elderly

women.
The Older Years

163

References

1. American Diabetes Association. Report of the Expert

Committee on the diagnosis and classification of diabetes mellitus. Diabetes Care 1997;20(7):1183–97.

2. Harris MI, Flegal KM, Cowie CC, et al. Prevalence of

diabetes, impaired fasting glucose, and impaired glucose

tolerance in U.S. adults. The Third National Health and

Nutrition Examination Survey, 1988–1994. Diabetes

Care 1998;21(4):518–24.

3. CDC. Trends in the prevalence and incidence of selfreported diabetes mellitus—United States, 1980–1994.

MMWR 1997;46(43):1014–8.

4. Kenny SJ, Aubert RE, Geiss LS. Prevalence and incidence of non–insulin-dependent diabetes. In: National

Diabetes Data Group, editors. Diabetes in America. 2nd

ed. Bethesda, MD: National Institutes of Health, 1995:

47–67. (NIH Publication No. 95-1468)

5. Centers for Disease Control and Prevention. Diabetes

Surveillance, 1997. Atlanta: U.S. Department of Health

and Human Services, 1997.

6. Leibson CL, O’Brien PC, Atkinson E, Palumbo PJ,

Melton LJ III. Relative contributions of incidence and

survival to increasing prevalence of adult-onset diabetes

mellitus: a population-based study. Am J Epidemiol

1997;146(1):12–22.

7. Colditz GA, Willet WC, Stampfer MJ, et al. Weight as a

risk factor for clinical diabetes in women. Am J

Epidemiol 1990;132(3):501–13.

8. Ford ES, Williamson DF, Liu S. Weight change and diabetes incidence: findings from a national cohort of U.S.

adults. Am J Epidemiol 1997;146(3):214–22.

9. Manson JE, Rimm EB, Stampfer MJ, et al. Physical

activity and incidence of non–insulin-dependent diabetes mellitus in women. Lancet 1991;338(8770):774–8.

10. Kuczmarski RJ, Flegal KM, Campbell SM, Johnson CL.

Increasing prevalence of overweight among U.S. adults:

the National Health and Nutrition Examination

Surveys, 1960 to 1991. JAMA 1994;272(3):205–11.

11. Crespo CJ, Keteyian SJ, Heath GW, Sempos CT.

Leisure-time physical activity among U.S. adults: results

from the Third National Health and Nutrition

Examination Survey. Arch Intern Med 1996;156(1):93–8.

12. Gu K, Cowie CC, Harris MI. Mortality in adults with

and without diabetes in a national cohort of the U.S. population, 1971–1993. Diabetes Care 1998;21(7):1138–45.

13. Moritz DJ, Ostfeld AM, Blazer D, Curb D, Taylor JO,

Wallace RB. The health burden of diabetes for the elderly

in four communities. Public Health Rep 1994;109:782–90. 

14. Cowie CC, Eberhardt MS. Sociodemographic characteristics of persons with diabetes. In: National Diabetes

Data Group, editors. Diabetes in America. 2nd ed.

Bethesda, MD: National Institutes of Health,

1995:85–116. (NIH Publication No. 95-1468)

15. Carter JS, Pugh JA, Monterrosa A. Non–insulindependent diabetes mellitus in minorities in the United

States. Ann Intern Med 1996;125(3):221–32.

16. Ellis JL, Campos-Outcalt D. Cardiovascular disease risk

factors in Native Americans: a literature review. Am J

Prev Med 1994;10(5):295–307.

17. CDC. Prevalence of diagnosed diabetes among

American Indians/Alaskan Natives—United States,

1996. MMWR 1998;47(42):

901–4.

18. Will JC, Strauss KF, Mendlein JM, Ballew C, White LL,

Peter DG. Diabetes mellitus among Navajo Indians:

findings from the Navajo Health and Nutrition

Examination Survey. J Nutr 1997;127(10 Suppl):

2106S–2113S.

19. Lee ET, Howard BV, Savage PJ, et al. Diabetes and

impaired glucose tolerance in three American Indian

populations aged 45–74 years: the Strong Heart Study.

Diabetes Care 1995;18(5):599–610.

20. Fujimoto WY. Diabetes in Asian and Pacific Islander

Americans. In: National Diabetes Data Group, editors.

Diabetes in America. 2nd ed. Bethesda, MD: National

Institutes of Health, 1995:661–77. (NIH Publication

No. 95-1468)

21. Flegal KM, Ezzati TM, Harris MI, et al. Prevalence of diabetes in Mexican Americans, Cubans, and Puerto Ricans

from the Hispanic Health and Nutrition Examination

Survey, 1982–1984. Diabetes Care 1991;14(7):628–38.

22. Johnson A, Taylor A. Prevalence of Chronic Diseases: A

Summary of Data from the Survey of American Indians

and Alaska Natives. Rockville, MD: Public Health

Service, 1991. (AHCPR Publication No. 91-0031)
164

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

23. CDC. Self-reported prevalence of diabetes among

Hispanics—United States, 1994–1997. MMWR

1999;48(1):8–12.

24. Costello C, Stone AJ, editors. The American Woman

1994–95: Where We Stand. New York: W.W. Norton &

Company, Inc., 1994.

25. O’Hare WP. A new look at poverty in America. Popul

Bull 1996;51(2):1–48.

26. Bild DE, Stevenson JM. Frequency of recording of diabetes on U.S. death certificates: analysis of the 1986

National Mortality Followback Survey. J Clin Epidemiol

1992;45(3):275–81.

27. Gu K, Cowie CC, Harris MI. Diabetes and decline in

heart disease mortality in U.S. adults. JAMA 1999;

281(14):1291–7.

28. Espino DV, Parra EO, Kriehbiel R. Mortality differences

between elderly Mexican Americans and non-Hispanic

whites in San Antonio, Texas. J Am Geriatr Soc 1994;

42(6):604–8.

29. Aubert RE, Geiss LS, Ballard DJ, Cocanougher B,

Herman WH. Diabetes-related hospitalization and hospital utilization. In: National Diabetes Data Group, editors. Diabetes in America. 2nd ed. Bethesda, MD:

National Institutes of Health, 1995:553–69. (NIH

Publication No. 95-1468)

30. Morley JE, Kaiser FE. Unique aspects of diabetes mellitus in the elderly. Clin Geriatr Med 1990;6(4):693–702.

31. Morley JE, Mooradian AD, Rosenthal MJ, Kaiser FE.

Diabetes mellitus in elderly patients: is it different? Am J

Med 1987;83(3):533–44.

32. Minaker KL. What diabetologists should know about

elderly patients. Diabetes Care 1990;13(Suppl 2):34–46.

33. Naliboff BD, Rosenthal M. Effects of age on complications in adult-onset diabetes. J Am Geriatr Soc 1989;

37(9):838–42.

34. Cooper RS, Pacold IV, Ford ES. Age-related differences

in case-fatality rates among diabetic patients with

myocardial infarction: findings from the National

Hospital Discharge Survey, 1979–1987. Diabetes Care

1991;14(10):903–8.

35. Palumbo PJ, Melton, LJ. Peripheral vascular disease and

diabetes. In: National Diabetes Data Group, editors.

Diabetes in America. 2nd ed. Bethesda, MD: National

Institutes of Health, 1995:401–8. (NIH Publication No.

95-1468) 

36. Neil HA, Thompson AV, Thorogood M, Fowler GH,

Mann JI. Diabetes in the elderly: the Oxford

Community Diabetes Study. Diabet Med 1989;

6(7):608–13.

37. Walters DP, Gatling W, Mullee MA, Hill RD. The distribution and severity of diabetic foot disease: a community study with comparison to a non-diabetic group.

Diabet Med 1992;9(4):354–8.

38. Bild DE, Selby JV, Sinnock P, Browner WS, Bravemen

P, Showstack JA. Lower-extremity amputation in people

with diabetes: epidemiology and prevention. Diabetes

Care 1989;12(1):24–31.

39. King H, Aubert RE, Herman WH. Global burden of

diabetes, 1995–2025: prevalence, numerical estimates,

and projections. Diabetes Care 1998;21(9):1414–31.

40. Neil HA, Dawson JA, Baker JE. Risk of hypothermia in

elderly patients with diabetes. Br Med J (Clin Res Ed)

1986;293(6544):416–8.

41. Klein BE, Klein R. Ocular problems in older Americans

with diabetes. Clin Geriatr Med 1990;6(4):827–37.

42. Robertson-Tchabo EA, Arenberg D, Tobib JD, Plotz JB.

A longitudinal study of cognitive performance in non–

insulin-dependent (type II) diabetic men. Expl Gerontol

1986;21(4–5):459–67.

43. Scott RD, Kritz-Silverstein D, Barrett-Connor E,

Wiederholt WC. The association of non–insulindependent diabetes mellitus and cognitive function in

an older cohort. J Am Geriatr Soc 1998;46(10):1217–22.

44. Tun PA, Nathan DM, Perlmuter LC. Cognitive and

affective disorders in elderly diabetics. Clin Geriatr Med

1990;6(4):731–46.

45. U’Ren RC, Riddle MC, Lezak MD, Bennington-Davis

M. The mental efficiency of the elderly person with type

II diabetes mellitus. J Am Geriatr Soc 1990;38(5):505–10.

46. Gavard JA, Lustman PJ, Clouse RE. Prevalence of

depression in adults with diabetes: an epidemiological

evaluation. Diabetes Care 1993;16(8):1167–78.
The Older Years

165

47. Peyrot M, Rubin RR. Levels and risks of depression and

anxiety symptomatology among diabetic adults. Diabetes

Care 1997;20(4):585–90.

48. Anthony JC, Aboraya A. The epidemiology of selected

mental disorders in later life. In: Birren JE, Sloane RB,

Cohen GC, editors. Handbook of Mental Health and

Aging. 2nd ed. San Diego, CA: Academic Press, 1992:

27–73.

49. U.S. Public Health Service. Health Data on Older

Americans: United States, 1992. Hyattsville, MD:

National Center for Health Statistics, 1993. (DHHS

Publication No. PHS 93-1411)

50. Pinsky JL, Branch LG, Jette AM, et al. Framingham

Disability Study: relationship of disability to cardiovascular risk factors among persons free of diagnosed cardiovascular disease. Am J Epidemiol 1985;122(4):644–56.

51. Klein BE, Klein R, Moss SE. Self-rated health and diabetes of long duration: the Wisconsin Epidemiologic

Study of Diabetic Retinopathy. Diabetes Care 1998;

21(2):236–40.

52. Songer TJ. Disability in diabetes. In: National Diabetes

Data Group, editors. Diabetes in America. 2nd ed.

Bethesda, MD: National Institutes of Health, 1995:

259–82. (NIH Publication No. 95-1468)

53. Zhang J, Markides KS, Lee DJ. Health status of diabetic

Mexican Americans: results from the Hispanic HANES.

Ethn Dis 1991;1(3):273–9.

54. Schoenborn CA. Health Promotion and Disease

Prevention: United States, 1985. Vital and Health

Statistics. Hyattsville, MD: National Center for Health

Statistics, U.S. Government Printing Office, 1988. Series

10, No. 163. (DHHS Publication No. PHS 88-1591)

55. O’Brien SJ, Vertinsky PA. Unfit survivors: exercise as a

resource for aging women. Gerontologist 1991;31(3):

347–57.

56. U.S. Department of Health and Human Services.

Physical Activity and Health: A Report to the Surgeon

General. Atlanta: U.S. Department of Health and

Human Services, Centers for Disease Control and

Prevention, National Center for Chronic Disease

Prevention and Health Promotion, 1996.

57. Harris MI. Epidemiology of diabetes mellitus among the

elderly in the United States. Clin Geriatr Med 1990;

6(4):703–19.

58. Institute of Medicine. The Second Fifty Years: Promoting

Health and Preventing Disability. Washington, DC:

National Academy Press, 1990.

59. Fertig BJ, Simmons DA, Martin DB. Therapy for diabetes. In: National Diabetes Data Group, editors.

Diabetes in America. 2nd ed. Bethesda, MD: National

Institutes of Health, 1995:519–40. (NIH Publication

No. 95-1468)

60. Glasgow RE, Toobert DJ, Hampson SE, Brown JE,

Lewinsohn PM, Donnelly J. Improving self-care among

older patients with type II diabetes: the “Sixty Something...” study. Patient Educ Counsel 1992; 19(1):61–74.

61. Rubin RR, Peyrot M, Saudek CD. Effect of diabetes

education on self-care, metabolic control, and emotional

well-being. Diabetes Care 1989;12(10):673–9.

62. Hiss RG, editor. Diabetes in Communities. Ann Arbor,

MI: University of Michigan, Michigan Diabetes

Research and Training Center, 1986.

63. Glasgow RE, Toobert DJ, Hampson SE. Participation in

outpatient diabetes education programs: how many

patients take part and how representative are they?

Diabetes Educ 1991;17(5):376–80.

64. Lin N. Conceptualizing social support. In: Lin N, Dean

A, Ensel W, editors. Social Support, Life Events, and

Depression. San Diego, CA: Academic Press, 1986:17–30.

65. Ferraro KF. Widowhood and health. In: Markides KS,

Cooper CL, editors. Aging, Stress, and Health. New York:

Wiley, 1989:69–89.

66. Anderson LA, Halter JB. Diabetes care in older adults:

current issues in management and research. In: Lawton

MP, editor. Annual Review of Gerontology and Geriatrics.

New York: Springer, 1989.

67. Bailey BJ, Kahn A. Apportioning illness management

authority: how diabetic individuals evaluate and respond

to spousal help. Qual Health Res 1993;3(1):55–73.

68. Silliman RA, Bhatti S, Khan A, Dukes KA, Sullivan

LM. The care of older persons with diabetes mellitus:

families and primary care physicians. J Am Geriatr Soc

1996;44(11):1314–21.

69. Rewers M, Hamman RF. Risk factors for non–insulindependent diabetes. In: National Diabetes Data Group,

editors. Diabetes in America. 2nd ed. Bethesda, MD:

National Institutes of Health, 1995:179–220. (NIH

Publication No. 95-1468)
166

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

70. Ben-Sira Z. Regression, Stress, and Readjustment in Aging:

A Structured Bio-Psychosocial Perspective on Coping and

Professional Support. New York: Praeger, 1991.

71. Christensen S, Long SH, Rodgers J. Acute health care

costs for the aged Medicare population: overview and

policy options. Milbank Q 1987;65(3):397–425.

72. Harris MI. Health insurance and diabetes. In: National

Diabetes Data Group, editors. Diabetes in America. 2nd

ed. Bethesda, MD: National Institutes of Health,

1995:591–600. (NIH Publication No. 95-1468)

73. U.S. Bureau of the Census. Statistical Abstract of the

United States: 1997. 117th ed. Washington, DC: U.S.

Government Printing Office, 1997.

74. U.S. Department of Health and Human Services.

Health Care Financing Review: Medicare and Medicaid

Statistical Supplement, 1997. Baltimore, MD: Health

Care Financing Administration, 1997. (Publication No.

03399)

75. Peddicord M, Lyons A, Tobin C, Vinicor F. Third-party

reimbursement for diabetes mellitus. Diabetes Spectrum

1989;3:9–12.

76. American Diabetes Association. <http://www.diabetes.

org/advocacy/states.asp> Last accessed January 12, 2001.

77. Janes GR. Ambulatory medical care for diabetes. In:

National Diabetes Data Group, editors. Diabetes in

America. 2nd ed. Bethesda, MD: National Institutes of

Health, 1995:541–52. (NIH Publication No. 95-1468)

78. U.S. Public Health Service. Health of Black and White

Americans. Hyattsville, MD: National Center for Health

Statistics, 1990.

79. Keeler EB, Solomon DH, Beck JC, Mendenhall RC,

Kane RL. Effects of patient age on duration of medical

encounters with physicians. Med Care 1982;20(11):

1101–8.

80. Jenny JL. A comparison of four age groups’ adaptation

to diabetes. Can J Public Health 1984;75(3):237–44.

81. Lipson LG. Diabetes in the elderly: diagnosis, pathogenesis, and therapy. Am J Med 1986;80(5A):10–21. Data

used with permission from publisher.

82. U.S. Department of Health and Human Services.

Medicare Diabetes Care. Washington, DC: Health,

Education, and Human Services Division, 1997.

(GAO/HEHS Publication No. 97-48)

83. American Diabetes Association. Clinical practice recommendations, 1997. Diabetes Care 1997;20(Suppl 1):

51–70.

84. Sharon B, Hennessy CH, Brandon LJ, Boyette LW.

Older adults’ experiences of a strength training program.

J Nutr Health Aging 1997;2:103–8.

85. Graham C. Exercise and aging: implications for persons

with diabetes. Diabetes Educ 1991;17(3):189–95.

86. Hopper SV. Meeting the needs of the economically

deprived diabetic. Nurs Clin North Am 1983;18(4):

813–25.

87. Lang GC. “Making sense” about diabetes: Dakota narratives of illness. Med Anthropol 1989;11(3):305–27.

88. Mezitis NH, Pi-Sunyer FX. Dietary management of

geriatric diabetes. Geriatrics 1989;44(12):70–2, 75–8.

89. Gilden JL, Casia C, Hendryx M, Singh SP. Effects of

self-monitoring of blood glucose on quality of life in

elderly diabetic patients. J Am Geriatr Soc 1990;38(5):

511–5.

90. Hampson SE, Glasgow RE, Foster LS. Personal models

of diabetes among older adults: relationship to self-management and other variables. Diabetes Educ 1995;21(4):

300–7.

91. Ross ME. Hardiness and compliance in elderly patients

with diabetes. Diabetes Educ 1991;17(5):372–5.

92. Tu KS, McDaniel G, Gay JT. Diabetes self-care knowledge, behaviors, and metabolic control of older adults—

the effect of a post-educational follow-up program.

Diabetes Educ 1993;19(1):25–30.

93. Wilson W, Pratt C. The impact of diabetes education

and peer support upon weight and glycemic control of

elderly persons with non–insulin-dependent diabetes

mellitus (NIDDM). Am J Public Health 1987;77(5):

634–5.

94. Zaldivar A, Smolowitz J. Perceptions of the importance

placed on religion and folk medicine by non-Mexican

American Hispanic adults with diabetes. Diabetes Educ

1994;20(4):303–6.

95. Reid BV. “It’s like you’re down on a bed of affliction:”

Aging and diabetes among black Americans. Soc Sci

Med 1992;34(12):1317–23.
The Older Years

167

96. Dellasega C. Self-care for the elderly diabetic. J Gerontol

Nurs 1990;16(1):16–20.

97. Kesson CM, Bailie GR. Do diabetic patients inject accurate doses of insulin? Diabetes Care 1981;4(2):333–7.

98. CDC. Total tooth loss in persons aged 65 years—selected states, 1995–1997. MMWR 1999;48(2):206–10.

99. Ship JA, Duffy V, Jones JA, Langmore S. Geriatric oral

health and its impact on eating. J Am Geriatr Soc 1996;

44(4):456–64.

100. Marchesseault LC. Diabetes and the elderly. Nurs Clin

North Am 1983;18(4):791–8.

101. Palmer CF. Special issues in the management of the elderly patient with diabetes. Mt Sinai J Med 1991;58(4):

287–92.

102. Nickols-Richardson SM, Johnson MA, Poon LW,

Martin P. Mental health and number of illnesses are 

predictors of nutritional risk in elderly persons. Exp

Aging Res 1996;22(2):141–54.

103. Diokno AC, Brock BM, Brown MB, Herzog AR.

Prevalence of urinary incontinence and other urological

symptoms in the noninstitutionalized elderly. J Urol

1986;136(5):1022–5.

169

7

MAJOR FINDINGS, PUBLIC HEALTH IMPLICATIONS,

AND CONCLUSIONS

P.E. Thompson-Reid, MAT, MPH, G.L.A. Beckles, MBBS, MSc

The findings presented in chapters 2–6 reinforce

criteria put forth in a report by the U.S. Public

Health Service Task Force on Women’s Health

Issues1 and establish that diabetes is indeed a

women’s health issue. We used well-defined stages

in the development of women’s lives—the adolescent years, the reproductive years, the middle years,

and the older years—to examine the effect of diabetes on the health of women. This approach was

chosen for two reasons: first, to gain insight into

the features of the social and environmental context

in which women live that may constitute barriers to

maintaining and improving the health status of

women in general and, second, to examine whether

this impact varies across the life stages of women

with diabetes. Within this framework, specific and

particular attention has been paid to the influence

of psychosocial, socioeconomic, and environmental

factors on the health behaviors and health outcomes of women with diabetes. Many of these factors are known to impair the abilities of all women,

with or without diabetes, to maintain their health

and to care for themselves when they are ill.

In general, we found that diabetes poses great challenges for women, and the risk factors for the disease are growing in such epidemic proportions that

if we do not act soon, the problem will be even

larger in the years ahead.

This final chapter presents major findings affecting

all women, with particular implications for women

with diabetes, and the public health implications

for women with diabetes across the life stages.

7.1 Major Findings

Feminization of Old Age

There is a large proportion of women aged 65

years or older in the U.S. population and an

increasing tendency for these women to be living

alone when they are more likely to be frail and vulnerable. The number of women aged 65 years or

older is expected to grow from approximately 

20 million in 1995 to 23 million in 2010.

Futhermore, the number of women aged 85 or

older is projected to increase from 2.6 million in

1995 to approximately 4 million in 2010. Women

live an average of 7 years longer than men, and

among adults aged 75 years or older, there are

nearly twice as many women as men. This difference in longevity accounts in part for the increasing tendency for women to live alone. Women

with diabetes have lower life expectancy than

women without diabetes; however, the median life

expectancy of women with diabetes is still greater

than that of men with diabetes.

Risk of Poverty

Studies have shown that indicators of social class

(e.g., income, education) are associated with type 2

diabetes. In absolute terms, it is important to note

that increasing numbers of women are at risk for

poverty. In 1995, an estimated 13.5 million

American women were living in poverty, accounting for 3 of 5 poor adults aged 18 years or older.

The risk of being poor is greatest for women of

childbearing age and elderly women. By age 65,

women are twice as likely as men to be poor.
170

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

Trends in Employment

Approximately 3 of 5 women aged 15 years or

older participate in the labor force. Many of these

women experience discontinuous employment

because of family responsibilities and tend to work

in small companies that provide fewer benefits and

lower pay than larger companies. Because the

majority of women in the work force are of reproductive age, they are at risk for gestational as well

as type 2 diabetes. There is also an increasing trend

among women 65 years or older to remain in the

labor force. Women with diabetes or other chronic

conditions may work under circumstances that

impede self-management and access to health care.

Inadequate Medical Insurance Coverage

Approximately 1 in 7 women are uninsured; 30%

of these women are poor, and an additional 10%

are nearly poor. Because of variations in eligibility

for Medicaid from state to state, many of these

women may not have access to health care.

Medicare provides insurance for acute illness or

hospitalization for persons 65 or older; however, for

persons with chronic diseases such as diabetes, this

type of coverage is not sufficient for recipients to

gain access to quality diabetes care or to adhere to

recommended preventive care practices.2,3

Increasing Overweight and Lack of Physical Activity

Overweight and lack of physical activity are risk

factors for type 2 diabetes. In 1994, approximately

36 million female adolescents and women were

overweight: 10% of adolescents aged 12–17 years,

20% of women aged 18–19 years, and 36% of

women aged 20 years or older. Increasing trends in

weight among women are steepest for the heaviest

and youngest women. In particular, overweight

adolescent girls are more likely to become overweight women than their peers who are not overweight. Three of 5 American women do not

exercise regularly. School-aged female adolescents,

female college students, and women are likely to

engage in less physical activity as they age.

Specific Groups of Women

Issues common to specific groups of women that

could potentially increase the burden of diabetes are

• The expected increase in the number of women

in racial and ethnic minority populations (from

35.5 million in 1995 to 50.2 million in 2010).

• Increasing diagnosis of type 2 diabetes among

adolescent black, American Indian, and Hispanic

girls, which may presage a steeper rise than

expected in the number of adolescent girls with

diabetes in future years.

• The persisting racial and ethnic disparities in

health status and access to adequate health care.

• The impact of immigration and acculturation on

the diabetogenic risk profile of adolescent girls

and women.

• The lack of access to adequate health care for

women in rural areas, notably women of childbearing age and elderly women.

7.2 Public Health Implications

The mission of public health is to “fulfill society’s

interest in assuring conditions in which people can

be healthy.”4 Healthy People 2010,

5 sets national

goals to address health disparities that exist among

Americans. In exercising its charge, the public

health community recognizes that health disparities

are expressed in a context that is influenced by

social, environmental, and behavioral determinants,

many of which are not clearly understood.

Furthermore, in many instances, public health has

no mandate to act to ameliorate some of these disparities. The health sector should acknowledge the

need for research that will identify the underlying

determinants of racial, ethnic, and sex disparities

and should collaborate with local communities and

with other sectors to develop, implement, and evaluate interventions for achieving community and

national goals.
Public Health Implications

171

The role of public health is defined by three core

functions: assessment, policy development, and

assurance.2 Public health agencies systematically collect, analyze, and disseminate information on the

health status of the population. When assessment is

ongoing and the data are used in the planning,

implementation, and evaluation of public health

activities, it is classified as surveillance. When the

data collection is designed to develop or to generate

new knowledge that can be applied more generally,

the activity is defined as research. The data obtained

from assessment activities provide the basis for the

formulation of public health policy. Finally, to

implement policy, it is essential that public health

agencies assure that the regulations and services

needed to achieve agreed upon public health goals

are in place and accessible. These functions are

operationally defined at the state and local levels

through the work of local health departments and

other public, nonprofit, and private organizations

that share common goals.

The following section summarizes the public health

implications of diabetes in women based on findings presented in chapters 2–6. These implications

are organized by the three core public health functions: assessment, policy development, and assurance.

Assessment

Surveillance.

Population dynamics indicate that the

greatest growth in the female population

is expected among elderly women and

among racial and ethnic minority groups

at high risk for diabetes.

We need a protocol for systematic surveillance of

these groups at the national and state levels.

Particular emphasis should be given to analyzing

and reporting data on health-related behaviors,

morbidity, and mortality by the socioeconomic status of women.

The majority of the white population is

dispersed relatively evenly across the

United States, although racial and ethnic

minority populations are concentrated in

specific geographic areas, determined by

their history and migration patterns.

Surveillance systems could take advantage of the

regional concentrations of specific ethnic groups at

risk for diabetes. In addition, the number of foreign-born women is increasing regionally. Emphasis

should be given to the analysis and reporting of

data on health-related behaviors, morbidity, and

mortality by region, duration and generation of residence in the United States, and degree of acculturation. This approach would provide additional

information to guide the development of policy

and the allocation of resources for interventions targeting women in high-risk populations.

Adolescent girls, young women, and elderly women constitute high-risk groups

for diabetes because of poor dietary

habits, low levels of physical activity, and

increasing overweight, obesity, and

weight gain.

Because of the continuing increase in risks associated with diabetes in these groups, opportunities to

systematically monitor diabetes-related health

behaviors (e.g., eating disorders) should be undertaken. Particular attention should be paid to adolescent girls and elderly women, notably women aged

85 years or older.

Preliminary evidence suggests that the

prevalence of type 2 diabetes is increasing among adolescents and reproductiveaged women, especially in minority

women.

Additional surveillance information is required to

confirm these initial observations and to inform

programmatic activities.
172

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

Diabetes during pregnancy is a serious

condition that affects not only the health

of the mother but also of the unborn

child. If not addressed appropriately, this

condition will add to the future burden

of diabetes as well as of other chronic

diseases.

Surveillance systems should be developed to monitor the prevalence of gestational diabetes and differentiate between gestational and preexisting diabetes,

especially in high-risk groups.

Women younger than 65 years of age

who are at high risk of developing diabetes are the least likely to have adequate

access to preventive health care services.

Access to and use of ambulatory diabetes-related

preventive care services need to be assessed and routinely monitored, and the resulting data should be

analyzed and reported for all high-risk groups of

women. This information is important for the planning, promotion, and delivery of these services.

Women aged 85 years or older are the

fastest growing group in the female population. They are expected to number 

3.9 million in 2010 and to almost double

to 7.3 million by 2020.

Because of the projected increase in the number of

women in this age group, national surveillance will

be needed to assess and monitor trends in behavioral risk factors for diabetes and other chronic diseases, the use of clinical preventive services, and

health-related quality of life. Oversampling and special surveys may be necessary to obtain reliable estimates for these subpopulations.

Research.

The gradient of risk for diabetes and

related health burden associated with

socioeconomic status, geographic region,

area of residence, and place of birth is

often greater than the risk gradients related to the traditionally used markers of

age and race/ethnicity.

We need to define and develop a consensus on valid

indicators of social status and social context appropriate for use in the surveillance of the health status

of various subgroups of women with or without

diabetes in the United States and its territories. For

example, blacks born in the South suffer poorer

health than blacks born in other parts of the country. Additional information is needed to identify

the determinants of excess risk for diabetes and its

complications.

The role and impact of environmental

factors such as availability of nutritious

foods, safe neighborhoods, social policy,

social context, and individual susceptibility on the development of diabetes are

not well established.

We need epidemiologic and health services research

to gain a better understanding of the interaction

between the social and economic environment and

individual characteristics to determine the effect of

these variables on the incidence of diabetes.

Deterioration in the health status of

immigrant females is associated with the

adoption of behaviors that increase their

risk for diabetes.

Research is needed to identify protective health

behaviors among immigrant groups and to develop

intervention strategies to preserve these behaviors.

Such findings may be useful for risk reduction

among other population groups.

Physical inactivity is an independent risk

factor for the development of diabetes.

The level of inactivity is high among all

women aged 20 years or older, especially

in racial and ethnic minority populations, and the level of physical activity

among adolescents decreases rapidly with

age.

Regular physical activity has many health benefits

for female adolescents and women. Additional studies are needed to identify modifiable individual and

structural barriers to physical activity among
Public Health Implications

173

school-aged girls and to identify and assess the

effectiveness of preferred types of physical activity

for women in various age, cultural, and socioeconomic groups.

Overweight and obesity are major risk

factors for the development of type 2 diabetes in middle-aged women.

More intensive study is needed to determine the

contribution of cumulative gestational weight gain

to overweight among middle-aged women and to

identify the psychosocial and socioenvironmental

factors that contribute to weight gain so that appropriate prevention strategies can be designed.

Women with diabetes are at greater risk

for heart disease, and especially first fatal

events, than men and women without

diabetes.

More research is needed to gain a better understanding of the excess risk of coronary heart disease

(CHD) among women with diabetes and to identify modifiable determinants of this sex differential

for use in the development of effective interventions. To assess the risk-benefit ratio of aspirin treatment among diabetic women, adequate numbers of

women with diabetes must be included in clinical

trials of aspirin use for the primary prevention of

myocardial infarction. Clinical trial data are also

needed to determine the balance of benefits and

risks of hormone replacement therapy (HRT) in

diabetic women. Adequate numbers of women with

diabetes should also be included in clinical trials of

HRT because they may derive greater benefit from

HRT than women at low risk for cardiovascular disease. More data are needed to determine if antioxidant or vitamin use or other potentially promising

new interventions will reduce CHD in women with

diabetes.

Studies document a high prevalence of

depression and other mental illness

among women with diabetes.

More research is needed to clarify the relationship

between diabetes and depression in women.

Findings from various studies are contradictory. For

example, some studies show that the onset of

depression usually precedes the diagnosis of type 2

diabetes but follows the diagnosis of type 1 diabetes.

Elderly women have a higher prevalence

of diabetes complications and concurrent

illnesses than other women with diabetes

because of the aging process and uncontrolled glycemia.

More epidemiologic research is needed to define

the natural history of diabetes in elderly women.

Research is needed to distinguish between outcomes resulting from aging and other comorbidities. In addition, current guidelines for diabetes

control may not be appropriate for disease management among elderly persons.

Elderly women with diabetes are at high

risk for poverty, are likely to live alone,

and suffer disproportionately from the

complications of diabetes.

The barriers to self-management of diabetes and

other chronic diseases among elderly women need

to be assessed at the community level, and the

modifiable determinants of such barriers need to be

identified to provide data for the development of

appropriate interventions.

Women with diabetes use health services

more often than men do.

In general, the health-seeking behaviors of women

indicate more frequent office visits than men, yet

women with diabetes do not fare as well with the

disease as men with diabetes. Additional research is

needed to elucidate the relationship between access

to care, health-seeking behaviors, and hospital

admission and readmission rates among women

with diabetes.

Despite remarkable advances in our scientific understanding of basic disease

processes, including diabetes, there is a

significant gap between our knowledge

base and what is actually provided to

individuals for the prevention and care of

diabetes.
174

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

As delineated by the Institute of Medicine,6 the

health care systems in the United States must be

“redesigned” to reflect the realities and needs of

chronic diseases like diabetes. Translational/effectiveness studies for diabetes prevention and control

are important activities that will inform the process

for improving the quality of care provided to persons with diabetes.7

There is a growing number of persons

with diabetes in racial and ethnic minority populations, yet health care providers

from these populations are underrepresented.

Studies show that members of racial and ethnic

minority populations are more satisfied with health

care providers of similar ethnic or cultural backgrounds. Training in cultural competency should be

required for all providers, especially those serving

populations with which they have little familiarity.

Given the diversity of the U.S. population, health

care providers should be able to communicate in

the languages of the populations they serve, or suitable arrangements should be made to facilitate

communication. Opportunities should also be provided to train minority health professionals, including health educators, scientists, and medical

personnel. Additional research is needed to determine the effects of these strategies on the delivery

of quality diabetes care.

Sex, ethnicity, socioeconomic status, and

women’s multiple roles are important

variables that affect women’s health.

As more women enter the work force and take on

multiple roles, more studies are needed to elucidate

the changing relationship between sex, ethnicity,

socioeconomic status, social support, and the

impact of these variables on health status, particularly among women with diabetes.

Policy Development

The prevalence of overweight and the

incidence of obesity are increasing rapidly among adolescent girls, and these girls

appear to have an increasing risk of

developing type 2 diabetes.

To make an impact on this public health issue and

potential public health problem, women’s health

advocates and health and education agencies at the

federal, state, and local levels should continue to

strengthen and expand their collaboration and

efforts to develop and implement programs

designed to

• Ensure that foods available in schools comply

with federal recommendations for healthy diets.

• Increase the incorporation of physical activity

programs throughout the entire school and

home life of adolescents, especially girls.

• Integrate information about the lifelong benefits

of physical activity, healthy eating, and other

preventive health behaviors into school curricula

in all grades.

Women at high risk for diabetes are least

likely to have adequate health insurance

coverage.

Health insurance coverage should focus on the provision of access to optimal preventive care for

women with diabetes and other chronic diseases in

all age and racial/ethnic groups. Specific attention

to adolescents, women less than 65 years of age,

and poor and nearly poor women of all age and

racial/ethnic groups should be considered. This

strategy may help to reduce the growing disparities

in health outcomes among persons with diabetes.

An increasing number of elderly women

with diabetes are at risk for poverty and

are more likely to live alone.

Access to medical care will not address all the selfmanagement needs of elderly women with diabetes.

Strategies that involve interagency collaboration

should be explored because they may be helpful in

the planning and delivery of community-based

services that specifically target the needs of the

increasing numbers of elderly women with diabetes

who live alone, often in poverty.
Public Health Implications

175

Because of the expected growth in the

elderly population, the demand for diabetes-related services will increase nationwide.

Resources need to be allocated to train health care

professionals qualified in the diagnosis and management of diabetes in elderly persons.

Assurance

Sex-related differences in health communications and health-seeking behaviors

should be considered in the planning and

delivery of services for women with diabetes.

Protocols need to be developed to assure delivery of

quality care for women to enhance the appropriate

use of resources for improving health outcomes.

This approach may entail designing innovative

models of health care delivery that are responsive to

the needs of women (e.g., extended hours, culturally competent providers, continuous access to preventive care services such as health education and

self-management training). Women should have a

primary health care entry point from which access

can be gained to other appropriate services as needed, including enabling services such as child care

and transportation.

Improving access to quality diabetes care

is an important strategy for reducing the

burden of diabetes in women at high risk

for the disease and its complications.

Particular attention also needs to be paid to providing adequate preventive services for women younger

than 65, women of childbearing age who live in

nonmetropolitan areas, and elderly women who live

alone. For persons with diabetes, this coverage

should include access to dental and mental health

services. A focused effort is needed to improve the

accessibility of high-quality diabetes care for all persons with diabetes. Delivery systems such as community health centers, managed care organizations,

or fee-for-service entities are important components

that could be targeted for intervention.

The need will increase for health care

professionals who are qualified to diagnose diabetes in women and provide

comprehensive treatment.

To prepare for the future needs of persons with

chronic diseases in general and those with diabetes

specifically, the public health community should

advocate for and facilitate the creation of incentives

for training health care providers, including community health workers, who are skilled in managing health care for elderly persons with diabetes.

Training for these workers should take into account

that the majority of their patients will be women,

many of whom will be very old.

Improved training about the risks of diabetes, its complications, and the importance of preventive care is essential for

health care professionals at all levels.

Mechanisms to facilitate improved adherence to

recommended standards of care, including promoting a better understanding among health care

providers of the role of the family and the community, should be identified and implemented to

achieve positive health outcomes for persons with

diabetes. Continuing education programs addressing provider attitudes toward women, the treatment of diabetes, and the role of families and the

community in the management of this disease are

important topics to include in the provider curriculum. Health delivery systems should use continuous quality improvement methods to improve

provider compliance with recommended standards

of care.

In conclusion, it is our intent to gain the attention

of the public health community, policy makers, and

the general public as well. Everyone is potentially at

risk for diabetes, and collaboration and the allocation of resources to reduce the burden of this disease are urgently needed. To stem the tide of the

increasing societal burden of diabetes, we know

there is much we can do now.
176

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

References

1. U.S. Public Health Service. Women’s Health: Report of

the Public Health Service Task Force in Women’s Health

Issues. Vol. 2. U.S. Department of Health and Human

Services, 1987.

2. Schoeder SA. Prospects for expanding health insurance

coverage. N Engl J Med 2001;344(11):847–52.

3. Ayanian JZ, Weissman JS, Schneider EC, Ginsburg JA,

Zaslavsky KM. Unmet health needs of uninsured adults

in the United States. JAMA 2000;284(16):2061–9.

4. Institute of Medicine. The Future of Public Health.

Washington, DC: National Academy Press, 1988.

5. U.S. Department of Health and Human Services.

Healthy People 2010 (Conference Edition in Two

Volumes). Washington, DC: U.S. Department of Health

and Human Services, January 2000.

6. Institute of Medicine Committee on Quality of Health

Care in America. Crossing the Quality Chasm: A New

Health System for the 21st Century. Washington, DC:

National Academy Press, 2001.

7. Narayan KM, Gregg EW, Engelgau MM, et al.

Translation research for chronic disease: the case of diabetes. Diabetes Care 2000;23(12):1794–98.
177

EPILOGUE

When we began this project, the principal aim was

to provide a reference document for public health

professionals and advocates for women’s health. As

the work progressed, we became more acutely

aware of some of the issues that affect our efforts to

reduce the burden of diabetes in women. First, the

challenges will soon become greater, as current

trends and projections show that women will contribute greatly to the growing number of prevalent

cases because of 1) the dominance of young women

among those developing so-called “type 2 diabetes

in youth,” 2) the impact of the intrauterine environment on the subsequent development of diabetes—both in the mother following gestational

diabetes and in the offspring several decades later,

and 3) the fact that women live longer than men,

alone and often poor, and increasingly with diabetes. Coupled with other socioeconomic and psychosocial determinants of disease, we must

acknowledge this increased diabetes burden in

women and begin to do something about it.

Second, it is unlikely that the traditional clinical

and individual-oriented approach to disease control

and prevention will, by itself, be effective. Although

such approaches have been successful in eradicating

and controlling certain diseases in populations

throughout the world,1 the emphasis to reduce the

burden of chronic diseases has primarily focused on

identifying and modifying risk in individuals. This

19th-century reductionist approach has persisted

because many of the determinants of disease that

may precede or underlie the current health status of

the population (e.g., social conditions in populations) have not been studied sufficiently to influence strategies for widespread public health

practice.2-4 Throughout this document, demographic and socioeconomic disparities were recurring

observations and themes at every stage of the lives

of women with diabetes. As disturbing as this can

be, this focus on women also revealed the presence

of structural barriers (e.g., inadequacy of insurance

coverage for persons with chronic disease) in the

environment that may impede efforts to reduce the

burden of disease, not only for this population but

for all persons with diabetes. 

Third, we also found confusion in the literature in

the use and understanding of the terms “gender”

and “sex.” In a recent report, the Institute of

Medicine5 defined sex as the classification of living

things, generally as male or female according to

their reproductive organs and functions assigned by

the chromosomal complement, and gender as a

person’s self-representation as male or female, or

how that person is responded to by social institutions on the basis of the individual gender presentation. Gender is shaped by environment and

experience.5 More precise use of these two terms

including the development of valid indicators or

measures should enhance the research agenda and

inform public health practice. There are still many

unanswered questions. For example, “How have

the changing roles of women, work, and family

responsibility affected health status?” As more

women participate in the workforce, do we have

policies that facilitate and support healthy lifestyles

for the prevention or control of chronic diseases

such as diabetes? The discordance between the traditional role expected of women and the realities of

their lives may expose them to chronic psychosocial

stressors that we now recognize may contribute to

poor health, including the development of diabetes

or other chronic diseases.

When we began this journey, there were many

skeptics among our peers who voiced concern

about our focus on women. Even in the literature,

we found that diabetes in women was frequently

discussed only from the perspective of “diabetes in
178

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

pregnancy,” and even within this limited view, protecting the child was the primary focus of practice.

In other words, women’s health was seen to be different solely because of their reproductive function.

This particular view has framed and guided many

institutional policies and has limited the scope of

public health understanding and practice. The discussion of public health implications in chapter 7

addresses many of these issues and presents ideas

for correcting some of these anomalies. 

Finally, in using the life-stage approach to frame

the body of this monograph, we hypothesized that

the needs of women with diabetes would change

during the various life stages, and we found this to

be the case. We would like to restate this assumption, and challenge others to adopt the life-stage

approach in all public health practice.

To inform health professionals and the general

public in a more helpful and useful manner, there

is great need for further study to understand the

true burden of diabetes in women. Specifically, a

major research goal could be to focus on underlying social conditions to understand how social

organizations or social capital might influence the

health or well-being of women. Social capital, a

concept that is now being embraced by the public

health community, is defined as the processes and

conditions among people and organizations that

lead to accomplishing a goal of mutual social benefit.6 There is also great need for research targeting

women with diabetes to translate available knowledge into effective clinical and public health practice. 

To provide comprehensive care for women with

diabetes and to protect and maintain the health of

women throughout their lives, the medical care system and the public health system must be woven

together. There are many examples of successful collaboration between these two important segments

of the health sector.7 The public and private sectors—government, universities, nongovernment

organizations, and private industry—all have critical

roles to play in these efforts if progress is to be

made in addressing diabetes, not only in women,

but in all people.

References

1. CDC. Ten great public health achievements—United

States, 1900–1999. MMWR 1999;48(12):241–3.

2. Link BG, Phelan J. Social conditions as fundamental

causes of disease. J Health Soc Behav 1995;Spec No:

80–94.

3. McKinlay JB, Marceau LD. To boldly go.... Am J Public

Health 2000;90(1):25–33.

4. McKinlay JB, Marceau LD. U.S. public health in the

21st century: diabetes mellitus. Lancet 2000;356(9231):

757–61.

5. Wizemann TM, Pardue M, editors. Exploring the

Biological Contributions to Human Health: Does Sex

Matter? Committee on Understanding the Biology of

Sex and Gender Differences, Board on Health Sciences

Policy. Institute of Medicine. Washington, DC: The

National Academy of Sciences, 2001.

6. Portes A. Social capital: its origin and application in

sociology. Annu Rev Sociol 1998;22:1–24.

7. Lasker RD. Committee on Medicine and Public Health.

Medicine and Public Health: The Power of Collaboration.

New York: The New York Academy of Medicine, 1997.
Age group (years)

Population 20–44 45–54 55–64 65–74 ≥75 45–64 ≥65 ≥20 ≥20†

All races

Both sexes 1.6 5.1 11.2 12.7 13.2 7.9 12.9 5.1 5.3

Women 1.7 4.5 11.0 13.3 12.8 7.6 13.1 5.4 5.2

Men 1.4 5.7 11.4 11.9 13.8 8.2 12.6 4.9 5.3

Non-Hispanic white

Both sexes 1.4 4.5 10.2 11.5 12.6 7.1 12.0 5.0 4.8

Women 1.5 3.2 9.6 11.7 12.3 6.3 11.9 5.0 4.5

Men 1.4 5.8 10.8 11.3 13.2 8.0 12.0 5.0 5.2

Non-Hispanic black

Both sexes 2.2 8.9 18.0 22.3 17.5 13.1 20.4 6.9 8.2

Women 2.1 10.2 19.2 26.5 19.0 14.3 23.3 7.8 9.1

Men 2.3 7.1 16.5 17.0 14.7 11.4 16.3 5.9 7.3

Mexican American

Both sexes 1.5 12.9 17.6 27.0 21.7 14.6 25.4 5.6 9.3

Women 7.2 14.8 20.9 30.9 25.0 2.0 17.1 7.2 10.9

Men 1.0 10.9 14.2 22.2 17.8 12.1 20.8 4.2 7.7

*NHANES III = Third National Health and Nutrition Examination Survey.

†

Age-standardized by direct method. Standard = 1980 U.S. population.

Sources:

Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, data from the Third National

Health and Nutrition Examination Survey. Data computed by the Division of Diabetes Translation.

Harris, MI, Flegal KM, Cowie CC, et al. Prevalence of diabetes, impaired fasting glucose, and impaired glucose tolerance in U.S. adults. The Third

National Health and Nutrition Examination Survey, 1988–1994. Diabetes Care 1998;21(4)518–24.

179

APPENDIX A

PERCENTAGE OF U.S. ADULT POPULATION WITH

PHYSICIAN-DIAGNOSED DIABETES, BY AGE, SEX,

AND RACE/HISPANIC ORIGIN—

NHANES III,* 1988–94

181

APPENDIX B

PERCENTAGE OF U.S. ADULT POPULATION WITH UNDIAGNOSED

DIABETES,* BY AGE, SEX, AND RACE/HISPANIC ORIGIN—

NHANES III,† 1988–94

Age group (years)

Population 20–44 45–54 55–64 65–74 ≥75 45–64 ≥65 ≥20 ≥20‡

All races

Both sexes 0.8 3.7 6.7 5.7 5.8 5.1 5.8 2.8 2.8

Women 0.6 4.4 6.0 3.6 4.9 5.2 4.2 2.5 2.5

Men 1.0 3.0 7.5 8.1 7.5 5.0 7.9 3.1 3.1

Non-Hispanic white

Both sexes 0.5 3.0 6.0 5.9 5.0 4.4 5.6 2.5 2.5

Women 0.4 3.5 5.1 3.4 4.4 4.3 3.8 2.1 2.0

Men 0.7 2.5 6.9 8.8 6.1 4.4 7.9 3.0 2.9

Non-Hispanic black

Both sexes 1.5 6.7 8.6 7.9 4.9 7.6 6.9 3.5 3.6

Women 1.6 7.0 11.6 9.0 7.5 9.2 8.4 4.1 4.5

Men 1.3 6.2 4.5 6.8 0.0 5.4 4.9 2.7 2.7

Mexican American

Both sexes 2.4 3.3 12.6 3.6 8.7 6.7 5.0 3.4 4.5

Women 2.3 1.8 10.0 5.1 6.8 4.7 5.6 3.0 3.6

Men 2.6 4.8 15.2 2.0 11.1 8.7 4.3 3.8 5.4

*Based on 1997 American Diabetes Association criteria.

†

NHANES III = Third National Health and Nutrition Examination Survey.

‡

Age-standardized by direct method. Standard = 1980 U.S. population.

Sources:

Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, data from the Third National

Health and Nutrition Examination Survey. Data computed by the Division of Diabetes Translation.

Harris, MI, Flegal KM, Cowie CC, et al. Prevalence of diabetes, impaired fasting glucose, and impaired glucose tolerance in U.S. adults. The Third

National Health and Nutrition Examination Survey, 1988–1994. Diabetes Care 1998;21(4)518–24.

183

APPENDIX C

AGE-STANDARDIZED PREVALENCE* OF DIAGNOSED DIABETES

PER 100 ADULT FEMALE POPULATION, BY STATE—

UNITED STATES, 1998–2000

3.646–4.175 4.230–4.758 4.962–5.684 5.752–7.604

WA

GA

AK

CA

OR

NV

AZ

ID

UT

MT

WY

CO

NM

TX

OK

KS

NE

SD

ND

MN

IO

MO

AR

LA

MS AL

FL

HI

SC

NC

TN

KY

VA

PA

NY

ME

OH

WV

IL IN

WI MI

VT

NH

MA

RI

DE

MD

NJ

CT

*3-year moving average.

Source: Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion,

Division of Adult and Community Health, data from the Behavioral Risk Factor Surveillance System. Data computed by the

Division of Diabetes Translation.

185

APPENDIX D

AGE-STANDARDIZED PREVALENCE* OF DIAGNOSED DIABETES

PER 100 ADULT FEMALE POPULATION, BY STATE—

UNITED STATES, 1994–96

2.790–3.649 3.715–4.206 4.258–4.751 4.863–6.325

WA

GA

AK

CA

OR

NV

AZ

ID

UT

MT

WY

CO

NM

TX

OK

KS

NE

SD

ND

MN

IO

MO

AR

LA

MS AL

FL

HI

SC

NC

TN

KY

VA

PA

NY

ME

OH

WV

IL IN

WI MI

VT

NH

MA

RI

DE

MD

NJ

CT

*3-year moving average.

Source: Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion,

Division of Adult and Community Health, data from the Behavioral Risk Factor Surveillance System. Data computed by the

Division of Diabetes Translation.

187

APPENDIX E

2001 QUICK REFERENCE GUIDE TO THE

AMERICAN DIABETES ASSOCIATION’S

STANDARDS OF CARE

PHYSICAL ASSESSMENT

• Visits: Continuing care visits every six months or

appropriate to meet patient’s needs and treatment

goals.

• Blood Pressure: Every continuing care visit. Goal is

<130/80.**

• Weight: Every continuing care visit; establish growth

chart for children.

• Comprehensive Foot Exam (adults): At least yearly

(more often in patients with high-risk foot conditions).

• Eye exam: Yearly dilated funduscopic exam (or retinal

photography); if diagnosed at age 29 or earlier, the initial eye exam should be performed within 3–5 years of

diagnosis once patient is age 10 or older. 

LABORATORY TESTS

• HbA1c: 2 times per year; more frequent if not meeting

goals. Adjust goals to prevent serious hypoglycemia.

Target goal is <1% above upper limit of normal (e.g.,

<7.0% for a HbA1c assay with an upper limit of normal of 6%). A value >2% (e.g., >8% for HbA1c) above

upper limit of normal requires greater attention.**

• Urine Protein (adults): Microalbumin measurement

annually (in the absence of previously demonstrated

microalbuminuia).

• Lipid Profile (adults): Yearly. Target goals**: total

cholesterol and triglycerides <200 mg/dL, LDLC<100mg/dL, HDL-C>45 mg/dL in men and >55

mg/dL in women.

SELF-MANAGEMENT TRAINING

• General Principles: Review goals at every continuing

care visit. Conduct comprehensive assessment yearly to

include patient’s understanding of diabetes, self-monitoring of blood glucose (SMBG), acute and chronic

complications.

• Medical Nutrition Therapy: Review goals at every

continuing care visit. Conduct comprehensive assessment yearly to include meal planning, reading food

labels, weight control

• SMBG: Should be performed as appropriate to meet

goals.

• Physical Activity: Review goals at every continuing

care visit. Conduct comprehensive assessment yearly to

include frequency and duration of activity and physical

limitations.

SPECIAL SITUATIONS

• Hypoglycemia: Recurrent hypoglycemia calls for

reassessment of treatment plan. Additional action suggested might include enhanced diabetes self-management education, comanagement with a diabetes team,

referral to an endocrinologist, change in pharmacological therapy, initiation or increased SMBG, or more frequent contact with the patient.

• Preconception Counseling: Begin counseling at

puberty; enhance counseling with adolescence; consult

with high-risk perinatal programs when appropriate. 

• Pregnancy Management: Intensify glycemic control;

consult with high-risk perinatal programs when appropriate.

• Smoking Cessation: Emphasize and assist as much as

possible.

• Aspirin Therapy: Enteric-coated aspirin

(81mg–325mg/day) as secondary prevention for CVD.

Consider for primary prevention in high-risk patients

(e.g., family history, smoking, hyperlipidemia, hypertension, albuminuria).

*These guidelines have been condensed from the American Diabetes

Association’s Standards of Medical Care for People with Diabetes. They do not

reflect all the actions that should be provided by health professionals in the

medical management of diabetes. Full text of the Association’s Clinical Practice

Recommendations, including the Standards of Medical Care, is available at

www.diabetes.org.

**If the patient is not making satisfactory progress toward treatment goals within a reasonable period (3–6 months), medical management should be

enhanced. Greater attention to self-management education, comanagement with

a diabetes team, referral to an endocrinologist, change in pharmacologic therapy, initiation of or increased SMBG, or more frequent contact with the patient,

are examples of actions that should be considered.

Reprinted with permission from the American Diabetes

Association

189

LIST OF ABBREVIATIONS

ADA American Diabetes Association

ARIC Atherosclerosis Risk in Communities Study

BRFSS Behavioral Risk Factor Surveillance System

BMI body mass index

CARE Cholesterol and Recurrent Events Study

CDC Centers for Disease Control and Prevention

CHD coronary heart disease

CMS Centers for Medicare and Medicaid Services (formerly HCFA)

CVD cardiovascular disease

DCCT Diabetes Control and Complications Trial

DERI Diabetes Epidemiology Research International Mortality Study

DM diabetes mellitus

DPP Diabetes Prevention Program

DSM-IV Diagnostic and Statistical Manual of Mental Disorders, 4th Edition

EPESE Established Populations for Epidemiologic Studies in the Elderly

ERT estrogen replacement therapy

ESRD end-stage renal disease

ETDRS Early Treatment of Diabetic Retinopathy Study

GDM gestational diabetes mellitus

HbA1c hemoglobin A1c

HDL high-density lipoprotein

HERS Heart and Estrogen/progestin Replacement Study

HCFA Health Care Financing Administration (currently CMS)

HHANES Hispanic Health and Nutrition Examination Survey (1982–84)

HOPE Heart Outcomes Prevention and Evaluation Study

HOT Hypertension Optimal Treatment Study

HRQOL health-related quality of life

HRSA Health Resources and Services Administration
190

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

HRT hormone replacement therapy

IDDM insulin-dependent diabetes mellitus

IGT impaired glucose tolerance

JDRF Juvenile Diabetes Research Foundation International

LDL low-density lipoprotein

LEAD lower-extremity arterial disease

NCEP National Cholesterol Education Program

NDEP National Diabetes Education Program

NIH National Institutes of Health

NHANES I First National Health and Nutrition Examination Survey (1971–75)

NHANES II Second National Health and Nutrition Examination Survey (1976–80)

NHANES III Third National Health and Nutrition Examination Survey (1988–94)

NHANS Navajo Health and Nutrition Survey (1991–92)

NHDS National Hospital Discharge Survey

NHES National Health Examination Survey (1963–65)

NHIS National Health Interview Survey

NHS Nurses’ Health Study

NIDDM non–insulin-dependent diabetes mellitus

NIH National Institutes of Health

PDR proliferative diabetic retinopathy

Project DIRECT Diabetes Interventions Reaching and Educating Communities Together

PVD peripheral vascular disease

SES socioeconomic status

UKPDS United Kingdom Prospective Diabetes Study

WESDR Wisconsin Epidemiology Study of Diabetic Retinopathy

WHO World Health Organization

WHR waist-to-hip ratio
191

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.
192

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

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.
Glossary

193

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.
194

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

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.
Glossary

195

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.
196

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

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.
Glossary

197

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.
198

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

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.