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Gender Affects Vascular Disease Associated with Diabetes

May 12, 2020
Editor: David L. Joffe, BSPharm, CDE, FACA

Author: Antonio Bess, Pharm D Candidate, Florida Agricultural & Mechanical University School of Pharmacy

How adipose tissue storage, which differs by gender, plays a role in the development and treatment of the disease. 

Cardiovascular disease is the most common complication of diabetes. Both men and women are affected by diabetes, but studies have shown that women are more significantly affected by macrovascular complications such as coronary artery disease and stroke. The exact mechanisms to explain to differences have not been found, but experts believe adipose tissue storage plays a vital role in the pathogenesis of the vascular disease. This article focuses on the role adipose tissue plays in the sex difference between men and women and how healthcare manages women with diabetes to minimize the risk for macrovascular complications.  


Biological aspects that affect diabetes-associated vascular disease highlight the reasons for the disparity. Women have a higher threshold for the signs and symptoms of diabetes than men. Therefore, when the diagnosis is made, the disease is more pronounced in women. Studies have found that women remain in the prediabetic range longer than men. The gap in BMI and waist circumference is larger for women than men when comparing people who have diabetes and those who do not with respect to gender. Women with diabetes also weigh more than men with diabetes when first diagnosed.  

Adipose tissue is directly related to the development of type 2 diabetes and vascular disease. Men and women store fat differently. Women store fat in more subcutaneous areas and on their lower extremities while men store fat in the abdominal region (visceral). Men store higher amounts of fat in areas other than adipose tissue such as the liver, skeletal muscle, heart, and pancreas (ectopic). This could explain why men develop diabetes earlier, since excessive amounts of fat on the pancreas could lead to dysregulations in insulin release and resistance. It also explains why women need to gain more weight prior to developing diabetes, since more excess fat is needed to be stored in ectopic areas. In women, visceral fat has a higher correlation of diabetes development and myocardial infarction than it does in men.  

The excess adipose tissue which continues to rise leads to obesity. Obesity can affect different hormones in the body, which increases the risk of vascular disease. Adipocytes contain a hormone called leptin, which regulates the body’s energy status by regulating hunger. Overfilled adipocytes release leptin, which can activate the sympathetic nervous system and the RAAS system. These systems lead directly to hypertension and, if left untreated, future vascular complications. 

The metabolic deterioration that women undergo before being converted to diabetes is underlined by worse levels of total cholesterol, HDL, triglycerides, and diastolic blood pressure at baseline than men when compared with participants of the same sex who did not develop diabetes. Women are also more prone to more significant endothelial dysfunction, hypertension, and dysregulated fibrinolysis and coagulation. Regarding known risk factors, the relative risk for women cannot be truly evaluated. Therefore, changes must be made to accurately assess a woman’s risk of developing vascular disease associated with diabetes mellitus. 

Sex differences can be found in healthcare, which has negative impacts on quality of life and disease management for women. The delay and prevention of vascular disease is a primary objective in the management of diabetes. Guidelines have similar recommendations for both sexes regarding lifestyle changes, including smoking cessation, physical activity, and diet. Unfortunately, women can present in stages requiring pharmacological therapy and miss the opportunity for prevention. Early detection allows for early intervention, which significantly improves outcomes.  

Studies are inconsistent when assessing sex differences in diabetes management. There is room for improvement in the management of diabetes for both sexes. Nonadherence can be a problem for someone newly diagnosed with diabetes. For women, this can be potentiated if vascular disease already poses a risk, and metabolic levels require intervention. More studies need to be conducted to identify risk factors and monitoring parameters for women. Studies should be diverse and include a large but equal amount of men and women to ensure no sex is being affected by a disease to a greater extent than the other. Since it’s known that women have to have more significant time to diagnose, that gives us more time for earlier intervention and prevention.  

Practice Pearls: 

  • Women have more metabolic deterioration than men at the diagnosis of diabetes. 
  • Adipose tissue storage is an underlying factor for sex differences found in people with diabetes. 
  • Health care does not adequately assess and monitor risk factors for vascular disease for women with diabetes. 


de Ritter, Rianneke et al. Sex differences in the risk of vascular disease associated with diabetes. Biology of sex differences vol. 11,1 1. 3 Jan. 2020, doi:10.1186/s13293-019-0277-z 


Antonio Bess, PharmD. Candidate of Florida Agricultural & Mechanical University School of Pharmacy 


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