On World Diabetes Day, a needed focus on women and girls

Dr Anil Kapur explores why women suffer disproportionately from NCDs - and what can be done about it.
Diabetes educator nurses, Sri Lanka
Diabetes educator nurses in Sri Lanka, where a WDF-supported national NCD response is helping women reduce their diabetes risks. Photo by Jesper Westley.
Non-communicable diseases (NCDs) have been the leading causes of death among women globally for at least the past three decades. Today, they are responsible for two in every three deaths among women. What’s worse, the NCD burden on women is expected to increase, especially in low and middle income countries.  
Why are women suffering disproportionately from diabetes, and what can be done about it? 
To mark World Diabetes Day and its 2017 theme Women and Diabetes – Our Right to a Healthy Future, WDF’s Communication Manager spoke with Board Chairman Dr Anil Kapur, who has worked to improve the lives of girls and women with NCDs in developing countries for more than 30 years.
Why are women suffering disproportionately from diabetes?
Although diabetes affects men and women equally, women are more severely impacted by its consequences.  For example:
Pre-menopausal women with diabetes lose the protection against heart disease that non-diabetic women have and are 50% more likely to die from heart disease than men 
Compared to men, women are at greater risk of blindness due to diabetic retinopathy 
Elderly women with type 2 diabetes and end-stage renal disease have a significantly higher risk of death than men 
Cyclical hormonal changes make diabetes control more difficult in women and increase the risk of diabetic ketoacidosis compared to men 
Women with diabetes more likely to develop depression than men
Then there is pregnancy, which presents its own set of diabetes-related risks. Pregnancy worsens pre-existing diabetic retinopathy and may lead to significant visual impairment. Pregnancy can worsen pre-existing kidney disease. Women who develop hyperglycaemia in pregnancy face a significantly increased risk of pregnancy complications and increased risk of future type 2 diabetes and cardio-metabolic disorders.
While the higher burden of complications in women with diabetes may be due to biological reasons, it is also a fact that in all countries - including the high income economies – women receive less intensive care and treatment than men. 
The problem is especially pronounced in low and middle-income countries, and expected to worsen in coming years. Why?
In the past, one of the most significant causes of death among women in the developing world was pregnancy or childbirth. Other important causes were undernutrition, anaemia, HIV, malaria and TB - often occurring during pregnancy and childbirth. The Millennium Development Goals’ focus on maternal and perinatal health led to remarkable reductions in deaths from these direct causes. 
At the same time, the risk factors for NCDs in these countries have increased. The result is an increased prevalence of obesity, diabetes, high blood pressure, cancers etc. This society-wide increase is especially pronounced in women for the reasons noted above.
Yet these women often don’t receive the care they need. Women in developing countries suffer disproportionately from economic, political and social discrimination, and consequently from poor health, lack of education, and employment. Girls and women often carry a double burden because of their health status and their gender in male-dominated societies. 
Pregnancy is a multiplier of the unfolding pandemic. Girls born with a low birth weight because their mothers were undernourished – still a common occurrence in countries with high levels of undernutrition and hunger - are more likely to develop gestational diabetes when they grow up and become pregnant. The offspring of these mothers with gestational diabetes are at a high risk of childhood obesity, early onset pre diabetes, type 2 diabetes and cardio-metabolic disorders. The daughter of a mother with gestational diabetes is at a very high risk of gestational diabetes herself. It’s a terrible, vicious circle. 
Almost one in six live births is impacted by hyperglycaemia in pregnancy globally but in some low and middle income countries it is even higher. These pregnancies are often complicated, with a risk of poor outcomes. 
How should policy makers and other stakeholders respond?
It is critical that public health experts, policy planners, funders and development agencies and care providers understand that maternal and child health is inextricably linked with NCDs. Malnutrition, obesity and hyperglycaemia in pregnancy are significant public health challenges and must be addressed. 
On the other hand, pregnancy offers a unique opportunity to integrate maternal and child health services with health promotion and NCD prevention, providing a bridge to more integrated services at the primary care level. 
What is WDF doing to address the problem?
WDF has been advocating on a greater focus on women's health particularly related to diabetes during pregnancy. As early as 2008 WDF organised an advocacy forum – Diabetes, Women and Development - at UN headquarters in New York. 
WDF has engaged with the International Federation of Obstetrics and Gynecology (FIGO) supporting symposia at six international meetings – which lead to FIGO developing guidelines and establishing a committee on maternal and offspring health and NCD prevention. WDF has also engaged with sexual and reproductive health and rights NGOs such as ARROW, and one of the most significant women' rights NGOs - Women Deliver - to develop awareness and advocacy initiatives on the subject. 
Similarly WDF engaged with the Pan American Health Organization and organised the Pan American Conference on Diabetes and Pregnancy. This meeting was attended by policy makers including ministry of health officials and experts in diabetes and obstetrics from 38 countries from Latin America and resulted in recommendations for greater focus and attention on the subject.
Since 2002, WDF has funded 77 projects in 39 countries addressing gestational diabetes. These projects have strengthened more than 4,000 clinics and screened more than 825, 000 women. 
One result of these initiatives is a much greater understanding on the links between maternal health and NCDs and many countries have already taken initiatives to ensure universal testing of women during pregnancy for diabetes. So there’s hope – but there’s still much to be done.