Gender, Health, and Diabetes Symposium Summary
Despite the recent adoption of the World Health Assembly's 2008 Action Plan for addressing non-communicable diseases, as well as the 2006 United Nations Diabetes Resolution (UN A/RES/61/225), the particular impact diabetes has on women worldwide remains virtually unattended. The main goal of this symposium was to expand the multisectoral dialogue addressing the lack of information and focus on the gender-based aspects of diabetes in the international policy arena.
Another goal for the symposium was to provide a forum for Member States to meet and receive necessary information directly from experts in the field. Given its role as the epicenter of international health policy and host to the highest-ranking health officials in the world, GAWH determined that this program would be most effective if held in Geneva, particularly during the 2009 World Health Assembly.
Using its extensive network of public, private, and international actors, GAWH hosted a near-capacity symposium luncheon, with almost 70 people in attendance during the panel presentations. Eleven Member States were in attendance at the symposium, with several Member States sending numerous representatives (listed in parenthesis):
- Algeria (1)
- Botswana (3)
- Cameroon (1)
- Chile (3)
- Democratic Republic of Congo (2)
- Ethiopia (1)
- Ghana (4)
- Senegal (2)
- Suriname (3)
- Tanzania (6)
- Uganda (1)
High-ranking officials in attendance included the Ministers of Health from the Democratic Republic of Congo and Suriname, as well as the Permanent Representative from Chile to the United Nations in Geneva was in attendance. The Chief Director of the Ministry of Health from Algeria was also present. All of the Member States present are members of the G77, a coalition of developing nations at the UN. This outreach to developing nations is always integral in GAWH's programs, as well as on the broader scale for policy development.
Please see Appendix I for a more comprehensive list of attendees summary.
Since 2003, the Global Alliance for Women's Health (GAWH) launched an awareness and advocacy campaign focused on women affected by diabetes. Throughout the campaign, GAWH has called for the recognition of diabetes as a chronic disease that challenges the advancement and empowerment of women and their families. In April 2008, GAWH held an expert meeting at UN Headquarters on "Diabetes, Women, and Development." Experts from around the world gathered to discuss critical issues such as diabetes and pregnancy and the socio-economic challenges faced by diabetic women. Several follow-up actions were proposed at the conclusion of this meeting:
- The experts encouraged GAWH to "carry forward the advocacy on diabetes through the organization of a parallel event emphasizing the direct effect of gestational diabetes on the epidemic of type 2 diabetes." 2
- The experts suggested the publication of information presented at the meeting in a scientific journal. Consequently, a supplement on diabetes and women was published in the International Journal of Gynecology and Obstetrics (IJGO) in early 2009.
Regardless of the ongoing campaign and the progress made on this issue as evidenced by the inclusion of diabetes in the Economic and Social Council (ECOSOC) 2009 AMR Ministerial Declaration, the dearth of information must be addressed. Doing so is paramount to achieving the UN Millennium Development Goals (MDGs), especially those pertaining to the empowerment of women, reducing child mortality, and improving maternal health (MDGs 3, 4, and 5 respectively).
The outcomes of the symposium were brought back to New York and presented to the Council on Gender-based Health and the Friends of the UN Diabetes Resolution (FUNDR), two ongoing multisectoral advocacy groups operating at the UN (GAWH is the secretariat). In a joint meeting of the Council and FUNDR on 9 June 2009, both groups discussed these conclusions within the context of the July 2009 ECOSOC Annual Ministerial Review (AMR) in Geneva, Switzerland.
GAWH drafted an intervention for the joint meeting incorporating the elements discussed at the symposium and asked attendees, including several delegates from ECOSOC and UN Member States, to review the language. The ultimate goal was to see the items outlined in the GAWH draft intervention, with language drawn from the conclusions from WHA, inserted into the Ministerial Declaration. Members encouraged GAWH to return to Geneva for the High-level Segment in July in order to continue their advocacy.
In the final draft of the Ministerial Declaration, issued on 10 July 2009, non-communicable diseases are specifically mentioned in paragraph 18 of the declaration's elements:
This paragraph expands to include several specific items on NCDs, including one on diabetes:
Due attention is paid to Maternal health and MDG 5 in Paragraph 15 of the Declaration:
These inclusions in the Ministerial Declaration are not only groundbreaking, but represent a milestone for GAWH's initiatives, including the WHA symposium. According to one Third Committee delegate, these inclusions are a direct result of GAWH's advocacy and something that should continue, at an even larger scale, well into the future. Due to the efficacy of the WHA symposium and the Ministerial Declaration, initiatives like the Council on Gender-based Health and FUNDR have a new framework for discussion and action, one that focuses on the increasing momentum and attention surrounding women, diabetes, and NCDs.
It has been suggested that GAWH extend beyond WHO and ECOSOC and campaign to UN agencies like UNFPA and UNICEF in order to see that women's health, including maternal health, and NCDs are put on their agendas.
The technical panel featured experts on gender, health, diabetes, and policy from around the world, including experts from the World Health Organization (WHO), Tel-Aviv University, and GAWH.
Diabetes in Men and Women
Dr. Gojka Roglic
Department of Chronic Diseases and Health Promotion, WHO
Dr. Roglic presented on diabetes in men and women and the importance of establishing a gender distinction when addressing the disease. Disaggregated data by gender is fundamental to the formulation of international policy and protocol. Without recognizing this gender disparity, the health of women around the world will continue to be compromised. During her presentation, Dr. Roglic called attention to several essential and significant facts regarding women and diabetes:
- The onset of diabetes is shifting to younger ages, thus increasing diabetes prevalence in pregnancy and conferring both short and long-term morbidity risk on the offspring.
- Diabetes increases the risk of death more in women than in men.
- An acute coronary event is more likely to be fatal in a woman with diabetes than in a man with diabetes.
- Women do not benefit as equally as men from modern management of diabetes.
Taking these facts into consideration, the health of women with diabetes worldwide (and their offspring) is clearly in jeopardy unless policies and programs are designed to meet their specific needs.
New Findings and Diagnostic Criteria in Gestational Diabetes—the HAPO Study
Dr. Moshe Hod
Director, Division of Maternal Fetal Medicine, Rabin Medical Center, Tel-Aviv University, Israel
An expert on high risk pregnancy and maternal metabolism during pregnancy, Professor Hod delivered a powerful report on the Hyperglycemia and Adverse Pregnancy Outcome (HAPO) study. The HAPO study aimed to solve one of the main challenges of the 21st century—the lack of consensus on diagnosing GDM. The study was conducted in a multinational, multicultural, ethnically diverse population from numerous countries. Approximately 25,505 women were tested.3 The HAPO study was designed to investigate and identify the correlation between adverse pregnancy outcomes to maternal glucose intolerance that fall short of overt diabetes values. It was also meant to set the evidence based criteria for diagnosis and classification of GDM, to be based upon the correlation between glycemic levels and perinatal outcome. The preliminary hypothesis of the study was that gestational hyperglycemia, even below the threshold for diabetes, will be associated with increased maternal, fetal, and neonatal morbidities.
As part of his presentation, Professor Hod provided key facts on diabetes in pregnancy:
- Overt diabetes clearly increases the risk of adverse pregnancy outcome.
- Hyperglycemia in pregnancy, less severe than overt DM (diabetes mellitus), is associated with increased risk of adverse maternal, fetal, and neonatal outcomes.
- In 2009, it is estimated that of the five million deliveries in the United States, approximately 250,000-400,000 were diabetic pregnancies.
- In India, of the 30 million deliveries, approximately 4 million were diabetic pregnancies, or 14 percent (under diagnosis).
- HAPO study results indicate strong, continuous associations of maternal glucose levels with adverse pregnancy outcome, such as: increased birth weight, increased cord-blood C-peptide levels (fetal hyperinsulinamia), increased rate of neonatal hypoglycemia, and increased rate of maternal preeclampsia (hypertension).
The HAPO study therefore demonstrates that fasting glucose levels and post 75g OGTT are correlated to maternal, perinatal, and neonatal outcomes in an essentially linear manner. Glucose has an impact on pregnancy outcome, even at levels below the current, commonly accepted range. There seems to be no apparent threshold, but rather a continuum of glucose levels. Professor Hod noted that these results now provide the evidence base for developing perinatal outcome-based standards to diagnose and classify GDM that are valid and therefore applicable worldwide.
Furthermore, these associations between adverse outcomes and "non-diabetic" hyperglycemia suggest the need to lower current diagnostic thresholds for GDM. It is anticipated that the International Association of Diabetes and Pregnancy Study Groups (IADPSG), will shortly publish its recommended criteria for GDM which are based on the findings from the HAPO study.
The consequences of undiagnosed, uncontrolled, or untreated diabetes in pregnancy are severe and endanger the health of the mother and her offspring. By using the results of HAPO to establish a new glycemic threshold for the purpose of diagnosis and treatment of GDM, the health of mothers and their offspring around the world will drastically improve, both now and into the future.
The Innovative Use of Health Data to Improve Impact of Maternal and Newborn Health Programs in Developing Countries
Dr. Anuraj Shankar
Coordinator, Department of Making Pregnancy Safer, WHO
Dr. Anuraj Shankar delivered a presentation to the audience on the use of data to improve the impact of maternal and infant health programs. Dr. Shankar stated that the purpose of gathering data is three-fold:
- Improving the health of the population
- Improving the quality of services
- Providing up-to-date estimates of health status
Data can also be used to analyze health systems and programs already in place, exposing shortcomings and areas for improvement. For example, data collected in low-income urban, suburban, and rural communities in India reveal the high prevalence of GDM in these areas. It is through this sort of information that the need for surveillance and screening becomes apparent as a crucial process to address the growing incidence of GDM. Data collected on the performance of community facilitators and the impact of interventions on infant death revealed a direct correlation between the skills of the facilitator and the relative risk of infant death—the better the facilitator, the more likely an infant is to survive. Attention to detail and quality of program implementation is therefore vital, especially in the context of management of GDM.
The gathering and use of local GDM and program performance data can not only illuminate the prevalence of severe health issues in communities, but also compel Member States and international health policy actors to implement practical and effective policies. Adjustments of procedures driven by data will translate into improved staff performance, better services, and ultimately, better health for the community at-large. This is especially critical to the effective management of GDM worldwide, especially in low income countries.
The Import of Sex and Gender on Policy
Dr. Saralyn Mark
President, SolaMed Solutions, GAWH Advisory Board Member
In her presentation on "Sex and Space: The New Frontier," Dr. Saralyn Mark discussed the history of sex and gender in medical research, as well as the outcomes of a national workshop on sex and environmental adaptation. Prior to regulations mandating the participation of women in clinical trials, women were severely underrepresented in medical research. In 1993, the National Institute of Health (NIH) Revitalization Act made the inclusion of women in all clinical trials law. A follow-up audit of NIH in 2000 by the General Accounting Office (GAO) showed that while the number of women in clinical trials is proportionate to the population, NIH is still behind in designing trials that "could reveal wheth er interventions affect women and men differently."4 Another barrier to progress is the widespread lack of clarification when using the words "sex" and "gender."
A National Workshop on "Research Priorities on Sex Differences in Human Responses to Changing Environments" sponsored by NASA and the National Center for Gender Physiology and Environmental Adaptation, aimed to "define and report" the necessary research needed to "increase our fundamental knowledge of gender and sex-specific factors that influence humankind's ability to adapt to challenging environments on Earth and in Space." Some highlights from the Workshop include:
- Cardiovascular—Women respond to cardiovascular stress with increased heart rates, whereas men respond with greater increase in vascular resistance.
- Immunological—Resistance to infectious diseases, immunizations and cancer and development of autoimmune disease are greatly influenced by sex on earth.
- Neurovestibular—Most clinical laboratories report that women present with symptoms of imbalance and disequilibrium at a rate of 2 to 1.
- Human Behavior—Some studies report that women feel that they have to work harder than men in regard to workload issues.
Dr. Mark also stated that there is an impact of sex on the immune response to the pandemic H1N1 virus. Women are generally more resistant to infection, but once infected, they mount very vigorous responses which can be described as a cytokine storm. Pregnant women lose that immunity as their immune systems are designed to not reject a fetus, yet they still mount robust responses and may have a more difficult time breathing due to a restrictive lung pattern from the pregnancy. These immune responses can be damaging to the lungs and may increase morbidity and mortality which has been seen in women, especially pregnant women.
One possible advantage to these responses can be that women may need less vaccine to be effectively immunized. Less vaccine dosage may minimize side effects from vaccines which occur more often in women compared to men. Studies need to be conducted to assess the impact of sex on the immune system especially for this global pandemic to ensure that both men and women are protected.
The summary of recommendations includes a greater need for collaborative research on sex-based biology and medicine, the exploration of mechanisms of sex differences in transgenic models and gene expression, and appropriate research and infrastructure to support models of sex-based research.
- The panelists categorically stated that gender is a significant health determinant that cannot be overlooked. This is especially true in the context of non-communicable diseases and specifically diabetes. Women with diabetes are at greater risk for comorbidity and mortality.
- Diabetes in pregnancy severely compromises the health of both the mother and the child and greatly increases the risk of adverse pregnancy outcomes. When diabetes goes undiagnosed, untreated, or uncontrolled during pregnancy, the mother and her offspring are at risk for developing grave long-term health complications.
- The lack of gender disaggregated data prevents the successful creation and implementation of health programs around the world. General research is needed to increase existing knowledge of gender and sex-based health and to create a system that supports gender-specific scientific research and clinical trials.
2 GAWH and WDF. Diabetes, Women, and Development Meeting Summary. May 2008.
3 The HAPO Study Cooperative Research Group. Hyperglycemia and Adverse Pregnancy Outcomes. N Engl J Med. 2008; 358 (19) 1991-2002. Accessed at: http://content.nejm.org/cgi/content/full/358/19/1991
4 Mark, S. "Sex and Space: The New Frontier."