4.9 8.

Review

Influence of Gender in Diabetes

Mellitus and Its Complication

Tiziana Ciarambino, Pietro Crispino, Gaetano Leto, Erika Mastrolorenzo, Ombretta Para and
Mauro Giordano

Special Issue
Recent Research on Diabetes Mellitus and Its Complications 2.0
Edited by
Dr. Abdelkrim Hmadcha

https://doi.org/10.3390/ijms23168850
 International Journal of
Molecular Sciences

Review
Influence of Gender in Diabetes Mellitus and Its Complication
Tiziana Ciarambino 1, *,† , Pietro Crispino 2,† , Gaetano Leto 3 , Erika Mastrolorenzo 4 , Ombretta Para 5
and Mauro Giordano 6

1 Internal Medicine Department, Hospital of Marcianise, ASL Caserta, 81037 Caserta, Italy
2 Emergency Department, Hospital of Latina, ASL Latina, 04100 Latina, Italy
3 Department of Experimental Medicine, University La Sapienza Roma, 00185 Roma, Italy
4 Emergency Department, Hospital of Careggi, University of Florence, 50121 Florence, Italy
5 Internal Emergency Department, Hospital of Careggi, University of Florence, 50121 Florence, Italy
6 Department of Medical Science, University of Campania, L. Vanvitelli, 81100 Naples, Italy
* Correspondence: [email protected]
† These authors contributed equally to this work.

Abstract: In medicine, there is growing evidence that gender differences are important and lead
to variations in the pathophysiology and treatment of many diseases with traits that appear to be
particularly relevant in influencing the outcomes of many morbid forms. Today, the inclusion of
gender in biomedical research, to improve the scientific quality and scientific relevance of knowledge,
of technology is an increasingly present element precisely due to the practical implications that
derive from it. Gender differences describe the biological variability between women and men,
which is, in turn, related to differences in the information contained in sex chromosomes, the specific
gene expression of autosomes linked to sex, the different number and quality of sex hormones, and
their different effects on systems and organs, without neglecting the fact that each of the sexes has
different target organs on which these hormones act. Additionally, both genders undergo metabolic
changes throughout their lives, and this is especially true for women who show more dramatic
Citation: Ciarambino, T.; Crispino, P.;
changes due to their role in reproduction. Gender differences are not only the result of our genetic
Leto, G.; Mastrolorenzo, E.; Para, O.;
makeup but are also mixed with socio-cultural habits, behaviors, and lifestyles, differences between
Giordano, M. Influence of Gender in
women and men, exposure to specific environmental influences, different food and lifestyle styles
Diabetes Mellitus and Its
or stress, or different attitude in compliance with treatments and disease prevention campaigns.
Complication. Int. J. Mol. Sci. 2022,
23, 8850. https://doi.org/10.3390/
Gender differences also affect behavior throughout life, and physical changes can have implications
ijms23168850 for lifestyle, social roles, and mental health. Therefore, determinism and therapeutic outcome in
chronic diseases are influenced by a complex combination of biological and environmental factors, not
Academic Editor: Abdelkrim
forgetting that there are many interactions of social and biological factors in women and men. This
Hmadcha
review will address the role of gender differences in the management of various forms of diabetes
Received: 20 June 2022 and its complications considering the different biological functions of hormones, the difference in
Accepted: 5 August 2022 body composition, physiological differences in glucose and fat metabolism, also considering the
Published: 9 August 2022 role of the microbiota. intestinal, as well as the description of gestational diabetes linked to possible
Publisher’s Note: MDPI stays neutral pathophysiological events typical of reproduction.
with regard to jurisdictional claims in
published maps and institutional affil- Keywords: diabetes mellitus; gender differences; complication
iations.

1. Background
Copyright: © 2022 by the authors.
In general, there are numerous reports from various countries that observe large differ-
Licensee MDPI, Basel, Switzerland.
ences in the ratio between the sexes in the determinism of diseases related to metabolism.
This article is an open access article
The differences in biology, culture, lifestyle, environment, and socioeconomic status of
distributed under the terms and
conditions of the Creative Commons
the various populations under study obviously affect the differences between males and
Attribution (CC BY) license (https://
females in terms of predisposition, development, and clinical presentation of diabetes
creativecommons.org/licenses/by/
mellitus. Genetic inheritance and epigenetic mechanisms, nutritional factors, and sedentary
4.0/). lifestyle influence the risk and complications differently in both sexes, in consideration

Int. J. Mol. Sci. 2022, 23, 8850. https://doi.org/10.3390/ijms23168850 https://www.mdpi.com/journal/ijms

Int. J. Mol. Sci. 2022, 23, 8850 2 of 13

of the socio-cultural environment of the populations. Recently, it has been observed that
diabetes mellitus can have some gender peculiarities and some data show that women
have more years of disease on average than their male counterparts and have a higher body
mass index (BMI). This seems to be related to the fact that sex hormones have a great impact
on energy metabolism, body composition, vascular function, and inflammatory responses.
Furthermore, in patients with type 1 diabetes, women show worse metabolic control over
time, while in men, as the years of illness increase, other risk factors are associated, such as a
higher incidence of uncontrolled or refractory arterial hypertension. standard therapies [1].
The sharp increase in type 2 diabetes mellitus and associated complications go hand in hand
with the growing evidence of clinically important gender differences in the determinism of
this form of diabetes. Thus, also in type 2 diabetes mellitus, it is highlighted that it is more
frequently diagnosed in men who have a lower age and body mass index than in men;
however, as with type 1 diabetes mellitus, the most important risk factor, which is obesity,
is more common in women. Both biological and psychosocial factors are responsible for sex
and gender differences in diabetes risk and outcome. Overall, psychosocial stress appears
to have a greater impact on women than on men. Gender differences are equally important
in the development, awareness, presentation, diagnosis, and therapy, as well as in the
prevention of the lifestyle-associated disease of patients with diabetes mellitus. It is also
true that awareness of the disease and the severity of its complications may not only depend
on gender in the strict sense but is also related to the experience of the man or woman and,
therefore, is dependent on the level of education, income, and quality of services, and social
and lifestyle support. Therefore, it is almost impossible to always make a clear distinction
between gender influences and exogenous factors or differences in everyday life because
these complex factors are interconnected and interact with each other throughout life.
Based on all these facts, in this review, gender differences will be described to indicate the
main biological differences and very generally to describe the predominant psychosocial
influences, but not universally concerning the reality present in the world population of
individuals affected by diabetes. The great impact of psychosocial risk factors in addition
to biological ones is the considerable regional differences and the prevalence in the various
territories of the various forms of diabetes in adult men and women. Most patients with
diabetes live in low-income countries, but prevalence rates in high-income countries are
comparable to those in developing countries and we consider the population with the
lowest socioeconomic level. This mainly depends on the diet of these populations shifted
to greater consumption of traditionally low-cost foods that have a high content of simple
or complex sugars and this goes hand in hand with the considerable regional differences
found in the increase in the phenomenon of obesity [2]. In addition, these estimates may
also be influenced by the fact that women in many parts of the world often suffer from
inequality in access to primary and secondary screening controls and more generally in
access to health care. In women, diabetes mellitus appears to be less controlled considering
each metabolic parameter, especially given the fact that they tend to have lower insulin
sensitivity than their male counterparts, resulting in greater use of insulin units to maintain
optimal glycemic values and compliant with therapeutic goals [2]. These differences in
glucose homeostasis between the two genders are to be found above all in the pre-diabetic
state where there is a reduced fasting glycemia, especially while women are more prone to
develop a reduced glucose tolerance in response to a meal or glucose load. [2]. In addition,
other evidence comes from the clustering disease of drug treatment of diabetes mellitus, in
which women are at higher risk of suffering from hypoglycemia using insulin, of urinary
and genital tract infections using glycosuric drugs such as glyphozines, and following the
use of thiazolidinediones, show an increased risk of postmenopausal bone fractures [2].
After what has been said, the genetic background, lifestyle, and environmental aspects
contribute greatly to the complexity of managing the diabetic patient and therefore, this
review will provide some clarification on the gender differences in diabetes mellitus.
Int. J. Mol. Sci. 2022, 23, 8850 3 of 13

2. Methods
In this narrative review, we have included clinical studies published by Pubmed up
to 30 May 2022. The keywords used were diabetes, comorbidities, and gender differences.
All articles and clinical publications published by Pubmed were studied by two authors.
Studies written in languages other than English were excluded. Two authors (PC, TC)
reviewed all articles, and all studies were qualitatively analyzed. The objective of this
review is to provide the necessary knowledge for decision support in the field of diabetic
pathology to promote robust approaches to managing disease and its complications in
functional gender. Despite the difficulty in finding scientific studies that emphasize the
role of gender in diabetic pathology and its complications, the rationale of reviewing this
pathology from a gender perspective remains an important function of health care, as a lack
of initial knowledge of this phenomenon can lead to loss of opportunities for investigation
and treatment and will certainly increase the level of adequate knowledge in the future
with consequent positive effects on the complete management of diabetes mellitus. We
conducted a comprehensive systematic search.

3. Types of Diabetes and Gender

3.1. Type 1 Diabetes
In type 1 diabetes, the pancreas is unable to produce insulin due to the destruction of
the beta-cells that can produce this hormone. It affects about 3–5% of people with diabetes
and generally occurs in childhood or adolescence but can also occur in adults. Type 1
diabetes is therefore characterized by beta-cell destruction, on an autoimmune or idiopathic
basis, which leads to absolute insulin deficiency. The cause of type 1 diabetes is unknown,
but it is now known that at the base of the disease there is a “sabotage” by the immune
system against the cells that produce insulin: the disease manifests itself in the presence of
direct antibodies in the blood against antigens present in the cells that produce insulin. It is,
for this reason, that type 1 diabetes is classified among the so-called “autoimmune” diseases.
The damage that the immune system causes to the cells that produce insulin is believed to
be linked to hereditary factors and/or environmental factors (including diet, lifestyle, and
contact with specific viruses). Type 1 diabetes is the only common autoimmune disease
not characterized by female predominance [2]. The pubertal period is associated with a
reduced incidence of Type 1 diabetes in girls who maintain stronger residual β-cell function
than boys [3]. This suggests that female gonadal hormones transiently protect against
type 1 diabetes and in general young adolescents with reduced serum estrogen activity
develop this form of diabetes [4,5]. In experimental models obtained from rats, it was
observed that the use of estradiol protects pancreatic islets from multiple metabolic and
pro-inflammatory lesions in vivo by restoring the immunomodulatory functions of natural
killer cells [6,7]. In contrast to previous studies that have shown no seasonality in the
incidence of type 1 diabetes, a Japanese study showed a higher incidence in women aged
0–19 years. These results, including the interaction we showed between age ranges and
seasons, may indicate that childhood-onset type 1 diabetes and adult type 1 diabetes have
different modes of onset [8]. Type 1 diabetes is diverse in its genetics, environmental
influences, immunology, metabolic characteristics, and clinical course. The heterogeneity
of type 1 diabetes stems from its polygenic nature, with interactions of multiple genes with
environmental factors. Recent advances in type 1 diabetes genetic knowledge and methods
have facilitated genotype–phenotype correlations. Age is a marker of heterogeneity in type
1 diabetes. Younger age is associated with higher risk and rate of progression through the
stages of the disease, as well as distinct histological characteristics, immunological patterns,
and genetic influences. In addition, clinical heterogeneity in type 1 diabetes is reflected
by differences in the risk of complications, which is related to a wide array of factors,
from hyperglycemia and longer diabetes duration, to race, ethnicity, and socioeconomic
factors [9].
Int. J. Mol. Sci. 2022, 23, 8850 4 of 13

Prediabetes
Prediabetes is a serious health condition that occurs when blood sugar levels are
higher than normal, but not high enough to diagnose type 2 diabetes. The prevalence of
prediabetes differs between the sexes, giving rise to clinical implications: Men develop
fasting blood glucose more often, while women more often show high post-meal blood
glucose levels. The increase in fasting glucose is characterized by increased hepatic glucose
production and reduced early insulin secretion, while postprandial hyperglycemia is mainly
due to peripheral insulin resistance [10]. Post-prandial hyperglycemia can better predict
progression to diabetes and is burdened by a greater risk of mortality since it is more
strictly the cause of an increase in cardiovascular risk. This underlines the importance
of performing oral glucose tolerance tests for screening especially in women if an initial
alteration of glucose metabolism is suspected.

3.2. Type 2 Diabetes

The prevalence of type 2 diabetes is also characterized by a gender difference. Overall,
the global prevalence of diabetes is higher in men, but there are more women with type
2 diabetes than men [2]. The gender difference in the prevalence of diabetes is reversed
according to the stage of reproductive life: that is, there are more diabetic men before pu-
berty, while there are more diabetic women after the age of menopause and in old age. The
combined effect of more elderly women than men in most populations and the increasing
prevalence of diabetes with age is the explanation given for this observation. This is an
important observation because, as discussed above, women show more impaired glucose
tolerance after a meal. Therefore, considering only fasting blood glucose as a screening and
with the exclusion of post-prandial blood glucose values in calculating the prevalence of
diabetes in women one could risk underestimating a much more evident phenomenon [11].
Faced with a greater prevalence of type 2 diabetes in women, it is important to underline
that the forms of diabetes complicated by ketosis or diabetic ketoacidosis are encountered
more in males [11]. The protection that women enjoy against ketosis and ketoacidosis
only fails if there is a hypoestrogenic state or a prolonged anovulatory condition [11]. It
is also interesting to note that the alterations in glucose homeostasis after meals are also
associated with an increase in visceral adipose tissue and the presence of the latter does
nothing but amplify insulin resistance in women, influencing the control of the values more.
glycemic levels, on glycated hemoglobin, on average glycemia over 24 h, and increasing the
therapeutic need for oral hypoglycemic agents in reaching the desired glycemic target [11].
Vitamin D can also directly stimulate insulin receptor expression, thereby improving glu-
cose transport in human cells [12]. A significant interaction between sex and vitamin D
was found prior to the sex-stratified analysis. In a population-specific cross-sectional study,
a low level of vitamin 25(OH)D3 was found in middle-aged Caucasians, independently
associated with type 2 diabetes in women but not in men [12]. The likelihood of having
newly diagnosed or known diabetes has more than doubled in women. Current type 2
diabetes guidelines to intensify therapy after metformin are largely based on potential
added benefits (e.g., weight reduction) or increased risk of side effects (e.g., hypoglycemia).
The reduction in MACE with therapy with sodium-glucose co-transport-2 inhibitors (SGLT-
2Is) appear to be significantly less in women with diabetes vs. men, while glucagon-like
peptide-1 receptor agonists (GLP-1Ras) confer a similar reduction in major adverse cardiac
events, irrespective of the gender [13,14].

3.3. Gestational Diabetes Mellitus

Gestational diabetes mellitus is a pathological entity in which the state of pregnancy
promotes or worsens greater insulin resistance in predisposed women or because they
are already overweight/obese by altering glucose homeostasis after meals. This form
of diabetes does not always limit itself or tends to disappear after pregnancy but where
it occurs it represents an important independent and strong female risk factor for the
possible onset of a form of type 2 diabetes [15]. As mentioned, gestational diabetes occurs
Int. J. Mol. Sci. 2022, 23, 8850 5 of 13

especially in women already affected by a certain level of insulin resistance such as obese
or overweight, however, women of normal weight can also be susceptible to this form of
diabetes due to genetic traits. which would appear in conjunction with the physiological
increase in insulin resistance during pregnancy. Despite the possibility of undertaking
intervention strategies against gestational diabetes, over 70% of women with it develop a
form of type 2 diabetes mellitus [16]. Furthermore, it is known that gestational diabetes is
more associated with adverse pregnancy outcomes that not only affect mothers but also
affect the newborn [15,16]. For the newborn, there may be an increase in birth weight,
an increased risk of hypoglycemia in the neonatal period, an increased risk of obesity in
childhood or adolescence, and an increased risk of type 2 diabetes in adulthood compared
to the children of a mother who did not have gestational diabetes. Newborns are at risk of
respiratory distress, hypoglycemia, hypocalcemia, hyperbilirubinemia, polycythemia, and
hyperviscosity. Furthermore, recent studies report that a pregnant woman with a male fetus
has a higher risk of developing gestational diabetes suggesting that the segregation of sex
chromosomes during fecundation affects to some extent the metabolic fate of the parturient
in the period of gestation [17–19]. Since the underlying mechanism is unclear, the authors
hypothesized several pathophysiological causes of these sex differences in β-cell function in
mothers. This could be related to the actions of the Y chromosome on sex-specific changes
in placental-derived hormones, as placental lactogen and prolactin or other proteins are
involved in the expansion of β cell mass [18]. Interestingly, the placenta in particular
exhibits many sex-specific alterations, including epigenetic mechanisms, which could really
have a huge impact on complications during and after pregnancy. These have recently
been examined in detail elsewhere [18,19]. Collectively, these new findings highlight the
impact of fetal sex on maternal glucose metabolism. The constant interaction between fetus
and mother, with potential future negative health impacts on both, clearly demonstrates
critical health neglect not only in the field of glucose metabolism, but also in the field of
gestational diabetes mellitus and fetal sex.

3.4. Menopause and Type 2 Diabetes in Women

The diabetic effect of menopausal estrogen deficiency in women can be considered
a form of gender difference between the two sexes. The exact effect of menopause on
impaired glucose metabolism in women, regardless of aging, has been studied by various
authors who agree that early menopause (before the age of 40) is associated with an
increased risk of type 2 diabetes compared to the menopause that occurs after the age
of 50 and that the cause of this is precisely the lack of estrogen since women who have
undergone surgical oophorectomy also have the same increased risk of diabetes [20,21].
The lack of estrogen due to menopause contributes to the development of type 2 diabetes
with three different mechanisms which include the alteration of insulin secretion by the beta
cells of the pancreas, the reduced sensitivity to insulin by the organs and tissues targeted,
and increased sensitivity to glucose by the main organs of diabetes-related pathology [21].
However, it should be emphasized that the protective action of estrogens on the onset
of diabetes occurs within a certain physiological range since it has been observed that if
circulating estrogens are physiologically increased or if they are used synthetically in the
form of oral contraceptives, insulin resistance develops. [20,21].

4. Gender and Metabolic Conditions Associated with Diabetes

4.1. Anthropometric Parameters
In women, aging and the transition from fertile life to menopause, with the loss of
estrogen production, is associated with changes in body shape and a preferential increase
in abdominal fat and perivisceral adiposity [22]. The lack of estrogen and increasing insulin
resistance means that diabetic women have a stronger association of obesity than diabetic
men [23]. Sex differences in body composition and fat deposition clearly contribute to the
diversification of diabetes risk between genders [21]. Increased leg fat has been found to
be associated with reduced cardiometabolic risk, especially in women, while increased
Int. J. Mol. Sci. 2022, 23, 8850 6 of 13

trunk fat is generally related to clustering of cardiometabolic risk factors in cross-sectional

population-based studies [22,23]. Recent studies have used the waist–call ratio as the
most effective index for evaluating the proportions between abdominal fat and leg muscle
mass and have shown that a favorable ratio to the former is an independent predictor
of cardiovascular disease, metabolic disease, steatosis, and hepatic fibrosis. In line with
this, women have a more noticeable increase in the waist–call ratio which becomes more
and more noticeable with increasing age than men. This also translates into a greater
cardiometabolic risk in women, in terms of glycemic and lipid abnormalities compared
to males [23] and a cardiovascular risk in women that becomes increasingly higher over
the years.

4.2. Brown Adipose Tissue

A high amount of brown adipose tissue is associated with reduced blood sugar levels
in humans, suggesting that brown adipose tissue, which is metabolically more active
because it carries out a greater turnover of fatty acids, also has a protective effect against
diabetes. However, the relationship between the consumption of glucose by brown adipose
tissue and systemic glycemic homeostasis is not so simple to define. Women have a much
higher prevalence and activity of this tissue [24]. It was observed only in mice, the activity
of brown adipose tissue is regulated by the growth factor for fibroblasts which in turn is
positively regulated by estrogen [25]. Therefore, especially in women, a greater presence of
brown adipose tissue could help reduce the risk of diabetes.

4.2.1. Adipokines
Adipokines are all molecules produced and secreted by adipose tissue with autocrine,
paracrine, or endocrine functions. Adipokines can be hormones, cytokines, chemokines,
regulators of lipid metabolism, regulators of glucose homeostasis, growth factors, proteins
of the alternative complement system, proteins involved in vascular homeostasis and pres-
sure regulators, proteins involved in angiogenesis, acute and stress response inflammatory
proteins, or components of the extracellular matrix. Some gender differences were also
highlighted in the expression of these molecules [26]. Leptin and adiponectin are important
in regulating satiety, food intake, and energy expenditure and can also influence the main
mechanisms that determine peripheral insulin resistance [26]. In general, women have
higher leptin and adiponectin levels than men [26]. The increase in plasma leptin is strongly
correlated with the increased risk of diabetes in males [26]. Women show an upregulation
of adiponectin and its receptor expression in abdominal adipose tissue which coincides
with a lower risk of diabetes and cardiovascular disease. In obese and diabetic subjects, an
inverse correlation is observed between plasma adiponectin levels and insulin sensitivity,
and this relationship is more frequently observed in women than in men [26].

4.2.2. Hepatic Steatosis

The liver is involved in various metabolic pathways, of which the control of glucose
production, the destruction of insulin, and the synthesis and sorting of fats are of great
importance. Fatty liver disease increases the risk of atherosclerosis and type 2 diabetes [27].
Women usually show less tendency to develop fatty liver disease than men and appear to
be protected against estrogens in the premenopausal age with a marked degree, described
in older women [28]. Furthermore, a sex-specific association between hepatic transaminase
levels and insulin sensitivity has been described [29].

4.3. Sex Hormones

Sex hormone-binding globulin (SHBG) is a protein produced in the liver that is capable
of binding testosterone, dihydrotestosterone, and estradiol (estrogen) and transporting
them in an inactive form into the bloodstream. Elevated SHBG levels may indicate a
polymorphism-mediated risk of diabetes that the SHBG gene may undergo [30]. In general,
Int. J. Mol. Sci. 2022, 23, 8850 7 of 13

women tend to have higher SHBG levels than men while reduced SHBG concentrations in
women may be associated with higher diabetes risk [30].

5. Gender Medicine for Diabetes and General Risk Factors

5.1. Social and Environmental Risk Factors
Modifiable social factors, such as low level of education, employment, and income,
contribute to a large extent to unhealthy lifestyle behaviors and social disparities and, there-
fore, are related to a higher risk of obesity and type 2 diabetes, particularly in women [31].
Socioeconomic status understood as the level of education, social position, and income
achieved, is inversely associated with the prevalence of obesity and type 2 diabetes in
developed countries [31]. A strong inverse association between employment and newly
detected diabetes was presented only in women [32]. The risk of diabetes is closely related
to indicators such as lower household income and food insecurity and is higher in women
but not in men [33]. In conclusion, the studies state that women seem more sensitive to
socio-environmental predictors and context, such as education, income, and employment,
for the future development of diabetes risk.

5.2. Psychosocial Stress and Sleep Disturbances

Discrimination of gender roles further increases environmental psychosocial stress,
as well as stress responses, especially in women. Females appear to be more vulnerable
to the adverse effects of the cardiometabolic impact of psychosocial stress, work stress,
and sleep disturbances, as well as partly due to unhealthy behavior [34,35]. However,
altogether the results are controversial [36]. Greater amounts of unpaid housework and
family responsibilities may contribute to feelings of mixed demands and sustained stress
levels in women, even in matched highly educated employee groups [37]. In a sex-specific
meta-analysis of epidemiological studies, it was shown that women of all ages have a 40%
higher risk of suffering from insomnia [38]. In turn, sleep loss, short sleep duration, and
reduced sleep quality were related to obesity and even more strongly to insulin resistance-
related (impaired glucose metabolism) [39]. In a meta-analysis, both short sleep (<5 h) and
difficulty initiating or maintaining sleep were associated with higher diabetes risk. How-
ever, comparable effect estimates were observed in both sexes after stratification by sex [39].
In a smaller prospective study looking for sex differences as a primary outcome, sleep
deprivation led to increased food and fat intake; however, males were more susceptible to
weight gain based on a higher daily calorie intake, especially during the night [36]. The
results of a meta-analysis of observational studies, with subgroups, analyzed by gender,
showed that shift work was associated with an increased risk of diabetes in men [36]. In
population-based cohort and occupational cohort studies, work strain has overall implied
a higher diabetes risk in women, especially in those who perceive a combination of lack
of control and high job demand, as well as low emotional support [40]. The controversial
findings of sex and gender differences in the work-stress–diabetes risk relationship can
be explained by differences in tolerance to inter-individual shift work, in the selection of
occupational groups, and in the specific definitions of work stress in the studies, as well as
differences in opportunities. for the recovery from work stress between men and women.
Taken together, these studies suggest that mismatches between the circadian clock and
social rhythms and between sex-dependent biological factors such as body composition
and gender-dependent social time affect the pathogenesis of diabetes in men and women.

5.3. Lifestyle and Nutrition

There are substantial sex differences in health behavior, nutrition, and physical activity,
which are closely associated with the risk of type 2 diabetes. According to sex-stratified
health research data, women are overall more inactive but engage more in a healthy
diet by consuming more fruit and vegetables and less meat [40]. The rapid economic
development and the simultaneous increase in the consumption of food derived from fast
food led to increased consumption of carbonated drinks, which contributes to the type 2
Int. J. Mol. Sci. 2022, 23, 8850 8 of 13

diabetes epidemic regardless of adiposity. In a prospective cohort study with separate

analysis for men and women, only women showed an increased risk of incident type 2
diabetes over 10 years, with a doubled risk in women with daily soft drink consumption
compared with non-alcoholic drinks. consumers [41]. Overall, only a slightly higher
number of deaths, however, have been found to have a minimally lower percentage of
deaths attributable to sugar-sweetened beverages for diabetes in women than in men [42].
In several observational studies, it has been shown that moderate alcohol consumption
is associated with a lower risk of type 2 diabetes. In fact, another meta-analysis based
on intervention studies showed that moderate alcohol consumption improves glycated
hemoglobin. in both sexes but tends to improve insulin sensitivity only in women [43]. A
cross-sectional analysis of the Nurses’ Health Study indicated that frequent alcohol intake
was independently related to higher levels of endogenous estradiol and that estradiol
alone influenced the protective association between alcohol consumption and diabetes
risk in patients, postmenopausal women [44]. Further research is needed to elucidate the
sex-specific dose–response relationships between alcohol consumption and type 2 diabetes
risk and the exact underlying mechanisms. The role of smoking and smoking has changed
substantially between men and women. Over the past decade, it has particularly increased
in young women, potentially contributing to a higher incidence of smoking-related diabetes
in women in the future [45]. Furthermore, a meta-analysis showed that the relative risk of
myocardial infarction, a major and frequent complication in diabetic subjects, conferred by
smoking appears to be 25% higher in women than in men [46]. A meta-analysis of cohort
studies with subgroup analyses by gender, both active and passive smoking is correlated
with a higher risk of developing type 2 diabetes in both men and women with no known
prominent sex differences [46].

6. Complications of Diabetes and Gender

6.1. Cardiovascular Complications
In newly diagnosed diabetic subjects without clinical cardiovascular disease, increased
atherosclerosis, and increased thickness of the intima-media in the carotid arteries were
found [47]. In general, the male sex, in addition to age, was more associated with carotid
plaques than the female sex. However, subgroup analysis revealed that, unlike male groups,
carotid atherosclerosis was more prevalent in newly diagnosed diabetic women than in
non-diabetic control women. These data confirm that in the presence of diabetes, the
protective effect that young women have is attenuated with a consequent increase in the
risk of cardiovascular events to a greater extent than in males [48]. Diabetes in association
with hypertension, low physical activity, and high alcohol intake were stronger predictors
of myocardial infarction in women than in men [49,50]. Furthermore, diabetes seems to
compromise the microcirculation more by altering the endothelial response in women
in a more dramatic way than in males, canceling the beneficial effects of estrogens [51].
Considering the specific results broken down by sex, a higher atherothrombotic risk is
highlighted for women with type 2 diabetes mellitus linked to greater prothrombotic
activity, and greater fibrin activity [52]. Another study investigated the effect of diabetes
on the development of collateral vessels after chronic total occlusion by observing that
in affected females there was poor angiogenesis in response to thrombotic insult [52].
Postmenopausal women are at a higher risk of ischemic stroke than men of comparable
age. Furthermore, the frequency of stroke recurrence in the years following the first event
is higher in diabetic women regardless of age. Considering the gender ratio, the risk of
fatal coronary heart disease or stroke is higher in women [49,50].

6.2. Heart Failure

Obesity, hypertension, and diabetes are all important and independent risk factors
for heart failure and can cause deterioration of myocardial function and metabolism more
in women than in men [53]. Males tend to suffer from heart failure more often at a
young age with a greater tendency to develop dilated cardiomyopathy while women
Int. J. Mol. Sci. 2022, 23, 8850 9 of 13

tend to develop hypertrophic cardiomyopathy more often with diastolic heart failure and
preserved ejection fraction [54]. The main differences in gender and in the presentation
of heart disease associated with myocardial pump failure are to be found in the different
adrenergic responses to physical activity with higher effects in women causing differences
in lipid metabolism and contributing to heart muscle hypertrophy [55].

6.3. Diabetic Foot

Men develop diabetic foot syndrome at an early age and more frequently experience
lower limb amputations [56,57]. Age, body mass index (BMI), and systolic blood pressure
in men, while age, uric acid levels, and insulin therapy were independent risk factors for
disease progression in women. Male sex, peripheral arterial disease, and renal failure are
predictors of long-term death [58].

6.4. Diabetic Retinopathy

Diabetic retinopathy does not show a clear gender prevalence. Furthermore, the
evidence available to date on the potential pathophysiological bases capable of explaining
the identified gender differences is very limited.

6.5. Diabetic Nephropathy

A higher prevalence of vascular and renal damage in women was observed in insulin-
resistant patients, with a greater increase in the intima-media thickness, a greater number
of vascular plaques, and a reduction in blood flow at the level of the afferent artery [59].
Despite this, however, men show a more rapid progression of diabetic nephropathy and
more often undergo dialysis therapy [60]. However, diabetic women have a higher mortality
risk than diabetic men during chronic dialysis treatment [61]. The death event can occur
for various causes, including cardiovascular ones, comorbidities related to old age, and
plows always characterized by a progressive deterioration due to worsening of glycemic
control. Underlying this has been recognized increased oxidative stress in diabetic women
with end-stage renal disease. Sex hormones may be a key to explaining these differences
between men and women, generally suggesting that women are protected from estrogen,
hindering the progression of non-diabetic kidney disease at least before menopause [62].
In older adults with type 2 diabetes, long-term effects of a moderate protein diet (MPD)
regimen are associated with a significant decline of renal function, proteinuria, low-grade
inflammation, and oxidative stress without a change in fat-free mass [63].
Giordano et al., reported that in elderly Type 2 diabetic patients, long term effects
of LPD 6/7 regimen in comparison to LPD 7/7 are associated with a similar decline in
CrCl, but with decreased depressive symptoms and a better quality of life [64]. No data
are reported on the long-term effects of a low protein diet (LPD) by gender on depressive
symptoms and the quality of life in elderly Type 2 diabetic.

6.6. Diabetic Neuropathy

Diabetic neuropathy, one of the most common and disabling chronic complications of
the disease, is characterized by a broad spectrum of functional and structural alterations of
the peripheral nerves that affect a proteiform clinical picture, of which distal symmetrical
peripheral neuropathy is the most common [65]. Women show an increased risk of devel-
oping painful symptoms of neuropathy, especially of an algogenic and nociceptive nature,
and more frequent symptoms of neuropathy such as paresthesia and loss of sensation in
the feet [66].

6.7. Diabetic Gastroparesis

Many studies have shown a higher prevalence of gastroparesis in women than in
men, other studies have not highlighted gender differences. In some studies, it has been
pointed out that even in diabetic subjects without gastroparesis, gastric emptying is slower
in women than in men [67,68]. It is known that glucose metabolism is influenced by gastric
Int. J. Mol. Sci. 2022, 23, 8850 10 of 13

emptying and intestinal glucose absorption and the gender difference could be related to
the way in which higher glucose is absorbed in women, possibly due to slower gastric
emptying [69,70].

6.8. Mental Disorders

Anxiety, eating disorders, and depression are more common in people with diabetes,
especially women [71]. Diabetic men appear to live more effectively with their disease,
displaying a lower prevalence of depression and anxiety, more problem-oriented and
resolution strategies, a better health-related quality of life, and positive well-being [72].

6.9. Sexual Function and Reproduction

Diabetic males and females are prone to suffer from sexual dysfunction and repro-
ductive problems, which appear to be underestimated in clinical practice. Pre-pregnancy
care in diabetic women of childbearing age is still unsatisfactory, due to steadily increasing
rates of severe perinatal complications, including excessive malformation rates and higher
mortality [73].

7. Conclusions
Gender medicine plays a fundamental role in the genesis of diabetes and in the
development of various complications. Sex hormones play a role, at least in part, in
these sex differences by regulating glucose homeostasis, insulin secretion, and action as
well as influencing the progression of diabetes and various complications. Knowledge
of the interactions between the endocrine regulation system and homeostasis is essential
to promote the development of therapeutic alternatives for diabetes based on gender
differences. Newer glucose-lowering agents used with metformin were associated with
a lower risk of major adverse cardiovascular events. This beneficial effect was more
pronounced in women than in men, especially for GLP-1RA users. Newer agents were also
associated with a lower risk of adverse events, with no clear sex–drug interactions. The
cholesterol absorption inhibitor ezetimibe and PCSK9 inhibitors have also been shown to
lower risk in patients with diabetes. Recently, the eicosapentaenoic (EPA) only n-3 fatty
acid, icosapent ethyl, has also shown benefit for cardiovascular risk reduction in patients
with diabetes. To date, no agents targeting HDL increase have shown cardiovascular benefit
in patients on background statin therapy. Difference in response to these drugs may be
related to pharmacokinetic and pharmacodynamic differences based on gender. Women
have a higher percentage of body fat and lower plasma volume with less organ blood
flow. Increased body fat content explains the faster onset and prolonged duration of action
and higher volume of distribution of lipophilic drugs, while the volume of distribution
of hydrophilic drugs is smaller, producing higher initial plasma levels and greater effects
when compared with males. Hepatic drug clearance is a function of cardiac output and
liver blood flow, which are lower in women, while hepatic enzyme activity involved in
phase I and II reactions, and transporters exhibit sex-specific differences.

Author Contributions: T.C.: Conceptualization, writing—original draft, supervision; P.C.: writing—

review and editing; G.L.: data curation; E.M.: supervision, writing—original draft; O.P.: writing—
original draft; M.G.: writing—review and editing. All authors have read and agreed to the published
version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.
Data Availability Statement: Not applicable.
Conflicts of Interest: The authors declare no conflict of interest.
Int. J. Mol. Sci. 2022, 23, 8850 11 of 13

References
1. Manicardi, V.; Russo, G.; Napoli, A.; Torlone, E.; Li Volsi, P.; Giorda, C.B.; Musacchio, N.; Nicolucci, A.; Suraci, C.;
Lucisano, G.; et al. Gender-disparities in adults with type 1 diabetes: More than a quality-of-care issue. A cross-sectional
observational study from the AMD Annals Initiative. PLoS ONE 2016, 11, e0162960. [CrossRef]
2. Campesi, I.; Franconi, F.; Seghieri, G.; Meloni, M. Sex-gender-related therapeutic approaches for cardiovascular complications
associated with diabetes. Pharmacol. Res. 2017, 119, 195–207. [CrossRef]
3. Samuelsson, U.; Lindblad, B.; Carlsson, A.; Forsander, G.; Ivarsson, S.; Kockum, I.; Lernmark, Å.; Marcus, C.; Ludvigsson,
J.; Better Diabetes Diagnosis (BDD) Study Group. Residual beta cell function at diagnosis of type 1 diabetes in children and
adolescents varies with gender and season. Diabetes Metab. Res. Rev. 2013, 29, 85–89. [CrossRef]
4. Martínez, D.; Castro, A.; Merino, P.M.; López, P.; Lardone, M.C.; Iñiguez, G.; Cassorla, F.; Codner, E. Oestrogen activity of the
serum in adolescents with Type 1 diabetes. Diabet. Med. 2016, 33, 1366–1373. [CrossRef]
5. Tiano, J.P.; Mauvais-Jarvis, F. Importance of oestrogen receptors to preserve functional beta-cell mass in diabetes. Nat. Rev.
Endocrinol. 2012, 8, 342–351. [CrossRef]
6. Mauvais-Jarvis, F. Role of Sex Steroids in beta Cell Function, Growth, and Survival. Trends Endocrinol. Metab. 2016, 27, 844–855.
[CrossRef]
7. Gourdy, P.; Bourgeois, E.A.; Levescot, A.; Pham, L.; Riant, E.; Ahui, M.L.; Damotte, D.; Gombert, J.M.; Bayard, F.; Ohlsson, C.; et al.
Estrogen Therapy Delays Autoimmune Diabetes and Promotes the Protective Efficiency of Natural Killer T-Cell Activation in
Female Nonobese Diabetic Mice. Endocrinology 2016, 157, 258–267. [CrossRef]
8. Nishioka, Y.; Noda, T.; Okada, S.; Myojin, T.; Kubo, S.; Higashino, T.; Ishii, H.; Imamura, T. Incidence and seasonality of type
1 diabetes: A population-based 3-year cohort study using the National Database in Japan. BMJ Open Diab. Res. Care 2020,
8, e001262. [CrossRef]
9. Redondo, M.J.; Hagopian, W.A.; Oram, R.; Steck, A.K.; Vehik, K.; Weedon, M.; Balasubramanyam, A.; Dabelea, D. The clinical
consequences of heterogeneity within and between different diabetes types. Diabetologia 2020, 63, 2040–2048. [CrossRef]
10. Unwin, N.; Shaw, J.; Zimmet, P.; Alberti, K.G. Impaired glucose tolerance and impaired fasting glycaemia: The current status
definition and intervention. Diabet. Med. 2002, 19, 708–723.
11. International Diabetes Federation. Diabetes Atlas, 8th ed.; International Diabetes Federation: Brussels, Belgium, 2017.
12. Stadlmayr, A.; Aigner, E.; Huber-Schönauer, U.; Niederseer, D.; Zwerina, J.; Husar-Memmer, E.; Hohla, F.; Schett, G.; Patsch, W.;
Datz, C. Relations of vitamin D status, gender and type 2 diabetes in middle-aged Caucasians. Acta Diabetol. 2015, 52, 39–46.
[CrossRef] [PubMed]
13. Singh, A.K.; Singh, R. Gender difference in cardiovascular outcomes with SGLT-2 inhibitors and GLP-1 receptor agonist in type 2
diabetes: A systematic review and meta-analysis of cardiovascular outcome trials. Diabetes Metab. Syndr. 2020, 14, 181–187.
[CrossRef] [PubMed]
14. Rea, F.; Ciardullo, S.; Savaré, L.; Perseghin, G.; Corrao, G. Comparing medication persistence among patients with type 2 diabetes
using sodium-glucose cotransporter 2 inhibitors or glucagon-like peptide-1 receptor agonists in real-world setting. Diabetes Res.
Clin. Pract. 2021, 180, 109035. [CrossRef]
15. Lende, M.; Rijhsinghani, A. Gestational Diabetes: Overview with Emphasis on Medical Management. Int. J. Environ. Res. Public
Health 2020, 17, 9573. [CrossRef]
16. Mack, L.R.; Tomich, P.G. Gestational Diabetes: Diagnosis, Classification, and Clinical Care. Obstet. Gynecol. Clin. N. Am. 2017, 44,
207–217. [CrossRef]
17. Retnakaran, R.; Shah, B.R. Sex of the baby and future maternal risk of type 2 diabetes in women who had gestational diabetes.
Diabet. Med. 2016, 33, 956–960. [CrossRef]
18. Gabory, A.; Roseboom, T.J.; Moore, T.; Moore, L.G.; Junien, C. Placental contribution to the origins of sexual dimorphism in health
and diseases: Sex chromosomes and epigenetics. Biol. Sex. Differ. 2013, 4, 5. [CrossRef]
19. Rosenfeld, C.S. Sex-specific placental responses in fetal development. Endocrinology 2015, 156, 3422–3434. [CrossRef]
20. Shen, L.; Song, L.; Li, H.; Liu, B.; Zheng, X.; Zhang, L.; Yuan, J.; Liang, Y.; Wang, Y. Association between earlier age at natural
menopause and risk of diabetes in middle-aged and older Chinese women: The Dongfeng-Tongji cohort study. Diabetes Metab.
2017, 43, 345–350. [CrossRef]
21. Mauvais-Jarvis, F.; Manson, J.E.; Stevenson, J.C.; Fonseca, V.A. Menopausal hormone therapy and type 2 diabetes prevention:
Evidence, mechanisms and clinical implications. Endocr. Rev. 2017, 38, 173–188. [CrossRef] [PubMed]
22. Tramunt, B.; Smati, S.; Grandgeorge, N.; Lenfant, F.; Arnal, J.F.; Montagner, A.; Gourdy, P. Sex differences in metabolic regulation
and diabetes susceptibility. Diabetologia 2020, 63, 453–461. [CrossRef] [PubMed]
23. Beaudry, K.M.; Devries, M.C. Sex-based differences in hepatic and skeletal muscle triglyceride storage and metabolism 1. Appl.
Physiol. Nutr. Metab. 2019, 44, 805–813. [CrossRef] [PubMed]
24. Wang, Q.; Zhang, M.; Xu, M.; Gu, W.; Xi, Y.; Qi, L.; Li, B.; Wang, W. Brown adipose tissue activation is inversely related to central
obesity and metabolic parameters in adult human. PLoS ONE 2015, 10, e0123795. [CrossRef] [PubMed]
25. Grefhorst, A.; van den Beukel, J.C.; van Houten, E.L.; Steenbergen, J.; Visser, J.A.; Themmen, A.P. Estrogens increase expression of
bone morphogenetic protein 8b in brown adipose tissue of mice. Biol. Sex Differ. 2015, 6, 7. [CrossRef]
26. Delaney, K.Z.; Santosa, S. Sex differences in regional adipose tissue depots pose different threats for the development of Type 2
diabetes in males and females. Obes. Rev. 2022, 23, e13393. [CrossRef]
Int. J. Mol. Sci. 2022, 23, 8850 12 of 13

27. Hocking, S.; Samocha-Bonet, D.; Milner, K.L.; Greenfield, J.R.; Chisholm, D.J. Adiposity and insulin resistance in humans: The
role of the different tissue and cellular lipid depots. Endocr. Rev. 2013, 34, 463–500. [CrossRef]
28. Pan, J.J.; Fallon, M.B. Gender and racial differences in non-alcoholic fatty liver disease. World J. Hepatol. 2014, 6, 274–283.
[CrossRef]
29. Buday, B.; Pach, P.F.; Literati-Nagy, B.; Vitai, M.; Kovacs, G.; Vecsei, Z.; Koranyi, L.; Lengyel, C. Sex influenced association of
directly measured insulin sensitivity and serum transaminase levels: Why alanine aminotransferase only predicts cardiovascular
risk in men? Cardiovasc. Diabetol. 2015, 14, 55. [CrossRef]
30. Muka, T.; Nano, J.; Jaspers, L.; Meun, C.; Bramer, W.M.; Hofman, A.; Dehghan, A.; Kavousi, M.; Laven, J.S.; Franco, O.H.
Associations of Steroid Sex Hormones and Sex Hormone-Binding Globulin with the Risk of Type 2 Diabetes in Women: A
Population-Based Cohort Study and Meta-analysis. Diabetes 2017, 66, 577–586. [CrossRef]
31. Kautzky-Willer, A.; Dorner, T.; Jensby, A.; Rieder, A. Women show a closer association between educational level and hypertension
or diabetes mellitus than males: A secondary analysis from the Austrian HIS. BMC Public Health 2012, 12, 392. [CrossRef]
32. Rivera, L.A.; Lebenbaum, M.; Rosella, L.C. The influence of socioeconomic status on future risk for developing type 2 diabetes in
the Canadian population between 2011 and 2022: Differential associations by sex. Int. J. Equity Health 2015, 14, 101. [CrossRef]
[PubMed]
33. Vetter, C.; Devore, E.E.; Ramin, C.A.; Speizer, F.E.; Willett, W.C.; Schernhammer, E.S. Mismatch of sleep and work timing and risk
of type 2 diabetes. Diabetes Care 2015, 38, 1707–1713. [CrossRef] [PubMed]
34. Silva-Costa, A.; Rotenberg, L.; Nobre, A.A.; Schmidt, M.I.; Chor, D.; Griep, R.H. Gender-specific association between nightwork
exposure and type-2 diabetes: Results from longitudinal study of adult health, ELSA-Brasil. Scand. J. Work Environ. Health 2015,
41, 568–578. [CrossRef] [PubMed]
35. Gan, Y.; Yang, C.; Tong, X.; Sun, H.; Cong, Y.; Yin, X.; Li, L.; Cao, S.; Dong, X.; Gong, Y.; et al. Shift work and diabetes mellitus: A
meta-analysis of observational studies. Occup. Environ. Med. 2015, 72, 72–78. [CrossRef] [PubMed]
36. Berntsson, L.; Lundberg, U.; Krantz, G. Gender differences in work-home interplay and symptom perception among Swedish
white-collar employees. J. Epidemiol. Community Health 2006, 60, 1070–1076. [CrossRef]
37. Zhang, B.; Wing, Y.K. Sex differences in insomnia: A metanalysis. Sleep 2006, 29, 85–89. [CrossRef]
38. Schmid, S.M.; Hallschmid, M.; Schultes, B. The metabolic burden of sleep loss. Lancet Diabetes Endocrinol. 2015, 3, 52–62. [CrossRef]
39. Cappuccio, F.P.; D’Elia, L.; Strazzullo, P.; Miller, M.A. Quantity and quality of sleep and incidence of type 2 diabetes: A systematic
review and meta-analysis. Diabetes Care 2010, 33, 414–420. [CrossRef]
40. Heraclides, A.M.; Chandola, T.; Witte, D.R.; Brunner, E.J. Work stress, obesity and the risk of type 2 diabetes: Gender-specific
bidirectional effect in the Whitehall II study. Obesity 2012, 20, 428–433. [CrossRef]
41. Ladabaum, U.; Mannalithara, A.; Myer, P.A.; Singh, G. Obesity, abdominal obesity, physical activity, and caloric intake in US
adults: 1988 to 2010. Am. J. Med. 2014, 127, 717–727.e712. [CrossRef]
42. Singh, G.M.; Micha, R.; Khatibzadeh, S.; Lim, S.; Ezzati, M.; Mozaffarian, D. Estimated global, regional, and national disease
burdens related to sugar-sweetened beverage consumption in 2010. Circulation 2015, 132, 639–666. [CrossRef] [PubMed]
43. Schrieks, I.C.; Heil, A.L.; Hendriks, H.F.; Mukamal, K.J.; Beulens, J.W. The effect of alcohol consumption on insulin sensitivity
and glycemic status: A systematic review and meta-analysis of intervention studies. Diabetes Care 2015, 38, 723–732. [CrossRef]
[PubMed]
44. Rohwer, R.D.; Liu, S.; You, N.C.; Buring, J.E.; Manson, J.E.; Song, Y. Interrelationship between alcohol intake and endogenous
sex-steroid hormones on diabetes risk in postmenopausal women. J. Am. Coll. Nutr. 2015, 34, 273–280. [CrossRef] [PubMed]
45. Raho, E.; van Oostrom, S.H.; Visser, M.; Huisman, M.; Zantinge, E.M.; Smit, H.A.; Verschuren, W.M.; Hulsegge, G.; Picavet, H.S.
Generation shifts in smoking over 20 years in two Dutch population-based cohorts aged 20–100 years. BMC Public Health 2015,
15, 142. [CrossRef] [PubMed]
46. Huxley, R.R.; Woodward, M. Cigarette smoking as a risk factor for coronary heart disease in women compared with men: A
systematic review and meta-analysis of prospective cohort studies. Lancet 2011, 378, 1297–1305. [CrossRef]
47. Catalan, M.; Herreras, Z.; Pinyol, M.; Sala-Vila, A.; Amor, A.J.; De Groot, E.; Gilabert, R.; Ros, E.; Ortega, E. Prevalence by sex of
preclinical carotid atherosclerosis in newly diagnosed type 2 diabetes. Nutr. Metab. Cardiovasc. Dis. 2015, 25, 742–748. [CrossRef]
48. Mascarenhas-Melo, F.; Marado, D.; Palavra, F.; Sereno, J.; Coelho, Á.; Pinto, R.; Teixeira-Lemos, E.; Teixeira, F.; Reis, F. Diabetes
abrogates sex differences and aggravates cardiometabolic risk in postmenopausal women. Cardiovasc. Diabetol. 2013, 12, 61.
[CrossRef]
49. Peters, S.A.; Huxley, R.R.; Woodward, M. Diabetes as a risk factor for stroke in women compared with men: A systematic review
and meta-analysis of 64 cohorts, including 775, 385 individuals and 12, 539 strokes. Lancet 2014, 383, 1973–1980. [CrossRef]
50. Peters, S.A.; Huxley, R.R.; Woodward, M. Diabetes as risk factor for incident coronary heart disease in women compared with
men: A systematic review and meta-analysis of 64 cohorts including 858, 507 individuals and 28, 203 coronary events. Diabetologia
2014, 57, 1542–1551. [CrossRef]
51. Dantas, A.P.; Fortes, Z.B.; de Carvalho, M.H. Vascular disease in diabetic women: Why do they miss the female protection? Exp.
Diabetes Res. 2012, 2012, 570598. [CrossRef]
52. Yetkin, E.; Topal, E.; Erguzel, N.; Senen, K.; Heper, G.; Waltenberger, J. Diabetes mellitus and female gender are the strongest
predictors of poor collateral vessel development in patients with severe coronary artery stenosis. Angiogenesis 2015, 18, 201–207.
[CrossRef] [PubMed]
Int. J. Mol. Sci. 2022, 23, 8850 13 of 13

53. Li, W.; Katzmarzyk, P.T.; Horswell, R.; Zhang, Y.; Wang, Y.; Johnson, J.; Hu, G. Body mass index and heart failure among patients
with type 2 diabetes. Circ. Heart Fail. 2015, 8, 455–463. [CrossRef] [PubMed]
54. McAllister, D.A.; Read, S.H.; Kerssens, J.; Livingstone, S.; McGurnaghan, S.; Jhund, P.; Petrie, J.; Sattar, N.; Fischbacher, C.;
Kristensen, S.L.; et al. Incidence of hospitalization for heart failure and case-fatality among 3.25 million people with and without
diabetes mellitus. Circulation 2018, 138, 2774e86. [CrossRef] [PubMed]
55. Wright, A.K.; Kontopantelis, E.; Emsley, R.; Buchan, I.; Mamas, M.A.; Sattar, N.; Ashcroft, D.M.; Rutter, M.K. Cardiovascular
risk and risk factor management in type 2 diabetes: A population-based cohort study assessing sex disparities. Circulation 2019,
139, 2742. [CrossRef]
56. Tang, Z.Q.; Chen, H.L.; Zhao, F.F. Gender differences of lower extremity amputation risk in patients with diabetic foot: A
meta-analysis. Int. J. Low. Extrem. Wounds 2014, 13, 197–204. [CrossRef]
57. Bruun, C.; Siersma, V.; Guassora, A.D.; Holstein, P.; de Fine Olivarius, N. Amputations and footulcers in patients newly diagnosed
with type 2 diabetes mellitus and observed for 19 years. The role of age, gender and co-morbidity. Diabet. Med. 2013, 30, 964–972.
[CrossRef]
58. Morbach, S.; Furchert, H.; Gröblinghoff, U.; Hoffmeier, H.; Kersten, K.; Klauke, G.T.; Klemp, U.; Roden, T.; Icks, A.;
Haastert, B.; et al. Long-term prognosis of diabetic foot patients and their limbs: Amputation and death over the course of a
decade. Diabetes Care 2012, 35, 2021–2027. [CrossRef]
59. Yu, M.K.; Katon, W.; Young, B.A. Associations between sex and incident chronic kidney disease in a prospective diabetic cohort.
Nephrology 2015, 20, 451–458. [CrossRef]
60. De Hauteclocque, A.; Ragot, S.; Slaoui, Y.; Gand, E.; Miot, A.; Sosner, P.; Halimi, J.M.; Zaoui, P.; Rigalleau, V.; Roussel, R.; et al.
The influence of sex on renal function decline in people with Type 2 diabetes. Diabet. Med. 2014, 31, 1121–1128. [CrossRef]
61. Radcliffe, N.J.; Seah, J.M.; Clarke, M.; MacIsaac, R.J.; Jerums, G.; Ekinci, E.I. Clinical Predictive Factors in Diabetic Kidney Disease
Progression. J. Diabetes Investig. 2017, 8, 6–18. [CrossRef]
62. Valdivielso, J.M.; Jacobs-Cachá, C.; Soler, M.J. Sex hormones and their influence on chronic kidney disease. Curr. Opin. Nephrol.
Hypertens. 2019, 28, 1–9. [CrossRef] [PubMed]
63. Giordano, M.; Ciarambino, T.; Castellino, P.; Cataliotti, A.; Malatino, L.; Ferrara, N.; Politi, C.; Paolisso, G. Long-term effects of
moderate protein diet on renal function and low-grade inflammation in older adults with type 2 diabetes and chronic kidney
disease. Clin. Nephrol. 2012, 78, 122–128. [CrossRef] [PubMed]
64. Ciarambino, T.; Castellino, P.; Paolisso, G.; Coppola, L.; Ferrara, N.; Signoriello, G.; Giordano, M. Long term effects of low protein
diet on depressive symptoms and quality of life in elderly Type 2 diabetic patients. Nutrition 2014, 30, 1045–1049. [CrossRef]
65. Lazo, M.D.; Bernabé-Ortiz, A.; Pinto, M.E.; Ticse, R.; Malaga, G.; Sacksteder, K.; Miranda, J.J.; Gilman, R.H. Diabetic Peripheral
Neuropathy in Ambulatory Patients with Type 2 Diabetes in a General Hospital in a Middle-Income Country: A Cross Sectional
Study. PLoS ONE 2014, 9, e95403. [CrossRef]
66. Lee, A.A.; Hasler, W.L. Diabetes and the Stomach. Curr. Treat. Options Gastroenterol. 2017, 15, 441–459. [CrossRef] [PubMed]
67. Krishnasamy, S.; Abell, T.L. Diabetic Gastroparesis: Principles and Current Trends in Management. Diabetes Ther. 2018, 9, 1–42.
[CrossRef]
68. Aslam, A.; Singh, J.; Rajbhandari, S. Prevalence of Painful Diabetic Neuropathy Using the Self Completed Leeds Assessment of
Neuropathic Symptoms and Signs Questionnaire in a Population with Diabetes. Can. J. Diabetes 2015, 39, 285–295. [CrossRef]
69. Fleischer, J. Diabetic autonomic imbalance and glycemic variability. J. Diabetes Sci. Technol. 2012, 6, 1207–1215. [CrossRef]
70. Anderwald, C.; Gastaldelli, A.; Tura, A.; Krebs, M.; Promintzer-Schifferl, M.; Kautzky-Willer, A.; Stadler, M.; DeFronzo, R.A.;
Pacini, G.; Bischof, M.G. Mechanism and effects of glucose absorption during an oral glucose tolerance among females and males.
J. Clin. Endocrinol. Metab. 2011, 96, 515–524. [CrossRef]
71. Grzymisławska, M.; Puch, E.A.; Zawada, A.; Grzymisławski, M. Do nutritional behaviors depend on biological sex and cultural
gender? Adv. Clin. Exp. Med. 2020, 29, 165–172. [CrossRef]
72. Siddiqui, M.A.; Khan, M.F.; Carline, T.E. Gender differences in living with diabetes mellitus. Mater. Sociomed. 2013, 25, 140–142.
[CrossRef] [PubMed]
73. Wing, R.R.; Bond, D.S.; Gendrano, I.N., III; Wadden, T.; Bahnson, J.; Lewis, C.E.; Brancati, F.; Schneider, S.; Kitabchi, A.E.; Van
Dorsten, B.; et al. Effect of intensive lifestyle intervention on sexual dysfunction in women with type 2 diabetes: Results from an
ancillary LookAHEAD study. Diabetes Care 2013, 36, 2937–2944. [CrossRef] [PubMed]