CFP
HOME HELP CONTACT US FEEDBACK SUBSCRIPTIONS CURRENT ISSUE PAST ISSUES SEARCH
QUICK SEARCH:   [advanced]


     

Can Fam Physician
Vol. 54, No. 2, February 2008, pp.219 - 227
Copyright © 2008 by The College of Family Physicians of Canada
This Article
Right arrow Abstract Freely available
Right arrow Résumé
Right arrow Full Text (PDF)
Right arrow Rapid Responses: Submit a response
Right arrow Alert me when this article is cited
Right arrow Alert me when Rapid Responses are posted
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Gucciardi, E.
Right arrow Articles by Stewart, D. E.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Gucciardi, E.
Right arrow Articles by Stewart, D. E.
Related Collections
Right arrow Résumés de recherche

Research

Characteristics of men and women with diabetes

Observations during patients’ initial visit to a diabetes education centre

Enza Gucciardi, MHSc PhD
Assistant Professor in the School of Nutrition at Ryerson University in Toronto, Ont, and an Affiliate Scientist at the University Health Network Women’s Health Program and the Toronto General Research Institute

Shirley Chi-Tyan Wang
Staff at the University Health Network Women’s Health Program in Toronto, Ont

Margaret DeMelo, RD CDE
Registered dietitian at the University Health Network Diabetes Education Centre

Lina Amaral, MSW RSW
Social worker at the University Health Network Diabetes Education Centre

Donna E. Stewart, MD DPsych FRCPC
Program Director of the University Health Network Women’s Health Program and a Professor in the Department of Psychiatry at the University of Toronto

Correspondence to: Dr Enza Gucciardi, School of Nutrition, Ryerson University, 350 Victoria St, Toronto, ON M5B 2K3; telephone 416 979–5000, extension 2728; fax 416 979–5204; e-mailegucciar{at}ryerson.ca

Although women in most developed and developing countries have lower mortality rates than men,1 they appear to lose this substantial survival advantage when they have diabetes. Studies have shown that the relative risk of cardiovascular disease (CVD),2,3 both coronary artery disease4,5 and stroke,6 is higher among women with diabetes than among men with diabetes.

While the literature suggests women are at higher risk of morbidity and mortality from diabetes complications, there is little research into why—specifically regarding management issues—this is the case. The few studies that have examined diabetes management in both women and men have reported differences by sex. Results indicated that women were more likely than men to view type 2 diabetes as having a negative effect on their lives and to worry about the complications associated with the disease.7 Men were more likely to be concerned about the limitations that diabetes would impose on their lives8 and to believe that diabetes is a controllable disease.9 In a recent study, men reported lower stress levels related to diabetes and a greater sense of well-being than women did.10

In general, men and women with diabetes also report different levels of social support.11 Men reported receiving greater family support in nutritional management than women did,9 a difference that might be due to traditional roles and the division of household labour.2 For instance, women are more often involved in the purchase and preparation of food in the household,12 so it is likely that women cooking for men with diabetes adjust the family’s diet in keeping with nutrition recommendations for diabetes, while women with diabetes often prepare separate modified meals for themselves rather than impose changes in diet on the rest of the family.13 Men view nutrition management as a broader family issue; women view it as a personal concern.14

Men and women differ not only biologically, but also in terms of attitudes, expectations, and life experiences within their social environments. Various factors can affect how people with diabetes manage the disease and consequently control the risk of future complications. The objective of this study was to identify differences in psychosocial, behavioural, and clinical measures between men and women with type 2 diabetes at the time of their first visit to a diabetes education centre.


   METHODS
TOP
 METHODS
RESULTS
 DISCUSSION
 Footnotes
 Acknowledgment
 References
 
Setting
The study was conducted at 2 large diabetes education centres located in the Toronto Western Hospital and the Trillium Health Centre in Ontario between October 2003 and October 2005. At the diabetes education centres, teams of dietitians, nurses, pharmacists, physiotherapists, psychologists, and social workers provide individual health assessments, follow-up visits, and group education. The research ethics boards at both institutions approved the study.

Participants
To be eligible for inclusion, participants had to be diagnosed with type 2 diabetes, responsible for managing their diabetes themselves, new to the centre or re-referred to the centre after a 2-year period, free from conditions known to influence participation (such as pregnancy or receiving hemodialysis), 18 years old or older, able to read and write English, not anticipating a change in residence within the next year, able to provide informed consent, and able to answer the questionnaire. Of the 1258 patients approached, 511 were eligible, and 281 consented, giving a participation rate of 55%. Data on 6 patients were excluded from the study analyses owing to unconfirmed diagnosis of type 2 diabetes during the study period, resulting in a total of 275 study participants.

Design
In this cross-sectional study, a questionnaire was administered to patients immediately after their appointments at the diabetes education centres. A glycosylated hemoglobin A1c (HbA1c) test was performed (if the most recent test results were not provided by patients’ referring physicians) to measure glycemic control following patients’ first visits. We also collected disease-related variables from patients’ medical charts.

Descriptive variables
The descriptive variables obtained from questionnaires and medical charts were sociodemographic, psychosocial, behavioural, clinical, and disease-related characteristics. Sociodemographic variables included age, education level, and household income (Table 1). Psychosocial variables included self-efficacy, outcome expectations, intention to use education services or adhere to recommended self-management activities, depressive symptoms, diabetes-specific and general social support, various aspects of satisfaction with diabetes education centre services, and intention to use further services (Table 2). Self-care activities included diet, exercise, foot care, and blood sugar testing during the previous 7 days (Table 3). Disease-related variables included number of months living with diabetes, family history of diabetes, previous diabetes education, knowledge about diabetes, total number of diabetes-related symptoms, total number of diabetes-related health conditions, smoking status, and type of diabetes management (Table 4). Clinical variables included body mass index (BMI), HbA1c and high-density lipoprotein cholesterol (HDL-C) levels, total cholesterol to HDL-C ratios, triglyceride and low-density lipoprotein cholesterol levels, and blood pressure (Table 5).


View this table:
[in this window]
[in a new window]

  		Table 1 Sociodemographic characteristics of the study population Mean age of all respondents was 54.4 years (standard deviation [SD] 11.8), of men was 53.86 years (SD 13.1), and of women was 55.7 years (SD 10.4) (P = .362). Some percentages do not add to 100 owing to missing data.

 

View this table:
[in this window]
[in a new window]

  		Table 2 Psychosocial characteristics of the study population Some percentages do not add to 100 owing to missing data.

 

View this table:
[in this window]
[in a new window]

  		Table 3 Self-care activities of the study population Some percentages do not add to 100 owing to missing data.

 

View this table:
[in this window]
[in a new window]

  		Table 4 Disease-related variables of the study population Some percentages do not add to 100 owing to missing data.

 

View this table:
[in this window]
[in a new window]

  		Table 5 Clinical characteristics of the study population Some percentages do not add to 100 owing to missing data.

 
Measures
Knowledge about diabetes was assessed using the Diabetes Knowledge Questionnaire.15 The General Practice Assessment Questionnaire was used to examine several domains of satisfaction with health services.16 The Diabetes Education Self-Efficacy Scale was employed to assess self-efficacy in using diabetes self-management education and in discussing self-management issues with health care providers. The Diabetes Education Outcome Expectations Scale was used to measure the helpfulness of diabetes self-management education. The Diabetes Education Intention Scale was used to measure intention to use diabetes education resources. The 21-item Beck Depression Inventory-II was used to measure symptoms of depression experienced during the previous 2 weeks.17,18 The Medical Outcomes Study Social Support Survey was used to measure general social support.19 The Perceived Social Support component of the Diabetes Care Profile20 was used to measure diabetes-specific social support. All scales have good validity and reliability.

Level of HbA1c was used as a reliable indicator of glycemic control during the preceding 3 to 4 months.21 All assays were conducted in laboratories certified as traceable to the Diabetes Control and Complications Trial reference method.22

Statistical analysis
For each descriptive variable, the mean, standard deviation, frequency, and proportion of the total study population with that variable were calculated. For the number of months people lived with diabetes, we calculated the median and interquartile range because of the skewed nature of the variable. To examine variables by sex, categorical variables were analyzed using the {chi}2 test, continuous variables were analyzed using the t test, and continuous variables with skewed distributions were analyzed using the Mann-Whitney test. A significance level of .05 was used in all analyses.


   RESULTS
TOP
 METHODS
 RESULTS
DISCUSSION
 Footnotes
 Acknowledgment
 References
 
About 75% of participants had been referred to the diabetes education centre by their primary care physicians. The study population was an average of 54.4 years old and had lived a median of 4 months with diabetes. Their mean BMI was 31.52, an indicator of obesity, and their mean HbA1c level (7.96%) was above the recommended target of 7.0%, suggesting poor glycemic control. Their total cholesterol to HDL-C ratio (4.43 mmol/L) was also greater than the recommended target of 4.0 mmol/L, showing inadequate management of lipids. Participants had an average blood pressure of 127.67/77.43 mm Hg, however, which is below the target level of 130/80 mm Hg.

As shown in Tables 1 to 5, significant differences between men and women were found in certain variables. Women were significantly more likely to have a family history of diabetes, previous diabetes education, higher expectations of the outcome of self-management activities, and higher perceived levels of support from professional health care teams. Mean BMI, HDL-C levels, and number of depressive symptoms were significantly higher among women than among men.


   DISCUSSION
TOP
 METHODS
 RESULTS
 DISCUSSION
Footnotes
 Acknowledgment
 References
 
Our findings showed that more women had family histories of diabetes and higher BMIs than men had upon arrival at a diabetes education centre. More than half the female participants (57.4%) fell within the obese category; fewer than half the men (48.1%) were obese. Both family history of diabetes and a high BMI are known risk factors for diabetes in men and women,23 and combination of the 2 further increases the risk of diabetes.24 Independent of family history, even a modest weight gain increases the risk of diabetes among middle-aged women.25 Obesity increases the risk of developing not only type 2 diabetes, but also hypertension, dyslipidemia, CVD, stroke, osteoarthritis, and some forms of cancer.26 With diabetes and obesity reaching epidemic proportions, it is incumbent on primary care providers to be vigilant about weight gain and the onset of diabetes in women.

According to clinical practice guidelines, screening patients as young as 40 in family physicians’ offices has proved useful for detecting unrecognized diabetes.27 While fasting plasma glucose is the recommended screening test, a 2-hour plasma glucose test in a 75-g oral glucose tolerance test might be indicated when fasting plasma glucose is 5.7 to 6.9 mmol/L28 and the likelihood of diabetes or impaired glucose tolerance is high (eg, among women with a history of gestational diabetes or who have given birth to babies weighing more than 4 kg; people with risk factors such as a first-degree relative with diabetes; and those who are overweight).29

Women with diabetes have a significantly higher risk of coronary artery disease and a higher mortality rate from CVD than men with diabetes do.30 Heart disease remains the leading cause of mortality among people with diabetes.31 Given the findings of our study, care providers should not only regularly screen women who have a family history of diabetes or who are overweight (BMI = 25) for diabetes, but should also screen those already diagnosed with diabetes for CVD. Canadian clinical practice guidelines for management of obesity and for prevention and management of diabetes emphasize the need to engage patients actively in lifestyle and diet modifications to manage their weight and reduce their risk of complications.26,29

Women in our study had sought education on diabetes in the past more often than men had. They also appeared to have higher expectations of the benefits of self-management to their overall health. Studies largely from industrialized western countries show that women report more frequent use of preventive and therapeutic health care services for acute and chronic conditions than men do.32,33 The literature also suggests that women suffer more morbidity, report illness more often, and have a greater propensity to seek health care overall.33–35 Our study did not find any differences by sex in intention to continue using diabetes education centre services or other diabetes-related resources in the future. These findings, however, raise some interesting questions. For instance, given women’s greater use of diabetes education services in the past, why are women at higher risk of diabetes-related complications? And are diabetes education and management strategies effective in preventing and reducing risk of complications for both men and women equally? Further research is needed to better understand how people use diabetes education services and how these services affect health outcomes in women and men.

Although no differences were observed in diabetes-specific, family, or general social support between men and women, women perceived they had higher levels of social support from their professional health care teams than men did. In general, women reported less family support than men did,9,36–38 and this support declined as women aged.39 Although there were no differences in living arrangements between men and women in our study population, we did find that more women than men were single, widowed, or divorced. It is plausible that women with diabetes felt the need to seek support from their health care teams owing to the lack of family or social support they need and were more receptive to the support they received from these teams. Because family and friends provide the necessary physical and emotional support for people with diabetes on an intimate and day-to-day basis, care providers should draw on this natural support resource by educating and counseling not only patients but also those close to patients.

Women in our study, as in other studies, were on average more likely to have depressive symptoms than men were.40–42 Although on average both men and women scored in the minimal depressive symptom category (total score between 0 and 13), more women than men were in the mild (14 to 19), moderate (20 to 29), and severe (29 to 63) categories. Women in the general population are approximately twice as likely as men to have major depression,43 and those with either type 1 or type 2 diabetes are twice as likely as people in the general population to be clinically depressed.44 Yet depression often goes undiagnosed among those with diabetes.45 The combination of depression and diabetes is especially dangerous and demands special attention because it is associated with substantially increased risk of all-cause mortality.46 Depression also has an adverse effect on sense of self-efficacy and personal interactions47 and reduces satisfaction with care,48 which predicts poor adherence to medical regimens.49

Diabetes-specific studies also demonstrate that depression is linked to poor health practices,50 such as missing diabetes-related medical appointments,51 paying less attention to diabetes self-care activities,52–54 having poor glycemic control, and, therefore, increasing risk of diabetic complications.52,55,56 Findings from both current and past studies suggest that diabetes health care services should screen patients, particularly women, for depressive symptoms, and provide timely, effective interventions. Patients at physicians’ offices and at diabetes education centres should undergo brief psychosocial screening as part of their initial assessment. Patients who score over a threshold level for depression should be evaluated by their family physicians and, if appropriate, be treated with antidepressants or psychotherapy. If necessary, patients can be referred to psychiatrists or clinical psychologists for more thorough mental-health assessment and appropriate treatment.

Limitations
Potential limitations of our study include the fact that some of the data collected were based on self-report, making them prone to recall bias and overestimation of actual behaviour to provide socially desirable responses.57,58 Studies have shown, however, that self-reported data on diabetes, chronic diseases, and several cardiovascular risk factors are reliable.59–61 In addition, study participants were all users of the diabetes education centre and, as such, do not reflect all people with diabetes. Last, the cross-sectional nature of our study allowed us to observe differences by sex only at a single point in time. Future research should investigate the development of differences between men and women living with diabetes over time to assess if and when these differences alter over the course of the disease and whether they influence health outcomes.

Conclusion
It appears that there are psychosocial, behavioural, and clinical differences between men and women with diabetes that might affect their risk of getting diabetes, their attitudes and behaviour toward self-care for diabetes, and consequently their health outcomes. It is important that physicians consider the differences between men and women’s attitudes to diabetes management when they are counseling, educating, and caring for them. Primary care providers should focus on promoting the benefits of diabetes self-management to men, and should regularly screen those at higher risk of developing diabetes, particularly women with a family history of diabetes or a high BMI (= 25). Men and women with and without diabetes need to be counseled on weight management in order to reduce both BMI and the risk of developing diabetes or future diabetes-related complications. Finally, primary care providers should be encouraged to screen for depressive symptoms, particularly among women with diabetes.



   EDITOR’S KEY POINTS
 
  • Results of this study suggest that men and women with diabetes have different psychosocial, behavioural, and clinical characteristics when they first come to a diabetes education centre. These differences can affect the risk of diabetes, attitudes and behaviour toward self-care, and health outcomes.
  • In this study, women were likely to perceive they had more support from their diabetes health care team, and to see self-management as being beneficial. Men had lower expectations of the benefits of self-management.
  • It is important that sex and gender differences be considered in screening for, counseling and educating about, and managing diabetes.

 


   Acknowledgment
TOP
 METHODS
 RESULTS
 DISCUSSION
 Footnotes
 Acknowledgment
References
 
We thank the Canadian Diabetes Association for grant support, the Canadian Institutes of Health Research for training support for Dr Gucciardi, the Banting and Best Diabetes Centre for the Charles Hollenberg Summer Studentship Award to Ms Wang, the Diabetes Education Centre staff for their ongoing support, and Rachel Brooks for editing the manuscript


   Footnotes
TOP
 METHODS
 RESULTS
 DISCUSSION
 Footnotes
Acknowledgment
 References
 
Contributors

Dr Gucciardi was involved in concept and design of the study, coordinated the acquisition of data, analyzed and interpreted the data, and drafted and revised the manuscript. Ms Wang was involved in analysis and interpretation of data and contributed to drafting, reviewing, and revising the manuscript. Ms DeMelo was involved in concept and design of the study, acquisition and interpretation of data, and reviewing and revising the manuscript. Ms Amaral was involved in concept and design of the study, provided guidance in the interpretation of data, and reviewed and revised the manuscript. Dr Stewart was involved in concept and design of the study and reviewed and revised the manuscript.

Competing interests

None declared

This article has been peer reviewed.


   References
TOP
 METHODS
 RESULTS
 DISCUSSION
 Footnotes
 Acknowledgment
 References
 

  1. World Health Organization. Gender, health and ageing. Geneva, Switz: World Health Organization; 2003.
  2. Barrett-Connor E, Giardina EG, Gitt AK, Gudat U, Steinberg HO, Tschoepe D. Women and heart disease: the role of diabetes and hyperglycemia. Arch Intern Med 2004;164(9):934-42.[Abstract/Free Full Text]
  3. Zandbergen AA, Sijbrands EJ, Lamberts SW, Bootsma AH. Normotensive women with type 2 diabetes and microalbuminuria are at high risk for macrovascular disease. Diabetes Care 2006;29(8):1851-5.[Abstract/Free Full Text]
  4. Huxley R, Barzi F, Woodward M. Excess risk of fatal coronary heart disease associated with diabetes in men and women: meta-analysis of 37 prospective cohort studies. BMJ 2006;332(7533):73-8.[Abstract/Free Full Text]
  5. Liao Y, Cooper RS, Ghali JK, Lansky D, Cao G, Lee J. Sex differences in the impact of coexistent diabetes on survival in patients with coronary heart disease. Diabetes Care 1993;16(5):708-13.[Abstract]
  6. Tuomilehto J, Rastenyte D, Jousilahti P, Sarti C, Vartiainen E. Diabetes mellitus as a risk factor for death from stroke. Prospective study of the middle-aged Finnish population. Stroke 1996;27(2):210-5.[Abstract/Free Full Text]
  7. Fitzgerald JT, Anderson RM, Davis WK. Gender differences in diabetes attitudes and adherence. Diabetes Educ 1995;21(6):523-9.[Free Full Text]
  8. Jonsson PM, Sterky G, Gafvels C, Ostman J. Gender equity in health care: the case of Swedish diabetes care. Health Care Women Int 2000;21(5):413-31.[Medline]
  9. Brown SA, Harrist RB, Villagomez ET, Segura M, Barton SA, Hanis CL. Gender and treatment differences in knowledge, health beliefs, and metabolic control in Mexican Americans with type 2 diabetes. Diabetes Educ 2000;26(3):425-38.[Free Full Text]
  10. Rubin RR, Peyrot M, Siminerio LM. Health care and patient-reported outcomes: results of the cross-national Diabetes Attitudes, Wishes and Needs (DAWN) study. Diabetes Care 2006;29(6):1249-55.[Abstract/Free Full Text]
  11. Nielsen AB, de Fine ON, Gannik D, Hindsberger C, Hollnagel H. Structured personal diabetes care in primary health care affects only women’s HbA1c. Diabetes Care 2006;29(5):963-9.[Abstract/Free Full Text]
  12. Wong M, Gucciardi E, Li L, Grace SL. Gender and nutrition management in type 2 diabetes. Can J Diet Pract Res 2005;66(4):215-20.[Medline]
  13. Day JL. Why should patients do what we ask them to do? Patient Educ Couns 1995;26(1–3):113-8.[Medline]
  14. Peel E, Parry O, Douglas M, Lawton J. Taking the biscuit? A discursive approach to managing diet in type 2 diabetes. J Health Psychol 2005;10(6):779-91.[Abstract/Free Full Text]
  15. Garcia AA, Villagomez ET, Brown SA, Kouzekanani K, Hanis CL. The Starr County Diabetes Education Study: development of the Spanish-language diabetes knowledge questionnaire. Diabetes Care 2001;24(1):16-21.[Abstract/Free Full Text]
  16. Ramsay J, Campbell JL, Schroter S, Green J, Roland M. The General Practice Assessment Survey (GPAS): tests of data quality and measurement properties. Fam Pract 2000;17(5):372-9.[Abstract/Free Full Text]
  17. Beck AT, Steer RA, Brown GK. Manual for Beck Depression Inventory-II. San Antonio, TX: Psychological Corporation; 1996.
  18. Beck AT, Ward CH, Mendelson M, Mock J, Erbaugh J. An inventory for measuring depression. Arch Gen Psychiatry 1961;4:561-71.[Abstract/Free Full Text]
  19. Sherbourne CD, Stewart AL. The MOS social support survey. Soc Sci Med 1991;32(6):705-14.[Medline]
  20. Hess GE, Davis WK, Harrison RV. A diabetes psychosocial profile. Diabetes Educ 1986;12(2):135-40.[Free Full Text]
  21. Nathan DM, Singer DE, Hurxthal K, Goodson JD. The clinical information value of the glycosylated hemoglobin assay. N Engl J Med 1984;310(6):341-6.[Abstract]
  22. National Glycohemoglobin Standardization Program. National Glycohemoglobin Standardization Program 2005. Columbia, MO: University of Missouri; 2005. Available from: http://www.ngsp.org. Accessed 2008 Jan 14.
  23. Rich SS. Mapping genes in diabetes. Genetic epidemiological perspective. Diabetes 1990;39(11):1315-9.[Abstract]
  24. Hariri S, Yoon PW, Qureshi N, Valdez R, Scheuner MT, Khoury MJ. Family history of type 2 diabetes: a population-based screening tool for prevention? Genet Med 2006;8(2):102-8.[Medline]
  25. 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.[Abstract/Free Full Text]
  26. Lau DC, Douketis JD, Morrison KM, Hramiak IM, Sharma AM, Ur E. 2006 Canadian clinical practice guidelines on the management and prevention of obesity in adults and children [summary]. CMAJ 2007;176(8 Suppl):S1-13.[Free Full Text]
  27. Leiter LA, Barr A, Belanger A, Lubin S, Ross SA, Tildesley HD, et al. Diabetes Screening in Canada (DIASCAN) Study: prevalence of undiagnosed diabetes and glucose intolerance in family physician offices. Diabetes Care 2001;24(6):1038-43.[Abstract/Free Full Text]
  28. Saydah SH, Byrd-Holt D, Harris MI. Projected impact of implementing the results of the diabetes prevention program in the US population. Diabetes Care 2002;25(11):1940-5.[Abstract/Free Full Text]
  29. Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada. Can J Diabetes 2003;27(Suppl_2):S14-5.
  30. Pilote L, Dasgupta K, Guru V, Humphries KH, McGrath J, Norris C, et al. A comprehensive view of sex-specific issues related to cardiovascular disease. CMAJ 2007;176(6):S1-44.[Abstract/Free Full Text]
  31. Mosca L, Manson JE, Sutherland SE, Langer RD, Manolio T, Barrett-Connor E. Cardiovascular disease in women: a statement for healthcare professionals from the American Heart Association. Writing Group. Circulation 1997;96(7):2468-82.[Free Full Text]
  32. Nathanson CA. Sex roles as variables in preventive health behavior. J Commun Health 1977;3(2):142-55.[Medline]
  33. Merzel C. Gender differences in health care access indicators in an urban, low-income community. Am J Public Health 2000;90(6):909-16.[Abstract/Free Full Text]
  34. Fillenbaum GG, Horner RD, Hanlon JT, Landerman LR, Dawson DV, Cohen HJ. Factors predicting change in prescription and nonprescription drug use in a community-residing black and white elderly population. J Clin Epidemiol 1996;49(5):587-93.[Medline]
  35. Yount KM, Agree EM, Rebellon C. Gender and use of health care among older adults in Egypt and Tunisia. Soc Sci Med 2004;59(12):2479-97.[Medline]
  36. Agrawal A, Jacobson KC, Prescott CA, Kendler KS. A twin study of sex differences in social support. Psychol Med 2002;32(7):1155-64.[Medline]
  37. Wang CW, Iwaya T, Kumano H, Suzukamo Y, Tobimatsu Y, Fukudo S. Relationship of health status and social support to the life satisfaction of older adults. Tohoku J Exp Med 2002;198(3):141-9.[Medline]
  38. King KM, Collins-Nakai RL. Short-term recovery from cardiac surgery in women: suggestions for practice. Can J Cardiol 1998;14(11):1367-71.[Medline]
  39. Coventry WL, Gillespie NA, Heath AC, Martin NG. Perceived social support in a large community sample—age and sex differences. Soc Psychiatry Psychiatr Epidemiol 2004;39(8):625-36.[Medline]
  40. Peyrot M, Rubin RR. Levels and risks of depression and anxiety symptomatology among diabetic adults. Diabetes Care 1997;20(4):585-90.[Abstract]
  41. Blazer DG, Moody-Ayers S, Craft-Morgan J, Burchett B. Depression in diabetes and obesity: racial/ethnic/gender issues in older adults. J Psychosom Res 2002;53(4):913-6.[Medline]
  42. McCollum M, Hansen LS, Lu L, Sullivan PW. Gender differences in diabetes mellitus and effects on self-care activity. Gend Med 2005;2(4):246-54.[Medline]
  43. Kessler RC. Epidemiology of women and depression. J Affect Disord 2003;74(1):5-13.[Medline]
  44. Anderson RJ, Freedland KE, Clouse RE, Lustman PJ. The prevalence of comorbid depression in adults with diabetes: a meta-analysis. Diabetes Care 2001;24(6):1069-78.[Abstract/Free Full Text]
  45. Lustman PJ, Griffith LS, Clouse RE. Depression in adults with diabetes. Semin Clin Neuropsychiatry 1997;2(1):15-23.[Medline]
  46. Egede LE, Nietert PJ, Zheng D. Depression and all-cause and coronary heart disease mortality among adults with and without diabetes. Diabetes Care 2005;28(6):1339-45.[Abstract/Free Full Text]
  47. Katz IR. On the inseparability of mental and physical health in aged persons: lessons from depression and medical comorbidity. Am J Geriatr Psychiatry 1996;4:1-16.
  48. Katon W, Von Korff M, Lin E, Walker E, Simon GE, Bush T, et al. Collaborative management to achieve treatment guidelines. Impact on depression in primary care. JAMA 1995;273(13):1026-31.[Abstract/Free Full Text]
  49. Sherbourne CD, Hays RD, Ordway L, DiMatteo MR, Kravitz RL. Antecedents of adherence to medical recommendations: results from the Medical Outcomes Study. J Behav Med 1992;15(5):447-68.[Medline]
  50. Zauszniewski JA, McDonald PE, Krafcik K, Chung C. Acceptance, cognitions, and resourcefulness in women with diabetes. Western J Nurs Res 2002;24(7):728-43.
  51. Karter AJ, Ferrara A, Darbinian JA, Ackerson LM, Selby JV. Self-monitoring of blood glucose: language and financial barriers in a managed care population with diabetes. Diabetes Care 2000;23(4):477-83.[Abstract]
  52. Ciechanowski PS, Katon WJ, Russo JE. Depression and diabetes: impact of depressive symptoms on adherence, function, and costs. Arch Intern Med 2000;160(21):3278-85.[Abstract/Free Full Text]
  53. McGill JB, Lustman PJ, Griffith LS. Relationship of depression to compliance with self-monitoring of blood glucose. Diabetes 1992;41:A84.
  54. Ciechanowski PS, Katon WJ, Russo JE, Hirsch IB. The relationship of depressive symptoms to symptom reporting, self-care and glucose control in diabetes 1. Gen Hosp Psychiatry 2003;25(4):246-52.[Medline]
  55. Goodnick PJ, Kumar A, Henry JH, Buki VM, Goldberg RB. Sertraline in coexisting major depression and diabetes mellitus. Psychopharmacol Bull 1997;33(2):261-4.[Medline]
  56. Lustman PJ, Anderson RJ, Freedland KE, de Groot M, Carney RM, Clouse RE. Depression and poor glycemic control: a meta-analytic review of the literature. Diabetes Care 2000;23(7):934-42.[Abstract]
  57. Little P, Margetts B. Dietary and exercise assessment in general practice. Fam Pract 1996;13(5):477-82.[Abstract/Free Full Text]
  58. Eccles M, Ford GA, Duggan S, Steen N. Are postal questionnaire surveys of reported activity valid? An exploration using general practitioner management of hypertension in older people. Br J Gen Pract 1999;49(438):35-8.[Medline]
  59. Weinger K, Butler HA, Welch GW, La Greca AM. Measuring diabetes self-care: a psychometric analysis of the Self-Care Inventory–Revised with adults. Diabetes Care 2005;28(6):1346-52.[Abstract/Free Full Text]
  60. Varni JW, Burwinkle TM, Jacobs JR, Gottschalk M, Kaufman F, Jones KL. The PedsQL in type 1 and type 2 diabetes: reliability and validity of the Pediatric Quality of Life Inventory Generic Core Scales and type 1 Diabetes Module. Diabetes Care 2003;26(3):631-7.[Abstract/Free Full Text]
  61. Toobert DJ, Hampson SE, Glasgow RE. The summary of diabetes self-care activities measure: results from 7 studies and a revised scale. Diabetes Care 2000;23(7):943-50.[Abstract]



This article has been cited by other articles:


Home page
 cfpHome page
D. Kelsall
The sounds of silence
Can Fam Physician, February 1, 2008; 54(2): 163 - 163.
[Full Text] [PDF]

This Article
Right arrow Abstract Freely available
Right arrow Résumé
Right arrow Full Text (PDF)
Right arrow Rapid Responses: Submit a response
Right arrow Alert me when this article is cited
Right arrow Alert me when Rapid Responses are posted
Right arrow Alert me if a correction is posted
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Download to citation manager
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Gucciardi, E.
Right arrow Articles by Stewart, D. E.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Gucciardi, E.
Right arrow Articles by Stewart, D. E.
Related Collections
Right arrow Résumés de recherche

HOME HELP CONTACT US FEEDBACK SUBSCRIPTIONS CURRENT ISSUE PAST ISSUES SEARCH