Women’s distinct diabetes self-management behaviours demand gender-specific diabetes research: improving chronic disease management and addressing clinical governance issues

Diabetes mellitus is currently ranked as the 12^th leading cause of disease burden in Australia,¹ outpacing the growth of other chronic conditions.² People living with diabetes are high users of primary health care,³ and Diabetes Australia and the Royal Australian College of General Practitioners (RACGP) have long called for changes that better support the complex and ongoing nature of chronic disease management for this condition.^4,5 Proposals have included changes to funding mechanisms (eg re-calibrating Medicare rebates and billable services that better match patient and service delivery needs), service delivery (eg streamlined and coordinated approaches across general practitioner (GP), allied health, and external providers), and strengthening person-centred care to improve individual self-management capacity and, in turn, health outcomes.^5,6 For people living with diabetes, successful self-management is a critical component of their care.^7,8 One aspect of diabetes self-management that has had limited research attention is the examination of gender differences.⁹

Although men are the majority of diabetes cases,¹⁰ women have distinct diabetes management risks from men, including being at greater risk of diabetic coma, loss of protective factors against developing cardiovascular disease once diagnosed with diabetes,¹¹ and being more likely to present with or develop a mental health condition over the course of the disease.^12,13 The presence of a mental health condition is a known threat to implementing and maintaining recommended healthy behaviours, such as diet, exercise, limiting alcohol consumption, and following routine care protocols,^9,14,15 in turn creating different diabetes management risk profiles for women and men. Additionally, reported risks¹⁶ and benefits¹⁷ of complementary medicine, associated with women’s propensity to use these treatments,^18,19 further differentiates women’s diabetes management risk profiles from those of men.

Despite known differentiating diabetes gender characteristics, limited gender-specific diabetes research exists. Focused examination of women’s distinguishing self-management behaviours and associated benefits and risks is required to address current chronic disease management gaps concerning women’s diabetes care. It would also aid current efforts to improve diabetes management in primary health care and better support primary care practitioners.

Considering conventional health service use (GP or allied health consultations, prescription medicine use, etc), research statistics are often not stratified by both gender and disease group. However, insights can be gained from known primary health-care consultation patterns of women, and general diabetes self-management behaviours. This includes the most recent Australian Institute of Health and Welfare report,²⁰ indicating that 1 in 4 women speak to their GP about their psychological health but only 11% receive care from a mental health professional, whereas almost half receive allied health care (such as from physiotherapists and dietitians) for a physical health issue. In addition, Diabetes Australia estimates that people living with diabetes have no more than eight consultation hours annually with any primary health-care (PHC) practitioner, and are often failing to consult with a range of recommended practitioners including diabetes educators, podiatrists, optometrists, and mental health-care workers.⁵

One gender-specific aspect of diabetes self-management that has been researched is complementary medicine, with women being identified as high users.^19,21 Complementary medicine can be defined as products such as herbal medicines, practices such as meditation, and consultations with providers such as naturopaths, who are not traditionally associated with mainstream health care.²² Few studies in Australia have explored complementary medicine use in association with diabetes, but preliminary results indicate the most commonly used complementary medicine products are supplements and herbal medicines, most commonly used complementary medicine practices are massage or mind–body therapies (eg yoga), and the most commonly consulted complementary medicine practitioners are chiropractors, osteopaths, naturopaths, herbalists and acupuncturists.¹⁹ Of importance to primary care providers, especially GPs, is that complementary medicine use raises clinical governance risks.

Broadly, clinical governance refers to primary care practitioners providing quality and safe care to their patients, with key components including provision of evidence-based practice and mutual information provision to ameliorate adverse health outcomes.²³ With respect to complementary medicine use, clinical governance refers to the capacity for primary care practitioners to provide risk management strategies.²⁴

Risks of complementary medicine use can be indirect or direct. Direct risks typically refer to health-related harms and indirect risks are not health-related harms (eg financial losses).¹⁶ One known driver of potential harms is non-disclosure of complementary medicine use to primary care practitioners,^18,25 thereby removing opportunities for communication between patient and practitioner, and thus clinical governance. In addition, complementary medicine is often self-prescribed^26,27 and used concurrently with conventional medicine,²⁸ raising the potential for adverse health outcomes.

Under-reporting of adverse outcomes to the Therapeutic Goods Administration is a known problem,²⁹ making it difficult to ascertain if, or to what extent, complementary medicine use in association with diabetes is an issue. Although it is known generally that serious adverse outcomes (eg death) are minimal,²⁵ primary care practitioners report concerns related to complementary medicine product use that may contraindicate common diabetes therapies. Some examples include potential hyperglycemic effects associated with niacin (vitamin B3) and canagliflozin, St John’s Wort (a common herb used by people with depression) and meglitinides, and fish oils in conjunction with insulin.³⁰

Estimates of complementary medicine prescription prevalence in Australia vary considerably. Supplement³¹ and herbal medicine²⁷ users have high rates of self-prescription. Apart from contraindications, other known risks stem from low health literacy and include exceeding the recommended daily levels of vitamins or minerals²⁶ and a self-perception that ‘natural’ products, such as herbals, are safe to self-prescribe.^28,32

Although adverse outcomes can be ameliorated by supervision from suitably trained primary care practitioners, self-prescription of complementary medicine products in conjunction with high rates of non-disclosure of use to conventional primary care practitioners remains a concern.²⁵

To address clinical governance issues arising from women’s distinctive self-management behaviours, further research is needed to better understand what the risks are, as well as what opportunities are available to address identified risks. Research is required that investigates how primary care practitioners can be better supported to provide chronic disease management for women living with diabetes. This includes a more detailed examination of the health service use patterns of women with diabetes, including:

• Identifying which conventional primary care practitioner groups are consulted by women with diabetes and how frequently;

• Examining if the presence of co-morbidities, such as mental health conditions, influences women’s health service choices;

• Analysing the factors that drive women with diabetes to use complementary medicine;

• Identifying which complementary medicine practitioner groups are regularly consulted by women with diabetes;

• Identifying which complementary medicine products are regularly used by women with diabetes and which are self-prescribed;

• Examining if there are differences in health outcomes stemming from gender-specific diabetes health care choices or self-management behaviours.

Having answers to these lines of inquiry would give primary care practitioners valuable information to provide targeted care and clinical governance for women with diabetes. This information can also assist to create education initiatives for primary care practitioners, especially GPs who often report that they ‘feel ill-equipped’ to provide clinical governance regarding complementary medicine use.³³

Globally, primary care practitioners have requested education programmes to help keep abreast of current trends and issues in relation to complementary medicine,³⁴ particularly assistance in communicating with patients around complementary medicine use.³⁵ Group education opportunities that include both conventional and complementary medicine practitioners can encourage inter-disciplinary discussion. This is especially relevant given diabetes care is multi-disciplinary, necessitating coordinated care involving multiple primary care practitioners as part of diabetes care teams.

Enhancing primary care chronic disease management for people living with diabetes requires accounting for gender differences. To address present knowledge gaps regarding women’s diabetes self-management behaviours, research that comprehensively examines health service use and self-management characteristics is warranted. This is especially important because of women’s distinct diabetes management risk profiles and associated clinical governance concerns. Clinical education programmes informed by gender-specific diabetes research would also benefit primary care practitioners requiring assistance to address any issues arising from complementary medicine use, as well as supporting coordinated care.

The authors declare no competing interests.

This research did not receive any specific funding.

Data sharing is not applicable as no new data were generated or analysed during this study.