A systematic review evaluating sex differences in children with type 1 diabetes (T1D) found that female children had higher rates of comorbidities, higher body mass index, required higher insulin doses, and had a lower quality of life compared with male children.
A systematic review assessing the sex differences between children and adolescents with type 1 diabetes (T1D) found that several outcomes, including comorbidity rates, insulin doses, obesity rates, and quality of life were worse in female children compared with male children.

The review, published in Diabetologia, sought to clarify whether sex influences care and outcomes among children with T1D, and it is the first to provide a complete overview of the current bodies of literature on sex differences in pediatric T1D care. Although sex differences have been observed in cardiovascular care and T1D care among adults, which often present during childhood, a better understanding and identification of factors that could affect outcomes in the young diabetes population are needed.

The authors conducted a literature search of the MEDLINE database for articles published through June 14, 2021. Any primary outcomes study evaluating children with T1D that mentioned a sex difference was included. Qualitative studies, case reports, and case series were excluded. Of the 8640 articles that were identified, 90 analyses including 643,217 participants were evaluated. The quality and risk of bias of the studies were assessed using Joanna Briggs Institute critical appraisal tools.

Of the 90 included studies, 30 evaluated clinical patient profile, 25 looked at glycemic control, 14 analyzed treatment, 20 evaluated complications, 14 looked at comorbidities, and 15 gauged quality of life.

Most studies showed a higher glycated hemoglobin (HbA1C) among female children compared with male children at diagnosis (n = 7) or during treatment (n = 20/21). The increase of HbA1C over time was also steeper among female children.
Female children were found to have higher body mass index as well as a higher prevalence of being overweight or obese and dyslipidemia. Ketoacidosis and hospitalization were more frequent among female children, whereas male participants experienced higher hypoglycemia and partial remission rates.

Female participants used pump therapy more frequently than male participants and required higher insulin doses. All 15 studies that reported on quality of life found that female children also had worse metrics.

The authors hypothesized that the onset of puberty may be to blame for the sex differences, saying that during puberty, female children experience hormonal spikes that may influence insulin sensitivity in T1D and develop more fat mass, which could be amplified in T1D depending on the amount of insulin the child is taking. However, this does not explain the differences in younger children.

“Treatment bias to the disadvantage of young girls may also influence daily clinical care, potentially affecting the treatment of risk factors. In fact, studies in adults have observed differences in disfavour of women in relation to prescriptions and the achievement of target lipid levels and [blood pressure]; our findings suggest that this disparity starts as early as adolescence,” the authors noted.

Additionally, hormonal fluctuations during puberty and differing coping mechanisms could influence perceived quality of life in adolescents. The authors said that their findings on quality of life are particularly relevant for reducing the risk of long-term complications because decreased quality of life may have an impact on treatment adherence and glycemic control.

“The unfavourable risk profile and related mortality risk in the female sex might start in the early years of the disease. This raises the question of whether young female children living with type 1 diabetes should be targeted more intensively on cardiovascular risk prevention, especially during or even before adolescence. Screening strategies and interventions that improve [quality of life] and alleviate psychiatric comorbidities also seem warranted,” the authors wrote.

They listed several study limitations including that no meta-analysis was conducted, no observational studies were included, and some studies from other databases may have been left out. They also suggested that future analyses distinguish between children and adolescents to ensure that the impact of puberty does not influence results.

de Vries SAG, Verheugt CL, Mul D, Nieuwdorp M, Sas TCJ. Do sex differences in paediatric type 1 diabetes care exist? a systematic review. Diabetologia. Published online January 26, 2023. doi:10.1007/s00125-022-05866-4
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