type one diabetes mellitus ( t1 dm ) , one of the most common chronic diseases in childhood , affects 15 million children in the world and is rapidly increasing in specific regions [ 1 , 2 ] so that an annual increase of 2 to 5 percent in europe , the middle east , and australia is reported . in addition , wide range of serious complications and associated diseases makes t1 dm a very serious medical problem so that the average life span of individuals with diabetes is about 10 years shorter than that of the non - diabetic population . these complications could be acute , subacute or chronic . and poor adherence resulting in poor control can predispose children at risk up these complications . therefore to decrease burden of this disease , the medical team should attempt to ensure a normal growth and development with minimal effect on lifestyle for the patient . in fact , intensive control dramatically reduces the risk of long - term vascular complications ( such as retinopathy , nephropathy and neuropathy ) by 46 - 76% , growth retardation and puberty delay and also reduces abnormalities in plasma lipid levels [ 1 , 47 ] . thus it is important to maintain a balance between tight glucose control and avoiding hypoglycemia . also issues like nutrition , exercise , and psychosocial factors that have an impact on glycemic control should be addressed in the management of children and adolescents with type 1 diabetes . a reliable index of long - term glycemic control is measurement of the fraction of glycosylated hemoglobin ( hba1c ) . therefore to obtain a profile of long - term glycemic control , it is recommended that hba1c measurments be obtained 3 to 4 times per year . beside checking hba1c , optimal glycemic and metabolic control is dependent upon frequent self - monitoring of blood glucose ( smbg ) . hence being female has been an independent risk factor of poor glycemic control in previous studies . springer in his study on 455 patients with type one diabetes found that mean hba1c level was higher in girls than in boys . in another study in 2180 swedish children ( 1033 girls and 1147 boys ) gerstl et al in study on 27035 patients with type 1 diabetes in germany and austria reported that gender has a significant influence on hba1c . in a study in 2270 californian children with insulin - dependent diabetes mellitus ( iddm ) , females had more diabetes hospitalization than did males . these occurred primarily in adolescents ( for females ages 10 - 14 years 50 vs. 38/100000 ) and for ages 15 - 18 ( 68 vs. 29/100000 ) . in another study by knerr et al , on 26687 children and adolescents in germany and austria ' female gender was one of the factors associated with higher prandial insulin doses . also mean hba1c was higher in females and girls reported higher insulin doses per cho units for 3 meals . in another study by habib in saudi arabia , females had more ketoacidosis at the onset of their illness ( 58.7% vs. 41.3% ) . in a study by ahmed et al on 46 children with iddm ( 23 girls and 23 boys ) he showed that final height in girls was shorter than in boys and at final height , they were significantly shorter with respect to mid parental height . because effect of gender on glycemic control has not been evaluated in iran , we have studied the t1 dm patients referring to our outpatient clinic to evaluate the effect of gender on glycemic control , diabetes complications and associated abnormalities . in a cross - sectional study on , patients with type one diabetes mellitus referred to endocrinology clinic in children 's medical center in tehran , iran from march 2005 to march 2007 were enrolled . all subjects provided informed consent and the study was approved by ethical committee affiliated with tehran university of medical sciences . patients within the age range of 3 to 16 years with type one diabetes mellitus who were diagnosed at least one year before our evaluation were included . the diagnosis of diabetes mellitus was based upon the guidelines of the american diabetes association ( ada ) . during the evaluation patients with following criteria were excluded : 1 ) type 2 diabetes mellitus as any secondary diabetes ( such as thalassemia , chronic active hepatitis , cystic fibrosis , mitochondrial disease ) , 2 ) in adequate clinic visits ( less than four visits per year ) . regarding these conditions 309 patients ( 156 females and 153 males ) boys and girls are different in their start of puberty , it can affect the comparison between boys and girls , therefore patients were categorized with respect to puberty stages . 1 ) prepubertal group ( younger than 11 years for boys and younger than 8 years for girls ) , 2 ) pubertal start group ( 11 to 13 years for boys and 8 to 10 years for girls ) , 3 ) mid puberty group ( older than 13 years for boys and older than 10 years for girls ) . hba1c levels according to ada levels was used as a reference as follows , for children 0 - 6 years , 7.5 - 8.5% , children 6 - 12 years < 8% , and for older children variables included sex , age , age at onset of diabetes , height , height standard deviation score ( sds ) , weight , bmi ( body mass index ) , duration of diabetes mellitus ( dm ) , mean hba1c of the last measured ones , daily insulin dose , number of blood glucose measurement in a day , lipid profile , thyroid function tests and puberty indexes ( based on tanner criteria ) . using spss software , genders differences were analyzed by using chi - square or fisher 's exact test for nominal variables and t - test or mann - whitney u - test for quantitative variables . our data collected from 309 ( 156 femeals and 153 males with age range of 3 - 16 years ) type 1 diabetes . descriptive and demographic data of all variables are summarized in table 1 . descriptive statistics of studied patients sd : standard deviation age at onset of disease , disease duration and bmi and sexual maturity rating ( smr ) are considered as baseline characteristics . hba1c as a measurement of glycemic control was significantly higher in females when evaluated quantitatively ( p<0.001 ) or qualitatively ( p<0.001 ) ( table 2 ) . comparison of glycemic control in different genders sd : standard deviation / hba1c : glycosylated hemoglobin insulin dose per kilogram of body weight ( insulin / kg ) was significantly different between females and males both when compared quantitatively and when compared between puberty groups ( table 3 ) . also self monitoring of blood glucose ( smbg ) was performed significantly more in boys compared to girls ( table 3 ) . comparison of insulin dose in both genders sd : standard deviation finally complications , co - morbidities and associated diseases of dm were compared between boys and girls . as shown in table 4 height sds was significantly lower in females than in males , bmi was not significantly different in females and males , total cholesterol , low density lipoprotein ( ldl ) , and triglyceride levels were significantly higher in females than in males respectively . hdl was not significantly different .. 
  complications and associated comorbidities of diabetes in both genders sds : standard deviation score / ldl : low density lipoprotein / hdl : high density lipoprotein / tsh : thyrotrophin - stimulating hormone / t4 : hormones thyroxine / dka : diabetic ketoacidosis in terms of thyroid function tests , hormones thyroxine ( t4 ) levels were significantly higher in girls than in boys though in the normal renege . the thyrotrophin - stimulating hormone ( tsh ) levels were not significantly different among the both sexes . diabetic ketoacidosis ( dka ) times were significantly higher in girls than in boys , also dka times based on the stage of puberty were higher in girls at all puberty stages ( table 4 ) . apart from gender differences , mean hba1c is higher than ada recommendation , this maybe indicative of our urgent need to improve glucose monitoring and patient education . it is worth to mention that our treatment policy has changed in the recent years from conventional therapy with two times insulin therapy a day towards much intensified treatment with 3 times a day insulin regimen . et al study on 27035 patients from different centers in austria and germany in all age groups , girls had higher hba1c levels than boys ( mean difference 0.1% ) . in another study by springer et al , girls had hba1c levels higher than boys that has been attributed to greater than boys that has been attributed to greater depression and psychological problems in girls . in our study hba1c was categorized due to puberty stages in both girls and boys and there was significant different within both sexes ( table 2 ) . there are known differences in glucose metabolism in women and men . it has been shown that healthy females are less insulin sensitive than healthy males , and this decreased sensitivity is compensated by increased insulin secretion . in another study higher insulin concentration during oral glucose tolerance test in non diabetic females than in males was shown . in our study insulin dose / kg these may be due to non compliance in the pubertal age group , these places adolescents at risk of poor glycemic control . kaufman showed in her study that adolescents have increased levels of hba1c and also decreased number of clinic visits . in terms of complications of type 1 diabetes as shown in table 4 for height , sds was significantly different between girls and boys and girls were shorter than boys . these differences have been shown in previous studies . in a study by ahmed et al on 46 children with diabetes , final height was shorter in girls than in boys , and at final height girls were significantly shorter with respect to mid parental height sds . he concluded that advanced bone age in girls at the onset of puberty may explain blunted pubertal growth spurt , hence their shorter final height . there was no significant difference in bmi between the genders these has been shown in the study by vanelli et al in italy . in terms of lipid control in type 1 diabetes , there was significant difference in total cholesterol , ldl , and triglyceride levels between sexes . these may be attributed to poorer diabetes control in girls than in boys and this may endanger them for cardiovascular diseases in adulthood . therefore the protectiveness of cardiovascular disease in premenopausal women maybe endangered in type 1 diabetes . in contrast to several studies , we did not find any significant difference in thyroid function tests between the two genders [ 18 , 19 ] , though t4 levels were higher in girls but they were in the normal range . similar findings were shown in a study in germany   and saudi arabia where a female to male ratio of 1.4 to 1 was found . in fact because children and their parents show poor ability to detect high or low blood glucose levels based on symptoms alone , frequent monitoring improves glycemic control and decreases prevalence of dka in children and decrease the frequency of severe hypoglycemic episodes . . thus lower rate of using smbg in girls could cause the worse glycemic control in them . regarding effect of nutritional and psychological factors on glycemic control , higher rate of nutritional and psychological problems in female patients could be another reason of worse glycemic control in girls . while available data suggests normal eating attitudes in most male patients , eating disorders and sub - threshold eating disorders are almost twice as common in adolescent females with t1 dm as in their non - diabetic peers [ 1 , 22 ] . also adolescent girls are at greater risk than adolescent boys for recurrent episodes of depression . because of worse glycemic control in female patients with t1 dm compared to males as well as higher incidence of dka , dyslipidemia and height growth retardation in female patients , it is needed to focus on girls in local guidelines of managing t1 dm regarding smbg , nutritional and psychological factors and puberty issues .