Introduction

Can non-responders be 'rescued' by increasing exercise intensity? A quasi-experimental trial of individual responses among humans living with pre-diabetes or type 2 diabetes mellitus in Canada

INTRODUCTION

Exercise is recommended to improve glycaemic control. Yet, individual changes in glycaemic control following exercise can vary greatly, meaning while some significantly improve others, coined 'non-responders', do not. Increasing the intensity of exercise may 'rescue' non-responders and help generate a response to training. This trial will identify non-responders to changes in glycated haemoglobin (HbA1c) across inactive individuals living with pre-diabetes or type 2 diabetes mellitus following an aerobic exercise programme and evaluate if increasing training intensity will elicit beneficial changes to 'rescue' previously categorised non-responders.

METHODS AND ANALYSIS

This study will recruit 60 participants for a two-phase aerobic exercise training programme. Participants will be allocated to a control group or assigned to an intervention group. Control participants will maintain their current lifestyle habits. During phase 1, intervention participants will complete 16 weeks of aerobic exercise at an intensity of 4.5 metabolic equivalents (METs) for 150 min per week. Participants will then be categorised as responders or non-responders based on the change in HbA1c. For phase 2, participants will be blocked based on responder status and randomly allocated to a maintained intensity, or increased intensity group for 12 weeks. The maintained group will continue to train at 4.5 METs, while the increased intensity group will train at 6.0 METs for 150 min per week.

ETHICS AND DISSEMINATION

Results will be presented at scientific meetings and submitted to peer-reviewed journals. Publications and presentations related to the study will be authorised and reviewed by all investigators. Findings from this study will be used to provide support for future randomised control trials. All experimental procedures have been approved by the Research Ethics Board at the University of New Brunswick (REB: 2018-168).

TRIAL REGISTRATION NUMBER

NCT03787836.

A retrospective observational population-based study to assess the prevalence and burden of illness of type 2 diabetes with an estimated glomerular filtration rate < 90 mL/min/1.73 m2 in Ontario, Canada

AIM

To better understand the healthcare burden of people with type 2 diabetes (T2D) and estimated glomerular filtration rate (eGFR) < 90 mL/min/1.73 m² in Ontario, Canada.

MATERIALS AND METHODS

We used administrative data to evaluate the prevalence of T2D, eGFR < 90 mL/min/1.73 m² and adverse cardiovascular co-morbidities in individuals aged ≥ 30 years living in Ontario, Canada. We also examined incremental healthcare costs and healthcare resource utilization (HCRU) for these patients with specific incident cardiovascular and renal outcomes, in comparison with controls without these outcomes.

RESULTS

While the prevalence of T2D in the general population aged ≥ 30 years in Ontario increased by 1.8% over a 5-year period (2011-2012 to 2015-2016), the prevalence of eGFR < 90 mL/min/1.73 m² among people with T2D increased by 35%. In comparison with corresponding controls without these outcomes, the per patient average total costs (Canadian dollars) over a 2-year analysis period were higher for patients with cardiovascular disease/chronic kidney disease related death ($69 827; n = 32 407), doubling of serum creatinine ($52 260; n = 22 825), those who started dialysis ($150 627; n = 3499) or received a kidney transplant ($50 664; n = 651). Similarly, HCRU was significantly greater for patients with these incident outcomes.

CONCLUSIONS

This real-world retrospective study highlights an increasing prevalence of T2D, eGFR < 90 mL/min/1.73 m² , and the substantially higher healthcare costs and HCRU when these patients have adverse cardiovascular and renal outcomes. The existence of such a large economic burden underpins the importance of preventing these diabetes-related complications.

Type 2 diabetes mellitus and risk of community-acquired pneumonia: a systematic review and meta-analysis of observational studies

BACKGROUND

People with type 2 diabetes are at greater risk for infections than those without type 2 diabetes. Our objective was to examine the association between type 2 diabetes and the risk of community-acquired pneumonia (CAP).

METHODS

In this systematic review and meta-analysis, we searched MEDLINE, Embase, CINAHL, ProQuest theses and dissertations, Global Health, the Global Index Medicus of the World Health Organization, and Google Scholar. We included observational studies published in English or French between Jan. 1, 1946 (start of MEDLINE) and July 18, 2020. Two independent reviewers extracted data and assessed quality using the ROBINS-I tool. DerSimonian-Laird random-effects models were used to pool estimates of the association between type 2 diabetes and CAP.

RESULTS

Our systematic review included 15 articles, reporting on 13 cohort studies and 4 case-control studies (14 538 968 patients). All studies reported an increased risk of pneumonia among patients with type 2 diabetes, and all were at serious risk of bias. When estimates were pooled across studies, the pooled relative risk was 1.64 (95% confidence interval [CI] 1.55-1.73); although there was a substantial amount of relative heterogeneity (I 2 94.2), the amount of absolute heterogeneity was more modest (T2 0.008). The relative risk was 1.70 (95% CI 1.63-1.77, I 2 85.2%, T2 0.002) among cohort studies (n = 13), and the odds ratio was 1.54 (95% CI 1.14-2.09, I 2 92.7%, T2 0.07) among case-control studies (n = 4).

INTERPRETATION

Type 2 diabetes may be associated with an increased risk of CAP; however, the available evidence is from studies at serious risk of bias, and additional, high-quality studies are needed to confirm these findings.

PROSPERO REGISTRATION

CRD42018116409.

Montreal-FH-SCORE Predicts Coronary Artery Calcium Score in Patients With Familial Hypercholesterolemia

BACKGROUND

Familial hypercholesterolemia (FH) is a monogenic disease characterized by a high concentration of low-density lipoprotein cholesterol. This population is considered to be at high cardiovascular risk; however, disease evolution remains heterogeneous among individuals. The coronary artery calcium (CAC) score is currently the best predictor of incidental major cardiovascular events in primary prevention in the general population. Few studies have described the CAC score in FH populations.

METHODS

The objective of our study was to determine the predictors of the CAC score in FH patients. We retrospectively studied FH patients followed at the Montreal Clinical Research Institute (IRCM) Lipid Clinic who had a cardiac scan for CAC score, using the Agatston method, between 2013 and 2019.

RESULTS

Final analysis included 62 FH patients. Mean age was 48 ± 14 years old, and 48% were men. Overall, 25 patients had a CAC score of 0 (40%), and 37 patients had a nonzero CAC score (60%). Sex, age, Montreal-FH-SCORE (MFHS), waist circumference, and statin exposure in years were significant predictors (P ≤ 0,05) of a nonzero CAC score in a univariate model. MFHS was the only factor that remained significant in a multivariate model (odds ratio 1.34, 95% confidence interval 1.11-1.61, P = 0.002).

CONCLUSIONS

In conclusion, we found that MFHS, which includes traditional cardiovascular risk factors, was a predictor of a nonzero CAC score in FH patients. This finding suggests that MFHS may play a role in determining the cardiovascular risk and therefore the intensity of treatment in FH patients.

Evaluation of telephone and virtual visits for routine pediatric diabetes care during the COVID-19 pandemic

AIMS

To evaluate pediatric type 1 diabetes telehealth visits during the COVID-19 pandemic, with a focus on assessing the usability of these visits and gathering patient perspectives.

METHODS

An online survey, which included a validated telehealth usability questionnaire, was offered via email to families with a telephone or virtual visit since the COVID-19-related cancellation of routine in-person care. Survey data was linked with the British Columbia (BC) Clinical Diabetes Registry. Outcomes between groups were assessed using Welch's t-test. Associations with type of visit as well as with desire to return to in-person care were assessed with logistic regression models.

RESULTS

The response rate was 47%. Of 141 survey respondents, 87 had clinical data available in the BC Clinical Diabetes Registry, and thus were included in our analysis. Overall, telephone and virtual visits were rated highly for usability. Telephone visits were easier to learn to use, and simpler to understand; however, telephone and virtual visits were similar across multiple areas. No factors associated with choosing one type of visit over the other, or with desire to return to in-person care, could be identified. 72% of participants want future telehealth care; however, some would like all future care to be in-person.

CONCLUSIONS

Telephone and virtual visits had impressive usability. Many families want telehealth to play a significant part in their future care.

Risk factors, incidence, and prevalence of diabetes among rural farm and non-farm residents of Saskatchewan, Canada; a population-based longitudinal cohort study

PURPOSE

Saskatchewan has a high prevalence of diabetes. It is the largest, rurally populated, predominantly agricultural province in Canada. This research aims to determine the risk factors associated with the incidence and longitudinal changes in the prevalence of diabetes among Saskatchewan's adult rural farm and non-farm residents.

METHODS

The Saskatchewan Rural Health Study (SRHS) is a prospective cohort study conducted in two phases: a baseline survey (2010, 8261 participants) and a follow-up survey (2014, 4867 participants). Generalized estimation equations and survival analysis techniques were used to determine diabetes prevalence and incidence risk factors, respectively.

RESULTS

Incidence of diabetes among rural residents was 2.75%. Positive family history, high BMI, sleep apnea and an abnormal Epworth Sleepiness Score (ESS) were significant predictors for diabetes incidence. A substantial increase (1.98%) of diabetes prevalence was observed after four years of follow-up. Risk factors of diabetes prevalence were increasing age, male, low income, positive family history, high BMI, hypertension and heart attack.

CONCLUSION

A mix of individual and contextual factors interacting in complex pathways were responsible for the high incidence and prevalence of diabetes among rural residents. The most original finding of that study was a positive association of sleep apnea, and ESS with incident diabetes warrants further research to identify a causal linkage. Increased diabetes risk among rural male insecticide users indicates an adverse consequence of unprotected chemical exposures in the agricultural field. Urgent population-based preventive measures should initiate to slow the increasing trend of diabetes prevalence among rural residents.

Evaluating the intended and unintended consequences of opioid-prescribing interventions on primary care in British Columbia, Canada: protocol for a retrospective population-based cohort study

INTRODUCTION

Between 2015 and 2018, there were over 40 000 opioid-related overdose events and 4551 deaths among residents in British Columbia (BC). During this time the province mobilised a variety of policy levers to encourage physicians to expand access to opioid agonist treatment and the College of Physicians and Surgeons of British Columbia (CPSBC) released a practice standard establishing legally enforceable minimum thresholds of professional behaviour in the hopes of curtailing overdose events. Our goal is to conduct a comprehensive investigation of the intended and unintended consequences of these policy changes. Specifically, we aim to understand the effects of these measures on physician prescribing behaviours, identify physician characteristics associated with uptake of the new measures, and measure the effects of the policy changes on patients' access to quality primary care.

METHODS AND ANALYSIS

This is a population-level, retrospective cohort study of all BC primary care physicians who prescribed any opioid medication for opioid-use disorder or chronic non-cancer pain during the study period, and their patients. The study period is 1 January 2013-31 December 2018, with a 1-year wash-in period (1 January 2012-31 December 2012) to exclude patients who initiated long-term opioid treatment prior to our study period or whose pain type (ie, 'chronic non-cancer', 'acute', 'cancer or palliative', or 'other') cannot be confirmed. The project combines five administrative health datasets under the authority of the BC Ministry of Health, with the CPSBC's Physician Registry, BC Cancer Agency's Cancer Registry and Vital Statistics' Mortality data. We will create measures of prescribing concordance, access, continuity, and comprehensiveness to assess primary care delivery and quality at both the physician and patient level. We will use generalised estimating equations, interrupted time series, mixed effects models, and funnel plots to identify factors related to changes in prescribing and evaluate the impact of the changes to prescribing policies. Results will be reported using appropriate Enhancing the QUAlity and Transparency Of health Research guidelines (eg, STrengthening the Reporting of OBservational studies in Epidemiology).

ETHICS AND DISSEMINATION

This study has been approved by McGill University's Institutional Review Board (#A11-M55-19A), and the University of British Columbia's Research Ethics Board (#H19-03537). We will disseminate results via a combination of open access peer-reviewed journal publications, conferences, lay summaries and OpEds.

A single-blind, randomised, crossover study to reduce hypoglycaemia risk during postprandial exercise with closed-loop insulin delivery in adults with type 1 diabetes: announced (with or without bolus reduction) vs unannounced exercise strategies

AIMS/HYPOTHESIS

For individuals living with type 1 diabetes, closed-loop insulin delivery improves glycaemic control. Nonetheless, maintenance of glycaemic control during exercise while a prandial insulin bolus remains active is a challenge even to closed-loop systems. We investigated the effect of exercise announcement on the efficacy of a closed-loop system, to reduce hypoglycaemia during postprandial exercise.

METHODS

A single-blind randomised, crossover open-label trial was carried out to compare three strategies applied to a closed-loop system at mealtime in preparation for exercise taken 90 min after eating at a research testing centre: (1) announced exercise to the closed-loop system (increases target glucose levels) in addition to a 33% reduction in meal bolus (A-RB); (2) announced exercise to the closed-loop system and a full meal bolus (A-FB); (3) unannounced exercise and a full meal bolus (U-FB). Participants performed 60 min of exercise at 60% [Formula: see text] 90 min after eating breakfast. The investigators were not blinded to the interventions. However, the participants were blinded to the sensor glucose readings and to the insulin infusion rates throughout the intervention visits.

RESULTS

The trial was completed by 37 adults with type 1 diabetes, all using insulin pumps: mean±SD, 40.0 ± 15.0 years of age, HbA_1c 57.1 ± 10.8 mmol/mol (7.3 ± 1.0%). Reported results were based on plasma glucose values. During exercise and the following 1 h recovery period, time spent in hypoglycaemia (<3.9 mmol/l; primary outcome) was reduced with A-RB (mean ± SD; 2.0 ± 6.2%) and A-FB (7.0 ± 12.6%) vs U-FB (13.0 ± 19.0%; p < 0.0001 and p = 0.005, respectively). During exercise, A-RB had the least drop in plasma glucose levels: A-RB -0.3 ± 2.8 mmol/l, A-FB -2.6 ± 2.9 mmol/l vs U-FB -2.4 ± 2.7 mmol/l (p < 0.0001 and p = 0.5, respectively). Comparison of A-RB vs U-FB revealed a decrease in the time spent in target (3.9-10 mmol/l) by 12.7% (p = 0.05) and an increase in the time spent in hyperglycaemia (>10 mmol/l) by 21% (p = 0.001). No side effects were reported during the applied strategies.

CONCLUSIONS/INTERPRETATION

Combining postprandial exercise announcement, which increases closed-loop system glucose target levels, with a 33% meal bolus reduction significantly reduced time spent in hypoglycaemia compared with the other two strategies, yet at the expense of more time spent in hyperglycaemia.

TRIAL REGISTRATION

ClinicalTrials.gov NCT0285530 FUNDING: JDRF (2-SRA-2016-210-A-N), the Canadian Institutes of Health Research (354024) and the Fondation J.-A. DeSève chair held by RR-L.

The Role of Pulses in Cardiovascular Disease Risk for Adults With Diabetes

Cardiovascular disease (CVD) is a leading cause of death among adults while associated comorbidities like diabetes further increase risks of CVD-related complications and mortality. Strategies to prevent and manage CVD risk, such as dietary change, are a key component for CVD and diabetes prevention and management. Pulses, defined as the dried edible seeds of plants in the legume family, have received attention for their superior nutritional composition as high-fiber, low-glycemic index foods and have been studied for their potential to reduce CVD and diabetes risk. Both observational and experimental studies conducted among adults with and without diabetes have provided support for pulses in their ability to improve lipid profiles, glycemic control, and blood pressure, all of which are major modifiable risk factors of CVD. These capabilities have been attributed to various mechanisms associated with the nutrient and phytochemical composition of pulses. Overall, this evidence provides support for the consumption of pulses as an important dietary strategy to reduce risk of CVD for those living with and without diabetes.

Semaglutide once weekly in people with type 2 diabetes: Real-world analysis of the Canadian LMC diabetes registry (SPARE study)

AIMS

To investigate real-world short-term clinical outcomes in adults with type 2 diabetes (T2D) who initiated semaglutide in a specialist endocrinology practice in Canada.

MATERIALS AND METHODS

This study was a retrospective observational study using data from the Canadian LMC Diabetes Registry. Adults with T2D who were naïve to glucagon-like peptide-1 receptor agonist (GLP-1RA) therapy, initiated semaglutide therapy as usual standard of care between February 2018 and February 2019, and maintained semaglutide therapy during follow-up, were eligible for analysis. The primary outcome was mean change in glycated haemoglobin (HbA1c) at 3- to 6-month follow-up.

RESULTS

In the final analytical cohort (n = 937), there was a statistically significant mean ± SD reduction in HbA1c of -1.03 ± 1.24% (11.3 ± 13.6 mmol/mol, P < 0.001) and weight of -3.9 ± 4.0 kg (P < 0.001), with no significant change in self-reported incidence of hypoglycaemia. There was a significant reduction in HbA1c and weight regardless of number of co-therapies or semaglutide dose. However, adults using the 1.0-mg dose had a significantly greater reduction in HbA1c compared to adults using the 0.25- to 0.5-mg dose (between-group difference - 0.24 ± 0.06%, 2.6 ± 0.7 mmol/mol; P < 0.001). Adults using basal-bolus therapy required a significantly lower median total daily dose of insulin after adding semaglutide (0.82 vs. 0.93 U/kg; P < 0.001).

CONCLUSIONS

This retrospective observational study demonstrated that GLP-1RA-naïve adults with T2D initiating semaglutide in a real-world clinical practice had a statistically and clinically significant reduction in HbA1c and body weight after 3 to 6 months, regardless of semaglutide dose or order of semaglutide therapy, with no significant change in reported incidence of hypoglycaemia.

Environmental Scan on Canadian Interactive Knowledge Translation Tools to Prevent Diabetes Complications in Patients With Diabetes

In this study, we identify existing interactive knowledge translation tools that could help patients and health-care professionals to prevent diabetes complications in the Canadian context. We conducted an environmental scan in collaboration with researchers and 4 patient partners across Canada. We conducted searches among the research team members, their networks and Twitter, and through searches in databases and Google. To be included, interactive knowledge translation tools had to meet the following criteria: used to prevent diabetes complications; used in a real-life setting; used any instructional method or material; had relevance in the Canadian context, written in English or French; developed and/or published by experts in diabetes complications or by a recognized organization; created in 2013 or after; and accessibility online or on paper. Two reviewers independently screened each record for selection and extracted the following data: authorship, objective(s), patients' characteristics, type of diabetes complications targeted, type of knowledge users targeted and tool characteristics. We used simple descriptive statistics to summarize our results. Thirty-one of the 1,700 potentially eligible interactive knowledge translation tools were included in the scan. Tool formats included personal notebook, interactive case study, risk assessment tool, clinical pathway, decision support tool, knowledge quiz and checklist. Diabetes complications targeted by the tools included foot-related neuropathy, cardiovascular diseases, mental disorders and distress and any complications related to diabetes and kidney disease. Our results inform Canadian stakeholders interested in the prevention of diabetes complications to avoid unnecessary duplication, identify gaps in knowledge and support implementation of these tools in clinical and patients' decision-making.

Effects of Linagliptin on Cardiovascular and Kidney Outcomes in People With Normal and Reduced Kidney Function: Secondary Analysis of the CARMELINA Randomized Trial

OBJECTIVE

Type 2 diabetes is a leading cause of kidney failure, but few outcome trials proactively enrolled individuals with chronic kidney disease (CKD). We performed secondary analyses of cardiovascular (CV) and kidney outcomes across baseline estimated glomerular filtration rate (eGFR) categories (≥60, 45 to <60, 30 to <45, and <30 mL/min/1.73 m2) in Cardiovascular and Renal Microvascular Outcome Study With Linagliptin (CARMELINA), a cardiorenal placebo-controlled outcome trial of the dipeptidyl peptidase 4 inhibitor linagliptin (NCT01897532).

RESEARCH DESIGN AND METHODS

Participants with CV disease and/or CKD were included. The primary outcome was time to first occurrence of CV death, nonfatal myocardial infarction, or nonfatal stroke (three-point major adverse CV event [3P-MACE]), with a secondary outcome of renal death, end-stage kidney disease, or sustained ≥40% decrease in eGFR from baseline. Other end points included progression of albuminuria, change in HbA1c, and adverse events (AEs) including hypoglycemia.

RESULTS

A total of 6,979 subjects (mean age 65.9 years; eGFR 54.6 mL/min/1.73 m2; 80.1% albuminuria) were followed for 2.2 years. Across eGFR categories, linagliptin as compared with placebo did not affect the risk for 3P-MACE (hazard ratio 1.02 [95% CI 0.89, 1.17]) or the secondary kidney outcome (1.04 [0.89, 1.22]) (interaction P values >0.05). Regardless of eGFR, albuminuria progression was reduced with linagliptin, as was HbA1c, without increasing risk for hypoglycemia. AEs were balanced among groups overall and across eGFR categories.

CONCLUSIONS

Across all GFR categories, in participants with type 2 diabetes and CKD and/or CV disease, there was no difference in risk for linagliptin versus placebo on CV and kidney events. Significant reductions in risk for albuminuria progression and HbA1c and no difference in AEs were observed.

Role of Gliclazide MR in the Management of Type 2 Diabetes: Report of a Symposium on Real-World Evidence and New Perspectives

In patients with type 2 diabetes mellitus (T2DM) who require additional glucose-lowering on top of first-line metformin monotherapy, sulfonylureas are the most common choice for second-line therapy followed by dipeptidyl peptidase inhibitors (DPP-4i). This article summarises presentations at a symposium entitled "Real-World Evidence and New Perspectives with Gliclazide MR" held at the International Diabetes Federation Congress in Busan, South Korea on 4 December 2019. Although guideline recommendations vary between countries, the guidelines with the highest quality ratings include sulfonylureas as one of the preferred choices as second-line therapy for T2DM. Data from randomised controlled trials (RCTs) have consistently demonstrated that sulfonylureas are effective glucose-lowering agents and that the risk of severe hypoglycaemia with these agents is low. In addition, both RCTs and real-world observational studies have shown no increased risk of mortality or cardiovascular disease with the use of newer-generation sulfonylureas compared with other classes of glucose-lowering treatments. However, differences between sulfonylureas do exist, with gliclazide being associated with a significantly lower risk of mortality or cardiovascular mortality compared with glibenclamide, as well as the lowest incidence of severe hypoglycaemia compared with other agents in this class. Recent real-world studies into the effectiveness and safety of gliclazide appear to confirm these findings, and publication of new data from these studies in patients with T2DM in the UK, and in Muslim patients who are fasting during Ramadan, are awaited with interest. Another study being undertaken with gliclazide is a pan-India study in patients with maturity-onset diabetes of the young (MODY) subtypes 1, 3 and 12. Patients with these MODY subtypes respond particularly well to sulfonylurea treatment, and sulfonylureas are the first-line agents of choice in these patients. These new and ongoing studies will add to the cumulative data on the efficacy and safety of certain sulfonylureas in patients with diabetes.

Incidence and costs of cardiovascular events in Spanish patients with type 2 diabetes mellitus: a comparison with general population, 2015

INTRODUCTION

Cardiovascular (CV) disease affects a high percentage of patients with type 2 diabetes mellitus (T2DM), especially in the hospital setting, impacting on mortality, complications, quality of life and use of health resources. The aim of this study was to estimate the incidence, mean length of hospital stay (LOHS) and costs attributable to hospital admissions due to CV events in patients with T2DM versus patients without diabetes mellitus (non-DM) in Spain.

RESEARCH DESIGN AND METHODS

Retrospective observational study based on the Spanish National Hospital Discharge Database for 2015. Hospital admissions for patients aged ≥35 years with a diagnosis of CV death, non-fatal acute myocardial infarction (AMI), non-fatal stroke, unstable angina, heart failure and revascularization were evaluated. The International Classification of Diseases, Ninth Revision (250.x0 or 250.x2) coding was used to classify records of patients with T2DM. For each CV complication, the hospital discharges of the two groups, T2DM and non-DM, were precisely matched and the number of hospital discharges, patients, LOHS and mean cost were quantified. Additional analyses assessed the robustness of the results.

RESULTS

Of the 276 925 hospital discharges analyzed, 34.71% corresponded to patients with T2DM. A higher incidence was observed in all the CV complications studied in the T2DM population, with a relative risk exceeding 2 in all cases. The mean LOHS (days) was longer in the T2DM versus the non-DM group for: non-fatal AMI (7.63 vs 7.02, p<0.001), unstable angina (5.11 vs 4.78, p=0.009) and revascularization (7.96 vs 7.57, p<0.001). The mean cost per hospital discharge was higher in the T2DM versus the non-DM group for non-fatal AMI (€6891 vs €6876, p=0.029) and unstable angina (€3386 vs €3304, p<0.001).

CONCLUSIONS

Patients with T2DM had a higher incidence and number of hospital admissions per patient due to CV events versus the non-DM population. This generates a significant clinical and economic burden given the longer admission stay and higher costs associated with some of these complications.

Dietary Potassium Intake and Risk of Chronic Kidney Disease Progression in Predialysis Patients with Chronic Kidney Disease: A Systematic Review

The prevalence of chronic kidney disease (CKD) is increasing and dietary interventions may be a strategy to reduce this burden. In the general population, higher potassium intake is considered protective for cardiovascular health. Due to the risk of hyperkalemia in CKD, limiting potassium intake is often recommended. However, given that poor cardiovascular function can cause kidney damage, following a low-potassium diet may be deleterious for patients with CKD. The aim of this systematic review was to summarize the evidence on dietary potassium intake and CKD progression. Multiple databases were searched on 7 June 2019 and data were managed with Covidence. No intervention trials met the inclusion criteria. Eleven observational studies met the inclusion criteria (10 post hoc analyses, 1 retrospective cohort), representing 49,573 stage 1-5 predialysis patients with CKD from 41 different countries. Of the 11 studies, 6 studies reported exclusively on early CKD (stage 1-2), 4 studies separately reported analyses on both early and late (stage 3-5) CKD, and 2 studies reported exclusively on late CKD. A total of 9 studies reported risk of disease progression in early CKD; in 4 studies high potassium intake was associated with lower risk, while in 2 studies the low intake showed a higher progression of risk, and 3 studies reported no relation. In late CKD, results are mixed: 2 studies suggested benefit of higher potassium intake and 1 suggested benefit of lower potassium intake, whereas 3 studies were neutral. These results should be interpreted with caution, as considerations preventing firm conclusions include 1) the overall low range of dietary potassium intake, with all studies reporting an average intake below the 2004 Kidney Disease Outcomes Quality Initiatives guidelines, and 2) the method used to assess potassium intake in most studies (i.e., urine) in late stages of CKD. Ideally, well-controlled intervention studies are needed to understand how dietary potassium intake is linked to CKD progression.

A Mixed Methods Evaluation of a Randomized Control Trial to Evaluate the Effectiveness of the Pure Prairie Living Program in Type 2 Diabetes Participants

The primary objective of this randomized control trial was to evaluate the effectiveness of the Pure Prairie Living Program (PPLP) in a primary care setting. Adults with type 2 diabetes were randomized into intervention (PPLP, n = 25) and wait-listed controls (CON, n = 24). The PPLP group participated in education sessions. The intervention yielded no significant within-group changes in HbA1c at three-month (-0.04 (-0.27 to 0.17) and -0.15 (-0.38 to 0.08)) or six-month (-0.09 (-0.41 to 0.22) and 0.06 (-0.26 to 0.38)) follow ups in either CON or PPLP groups, respectively. Dietary adherence scores improved in the PPLP group (p < 0.05) at three and six months but were not different in the between-group comparison. No changes in diabetes self-efficacy scores were detected. In the qualitative analysis, participants described the program as clear and easy to understand. Knowledge acquired influenced their everyday decision making but participants faced barriers that prevented them from fully applying what they learned. Healthcare professionals enjoyed delivering the program but described the "back-stage" workload as detrimental. In conclusion, while some positive effects of the PPLP intervention were observed, they were not comparable to those previously attained by our group in an academic setting or to what the guidelines recommend, which reflects the challenge of translating lifestyle intervention to real-world settings.

Regional variability in Canadian routine care of type 2 diabetes, hypercholesterolemia, and hypertension: Results from the The Cardio-Vascular and metabolic treatments in Canada: Assessment of REal-life therapeutic value (CV-CARE) registry

BACKGROUND

Regional differences in the profile and treatment strategies of patients with cardiometabolic diseases have been studied in several different countries. The Cardio-Vascular and metabolic treatments in Canada: Assessment of REal-life therapeutic value (CV-CARE) registry was designed to evaluate patient profiles and medical management of cardiometabolic diseases in routine clinical care settings across Canada. Primary objectives were to (1) evaluate regional variability of patient profiles with cardiometabolic disease(s) and (2) assess treatment differences of patients treated for type 2 diabetes (T2D), hypercholesterolemia (HCh), and hypertension (HTN) across Canada.

METHODS

CV-CARE is a multi-center, observational, prospective registry that enrolled Canadian patients treated with metformin-extended release (MetER) for T2D, colesevelam (C) for HCh, azilsartan (AZI) for mild-to-moderate essential HTN and azilsartan/chlorthalidone (AZI/CHL) for severe, essential HTN. Patient characteristics and treatments were assessed at baseline.

RESULTS

The registry enrolled 6960 patients, with a total of 4194 patients making up the primary analysis population [MetER (n=995); C (n=1639); AZI (n=1364); AZI/CHL (n=498)]. First-line use of MetER was more common in British Columbia (BC; 45.5%) compared to Ontario (ON; 29.8%), and Quebec (QC; 12.9%). C treatment for HCh was used as monotherapy most readily in BC (68.7%) compared with QC (59.7%) and ON (35.8%). Dual action of low-density lipoprotein cholesterol and hemoglobin A1c reduction was the predominant reason for C add-on therapy (46.8%), with highest usage seen in ON (62.9%). AZI treatment for HTN was most frequently used in BC (43.8%), and AZI/CHL was most commonly used in ON (12.0%). First-line use of AZI was more common in QC (50%) vs. ON (34.9%) and BC (24.1%). The primary reason for switching to AZI and AZI/CHL from prior treatment was lack of efficacy across provinces.

CONCLUSION

This is the first regional description of the CV-CARE cohort. Significant variations in both baseline profile and treatments were observed which could have an impact on long-term outcomes.

Disparities in the hospital cost of cardiometabolic diseases among lesbian, gay, and bisexual Canadians: a population-based cohort study using linked data

OBJECTIVES

Sexual identity has been recognized as a social determinant of health; however, evidence is limited on sexual minority status as a possible contributor to inequalities in cardiometabolic outcomes and the related hospital burden. This study aimed to investigate the association between sexual identity and hospital costs for cardiometabolic diseases among a cohort of Canadians using linked survey and administrative data.

METHODS

Data from the 2007-2011 Canadian Community Health Survey were linked to acute-care inpatient records from the 2005/2006-2012/2013 Discharge Abstract Database. Multiple linear regression was used to assess the association between self-reported sexual identity and inpatient resource use for cardiometabolic diseases.

RESULTS

Among the population ages 18-59, 2.1% (95% CI 1.9-2.2) identified as lesbian, gay, or bisexual (LGB). LGB individuals more often reported having diabetes or heart disease compared with heterosexuals. The mean inflation-adjusted cost for cardiometabolic-related hospitalizations was found to be significantly higher among LGB patients (CAD$26,702; 95% CI 26,166-60,365) than among their heterosexual counterparts ($10,137; 95% CI 8,639-11,635), in part a reflection of longer hospital stays (13.6 days versus 5.1 days). Inpatient costs remained 54% (95% CI 8-119) higher among LGB patients after controlling for socio-demographics, health status, and health behaviours.

CONCLUSION

This study revealed a disproportionate cost for potentially avoidable hospitalizations for cardiometabolic conditions among LGB patients, suggesting important unmet healthcare needs even in the Canadian context of universal coverage.

Multidisciplinary Management of Diabetic Foot Ulcers in Primary Cares in Quebec: Can We Do Better?

A growing body of evidence supports the presence of integrated foot care based on multidisciplinary and interdisciplinary teams in the management and prevention of diabetic foot ulcer (DFU) worldwide. This model of care is however rare in the clinical setting in Quebec, Canada. Many best practice gaps are identified as well as probable causal hypothesis are listed in this commentary. We support our opinions with a pilot audit conducted as part of a continuous quality improvement process in managing patients with DFU in our area and on Canadian facts and data. Our pilot study (n = 27 hospitalized patients) included a typical DFU population with neuropathy, peripheral arterial disease and previous amputation. It highlights underachievement of best practice recommendations implementation such as multidisciplinary DFU management and offloading interventions in our establishment. Due the high morbidity and mortality associated with DFU patients, four died during the studied hospitalization episode. Several barriers were encountered in the pilot audit justifying that no robust conclusion can be raised. However, our observations are concerning. Even though data accessibility was limited, our observations are sadly coherent with what is found in the literature. Economic data of what this means for our health system is put forward in the overall discussion. We are preoccupied by the trends outlined by some facts and observations, and this commentary was written with this in mind. In the face of the diabetes crisis that is arising, a plea is made to reassess care pathway for this vulnerable population as we emphasize the importance of teamwork in managing DFU.

Use of sodium-glucose cotransporter-2 inhibitors and risk of acute kidney injury in older adults with diabetes: a population-based cohort study

BACKGROUND

Regulatory agencies warn about the risk of acute kidney injury (AKI) after the initiation of sodium-glucose cotransporter-2 (SGLT2) inhibitors. Our objective was to quantify the 90-day risk of AKI in older adults after initiation of SGLT2 inhibitors in routine clinical practice.

METHODS

We conducted a population-based retrospective cohort study in Ontario, Canada, involving adults with diabetes who were aged 66 years or older and who were newly dispensed either an SGLT2 inhibitor or a dipeptidyl peptidase-4 (DPP4) inhibitor in an outpatient setting between 2015 and 2017. We used inverse probability of treatment weighting based on a propensity score to balance the 2 groups on measured baseline characteristics. The primary outcome was 90-day risk of a hospital encounter (i.e., visit to the emergency department or admission to hospital) with AKI, which we defined by a 50% or greater increase in the concentration of serum creatinine from the baseline value or an absolute increase of at least 27 μmol/L after an SGLT2 or DDP4 inhibitor was dispensed. We obtained weighted risk ratios using modified Poisson regression and weighted risk differences using binomial regression.

RESULTS

We included 39 094 patients with a median age of 70 (interquartile range 68-74) years in the study. Relative to new use of a DPP4 inhibitor, initiation of a SGLT2 inhibitor was associated with a lower 90-day risk of a hospital encounter with AKI: 216 events in 19 611 patients (1.10%) versus 388 events in 19 483 patients (1.99%); weighted risk ratio 0.79 (95% confidence interval 0.64-0.98).

INTERPRETATION

In routine care of older adults, new use of SGLT2 inhibitors compared with use of DPP4 inhibitors was associated with a lower risk of AKI. Together with previous evidence, our findings suggest that regulatory warnings about AKI risk with SGLT2 inhibitors are unwarranted.

FINDRISC in Latin America: a systematic review of diagnosis and prognosis models

This review aimed to assess whether the FINDRISC, a risk score for type 2 diabetes mellitus (T2DM), has been externally validated in Latin America and the Caribbean (LAC). We conducted a systematic review following the CHARMS (CHecklist for critical Appraisal and data extraction for systematic Reviews of prediction Modelling Studies) framework. Reports were included if they validated or re-estimated the FINDRISC in population-based samples, health facilities or administrative data. Reports were excluded if they only studied patients or at-risk individuals. The search was conducted in Medline, Embase, Global Health, Scopus and LILACS. Risk of bias was assessed with the PROBAST (Prediction model Risk of Bias ASsessment Tool) tool. From 1582 titles and abstracts, 4 (n=7502) reports were included for qualitative summary. All reports were from South America; there were slightly more women, and the mean age ranged from 29.5 to 49.7 years. Undiagnosed T2DM prevalence ranged from 2.6% to 5.1%. None of the studies conducted an independent external validation of the FINDRISC; conversely, they used the same (or very similar) predictors to fit a new model. None of the studies reported calibration metrics. The area under the receiver operating curve was consistently above 65.0%. All studies had high risk of bias. There has not been any external validation of the FINDRISC model in LAC. Selected reports re-estimated the FINDRISC, although they have several methodological limitations. There is a need for big data to develop-or improve-T2DM diagnostic and prognostic models in LAC. This could benefit T2DM screening and early diagnosis.

Impact of diabetes education teams in primary care on processes of care indicators

AIMS

To evaluate the impact of the integration of onsite diabetes education teams in primary care on processes of care indicators according to practice guidelines.

METHODS

Teams of nurse and dietitian educators delivered individualized self-management education counseling in 11 Ontario primary care sites. Of the 771 adult patients with HbA1c ≥7% who were recruited in a prospective cohort study, 487 patients attended appointments with the education teams, while the remaining 284 patients did not (usual care group). Baseline demographic, clinical information, and patient care processes (diabetes medical visit, HbA1c test, lipid profile, estimated glomerular filtration rate, and albumin-to-creatinine ratio, measuring blood pressure, performing foot exams, provision of flu vaccine, and referral for dilated retinal exam) were collected from patient charts one year before (pre period) and after (post period) the integration began. A multi-level random effects model was used to analyze the effect of group and period on whether the process indicators were met based on practice guidelines.

RESULTS

Compared to the usual care group, patients seen by the education teams had significant improvements on indicators for semi-annual medical visit and annual foot exam. No significant improvements were found for other process of care indicators.

CONCLUSIONS

Onsite education teams in primary care settings can potentially improve diabetes management as shown in two process of care indicators: medical visits and foot exams. The results support the benefits of having education teams in primary care settings to increase adherence to practice guidelines.

Insulin Therapy in Adults with Type 1 Diabetes Mellitus: a Narrative Review

Here, we review insulin management options and strategies in nonpregnant adult patients with type 1 diabetes mellitus (T1DM). Most patients with T1DM should follow a regimen of multiple daily injections of basal/bolus insulin, but those not meeting individual glycemic targets or those with frequent or severe hypoglycemia or pronounced dawn phenomenon should consider continuous subcutaneous insulin infusion. The latter treatment modality could also be an alternative based on patient preferences and availability of reimbursement. Continuous glucose monitoring may improve glycemic control irrespective of treatment regimen. A glycemic target of glycated hemoglobin < 7% (53 mmol/mol) is appropriate for most nonpregnant adults. Basal insulin analogues with a reduced peak profile and an extended duration of action with lower intraindividual variability relative to neutral protamine Hagedorn insulin are preferred. The clinical advantages of basal analogues compared with older basal insulins include reduced injection burden, better efficacy, lower risk of hypoglycemic episodes (especially nocturnal), and reduced weight gain. For prandial glycemic control, any rapid-acting prandial analogue (aspart, glulisine, lispro) is preferred over regular human insulin. Faster-acting insulin aspart is a relatively new option with the advantage of better postprandial glucose coverage. Frequent blood glucose measurements along with patient education on insulin dosing based on carbohydrate counting, premeal blood glucose, and anticipated physical activity is paramount, as is education on the management of blood glucose under different circumstances.Plain Language Summary: Plain language summary is available for this article.

A Safety Comparison of Metformin vs Sulfonylurea Initiation in Patients With Type 2 Diabetes and Chronic Kidney Disease: A Retrospective Cohort Study

OBJECTIVE

To compare the safety of metformin vs sulfonylureas in patients with type 2 diabetes by chronic kidney disease (CKD) stage.

PATIENTS AND METHODS

This retrospective cohort study included adults in Manitoba, Canada, with type 2 diabetes, an incident monotherapy prescription for metformin or a sulfonylurea, and a serum creatinine measurement from April 1, 2006, to March 31, 2017. Patients were stratified by estimated glomerular filtration rate (eGFR) into the following groups: eGFR of 90 or greater, 60 to 89, 45 to 59, 30 to 44, or less than 30 mL/min/1.73 m². Outcomes included all-cause mortality, cardiovascular events, and major hypoglycemic episodes. Baseline characteristics were used to calculate propensity scores and perform inverse probability of treatment weights analysis, and eGFR group was examined as an effect modifier for each outcome.

RESULTS

The cohort consisted of 21,996 individuals (19,990 metformin users and 2006 sulfonylurea users). Metformin use was associated with lower risk for all-cause mortality (hazard ratio [HR], 0.48; 95% CI, 0.40-0.58; P<.001), cardiovascular events (HR, 0.67; 95% CI, 0.52-0.86; P=.002), and major hypoglycemic episodes (HR, 0.14; 95% CI, 0.09-0.20; P<.001) when compared with sulfonylureas. CKD was a significant effect modifier for all-cause mortality (P=.002), but not for cardiovascular events or major hypoglycemic episodes.

CONCLUSION

Sulfonylurea monotherapy is associated with higher risk for all-cause mortality, major hypoglycemic episodes, and cardiovascular events compared with metformin. Although the presence of CKD attenuated the mortality benefit, metformin may be a safer alternative to sulfonylureas in patients with CKD.

Pharmacist-led therapeutic carbohydrate restriction as a treatment strategy for type 2 diabetes: the Pharm-TCR randomized controlled trial protocol

BACKGROUND

The current treatment paradigm for type 2 diabetes mellitus (T2D) typically involves use of multiple medications to lower glucose levels in hope of reducing long-term complications. However, such treatment does not necessarily address the underlying pathophysiology of the disease and very few patients achieve partial, complete, or prolonged remission of T2D after diagnosis. The therapeutic potential of nutrition has been highlighted recently based on results of clinical trials reporting remission of T2D with targeted dietary approaches. During the initial phase of such interventions that restrict carbohydrates and/or induce rapid weight loss, hypoglycemia presents a notable risk to patients. We therefore hypothesized that delivering very low-carbohydrate, low-calorie therapeutic nutrition through community pharmacies would be an innovative strategy to facilitate lowering of glycated hemoglobin (A1C) while safely reducing the use of glucose-lowering medications in T2D.

METHODS

A community-based randomized controlled trial that is pragmatic in nature, following a parallel-group design will be conducted (N = 200). Participants will have an equal chance of being randomized to either a pharmacist-led, therapeutic carbohydrate restricted (Pharm-TCR) diet or guideline-based treatment as usual (TAU). Pharm-TCR involves a 12-week very low carbohydrate, calorie-restricted commercial diet plan led by pharmacists and lifestyle coaches with pharmacists responsible for managing medications in collaboration with the participants' family physicians. Main inclusion criteria are diagnosis of T2D, currently treated with glucose-lowering medications, age 30-75 years, and body mass index ≥ 30. The primary outcome is a binary measure of use of glucose-lowering medication. Secondary outcomes include A1C, anthropometrics and clinical blood markers.

DISCUSSION

There are inherent risks involved if patients with T2D who take glucose-lowering medications follow very low carbohydrate diets. This randomized controlled trial aims to determine whether engaging community pharmacists is a safe and effective way to deliver therapeutic carbohydrate restriction and reduce/eliminate the need for glucose-lowering medications in people with T2D.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03181165. Registered on 8 June 2017.

The impact of environmental cadmium exposure on type 2 diabetes risk: a protocol for an overview of systematic reviews

BACKGROUND

Type 2 diabetes mellitus (T2DM) is a worldwide epidemic, and while its etiology is polygenic, the role of environmental contaminant exposure in T2DM pathogenesis is of increasing importance. However, the evidence presented in systematic reviews on the relationship between cadmium exposure and T2DM development is inconsistent. This overview aims to assess existing evidence from systematic reviews linking cadmium exposure to T2DM and select metabolic disorders in humans.

METHODS

Searches will be conducted in Medline, Embase, Web of Science, GEOBASE, BIOSIS Previews, and Cochrane Database of Systematic Reviews. Two reviewers (J.H and S.T.) will independently complete screening, data abstraction, risk of bias evaluation, and quality assessment. The primary outcome will be the association between cadmium exposure and T2DM prevalence. Secondary outcomes will include prediabetes, obesity, dyslipidemia, hypertension, and non-alcoholic fatty liver disease. We will perform a meta-analysis if two or more studies assess similar populations, utilize analogous methods, have related study designs, and evaluate similar outcomes.

DISCUSSION

This overview will assess current evidence from systematic reviews for the association between cadmium exposure and risk of T2DM and other metabolic morbidities. This overview may be helpful for policy-makers and healthcare teams aiming to mitigate T2DM risk in populations at risk of cadmium exposure.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42019125956.

Polypharmacy and Pharmacological Treatment of Diabetes in Older Individuals: A Population-Based Study in Quebec, Canada

Our objectives were to describe the use of pharmacological treatments in older adults with diabetes and to identify the factors associated with the use of a combination of hypoglycemic, antihypertensive and lipid-lowering agents. Using the Quebec Integrated Chronic Disease Surveillance System, we conducted a population-based cohort study among individuals aged 66-75 years with diabetes in 2014-2015. We described the number of medications and the classes of medications used and calculated the proportion of individuals using at least one medication from each of these classes: hypoglycemics, antihypertensives and lipid-lowering agents. We identified the factors associated with the use of this combination of treatments by performing robust Poisson regressions. The 146,710 individuals used an average of 12 (SD 7) different medications, mostly cardiovascular (91.3% of users), hormones, including hypoglycemic agents (84.5%), and central nervous system medications (79.8%). The majority of individuals (59%) were exposed to the combination of treatments and the factor most strongly associated was the presence of cardiovascular comorbidities (RR: 1.29; 99% CI: 1.28-1.31). Older individuals with diabetes are exposed to a large number of medications. While the use of the combination of treatments is significant and could translate into cardiovascular benefits at the population level, the potential risk associated with polypharmacy needs to be documented.

Risk scores for type 2 diabetes mellitus in Latin America: a systematic review of population-based studies

AIM

To summarize the evidence on diabetes risk scores for Latin American populations.

METHODS

A systematic review was conducted (CRD42019122306) looking for diagnostic and prognostic models for type 2 diabetes mellitus among randomly selected adults in Latin America. Five databases (LILACS, Scopus, MEDLINE, Embase and Global Health) were searched. type 2 diabetes mellitus was defined using at least one blood biomarker and the reports needed to include information on the development and/or validation of a multivariable regression model. Risk of bias was assessed using the PROBAST guidelines.

RESULTS

Of the 1500 reports identified, 11 were studied in detail and five were included in the qualitative analysis. Two reports were from Mexico, two from Peru and one from Brazil. The number of diabetes cases varied from 48 to 207 in the derivations models, and between 29 and 582 in the validation models. The most common predictors were age, waist circumference and family history of diabetes, and only one study used oral glucose tolerance test as the outcome. The discrimination performance across studies was ~ 70% (range: 66-72%) as per the area under the receiving-operator curve, the highest metric was always the negative predictive value. Sensitivity was always higher than specificity.

CONCLUSION

There is no evidence to support the use of one risk score throughout Latin America. The development, validation and implementation of risk scores should be a research and public health priority in Latin America to improve type 2 diabetes mellitus screening and prevention.

A high-throughput test for diabetes care: An evaluation of the next generation Roche Cobas c 513 hemoglobin A1C assay

Objectives

The level of glycated hemoglobin A (HbA_1C) in blood is the preferred marker for diabetes monitoring and treatment. Here, we evaluate the analytical performance of the Roche Diagnostics Cobas c 513, a stand-alone HbA_1C immunoassay analyzer.

Design and Methods

Performance was assessed with regards to imprecision, accuracy, linearity, method comparison against the Roche Cobas Integra 800 CTS, specimen stability, interference from common hemoglobin variants and hemoglobin F, and throughput.

Results

Within-run and between-run precisions were 0.5–0.7 and 0.8–1.3%CV, respectively. An average bias of −1.6% to proficiency survey samples was observed. The c 513 correlated well with the Integra (slope = 0.94, y-intercept = 0.50, and correlation coefficient = 0.998). The effect of hemoglobin variants on this assay was negligible while specimens containing ≥10% HbF demonstrated a negative bias. The c 513 instrument can process up to 340 samples per hour.

Conclusions

The c 513 is a precise, accurate, automated high throughput analyzer for measuring HbA_1C in large laboratories.

Food Insecurity Screening Among Families of Children With Diabetes

Little is known about screening in clinical settings for food insecurity (FI) among households of children with diabetes. This study evaluated the acceptability and feasibility of an FI screening initiative in a pediatric diabetes clinic that was implemented to help diabetes dietitian educators tailor management plans for families of children with type 1 or type 2 diabetes facing FI. The initiative comprised three validated screening questions, a care algorithm, a community resource handout, and a poster. In total, 50 families of children and adolescents aged 0-18 years with type 1 or type 2 diabetes were screened for FI. In-person semi-structured interviews combining open-ended and Likert-scale questions were conducted with 37 of the screened families and the three diabetes dietitian educators who conducted the screening. Perceived barriers and facilitators of the screening initiative were identified using content analysis, and Likert-scale questionnaires rated interviewees' comfort level with the screening questions. A reflective journal kept by an onsite research interviewer also facilitated the data interpretation process. Most families felt comfortable answering the screening questions. Families with FI appreciated the opportunity to express their concerns and learn about affordable food resources. However, ∼20% of these families described stigma and fear of judgment by clinicians if they screened positive for FI. Diabetes educators also felt comfortable with the screening questions but reported lack of time to screen all families and to follow-up with resources after a positive screen. A self-reported intake form was recommended to ensure that everyone is systematically screened. A standardized and respectful method of assessing FI could help clinicians better tailor treatment plans and support for families of children with diabetes who face FI. Based on these findings, similar FI screening initiatives should be implemented in other clinical settings as part of routine clinical practice.

The prevalence of cardiometabolic multimorbidity and its association with physical activity, diet, and stress in Canada: evidence from a population-based cross-sectional study

BACKGROUND

Cardiometabolic multimorbidity (CM) is defined as having a diagnosis of at least two of stroke, heart disease, or diabetes, and is an emerging health concern, but the prevalence of CM at a population level in Canada is unknown. The objectives of this study were to quantify the: 1) prevalence of CM in Canada; and 2) association between CM and lifestyle behaviours (e.g., physical activity, consumption of fruits and vegetables, and stress).

METHODS

Using data from the 2016 Canadian Community Health Survey, we estimated the overall and group prevalence of CM in individuals aged ≥50 years (n = 13,226,748). Multiple logistic regression was used to quantify the association between CM and lifestyle behaviours compared to a group without cardiometabolic conditions.

RESULTS

The overall prevalence of CM was 3.5% (467,749 individuals). Twenty-two percent (398,755) of people with diabetes reported having another cardiometabolic condition and thus CM, while the same was true for 32.2% (415,686) of people with heart disease and 48.4% (174,754) of stroke survivors. 71.2% of the sample reported eating fewer than five servings of fruits and vegetables per day. The odds of individuals with CM reporting zero minutes of physical activity was 2.35 [95% CI = 1.87 to 2.95] and having high stress was 1.89 [95% CI = 1.49 to 2.41] times the odds of the no cardiometabolic condition reference group. The odds of individuals with all three cardiometabolic conditions reporting zero minutes of physical activity was 4.31 [95% CI = 2.21 to 8.38] and having high stress was 3.93 [95% CI = 2.03 to 7.61].

CONCLUSION

The number of Canadians with CM or at risk of CM is high and these individuals have lifestyle behaviours that are associated with adverse health outcomes. Lifestyle behaviours tend to diminish with increasing onset of cardiometabolic conditions. Lifestyle modification interventions focusing on physical activity and stress management for the prevention and management CM are warranted.

First Nations people with diabetes in Ontario: methods for a longitudinal population-based cohort study

BACKGROUND

To improve diabetes care, First Nations leaders and others need access to population-level health data. We provide details of the collaborative methods we used to describe the prevalence and incidence of diabetes in First Nations people in Ontario and present demographic data for this population compared to the rest of the Ontario population.

METHODS

To identify the population of First Nations people and other people in Ontario, we created annual cohorts of the Ontario population for each year between Apr. 1, 1995, and Mar. 31, 2015. Through a partnership between First Nations and academic researchers, we linked provincial population-based health administrative data stored at ICES with the Indian Register, which identifies all Status First Nations people. Our collaborative process was guided by the First Nations principles of ownership, control, access and possession (OCAP).

RESULTS

Demographic characteristics for the 2014/15 cohort (n = 13 406 684) are presented here. The cohort includes 158 241 Status First Nations people and 13 248 443 other people living in Ontario. Using postal codes, we were able to identify virtually all (99.9%) First Nations people in Ontario as living in (n = 55 311) or outside (n =102 889) a First Nations community. First Nations people were younger and more likely to live in semiurban or rural areas than the rest of Ontario's population.

INTERPRETATION

The collaborative methodology used in this study is applicable to many jurisdictions working with Indigenous groups who have access to similar data. The Ontario cohort defined here is being used to conduct analyses of health outcomes and use of health care services among First Nations people with diabetes in Ontario.

Capacity and confidence building for general practitioners on optimum insulin use

Type 2 diabetes is characterised by a progressive decline in insulin secretion, and sooner or later patients require insulin therapy. However, physicians are reluctant to initiate insulin therapy because of perceived inadequacy in managing insulin therapy, cost and lack of benefits. Experts from across the country met at a workshop during 12th National Insulin Summit which was held in September at Hyderabad and came up with key recommendations to build capacity and confidence in general practitioners for insulin usage. Barriers can be overcome through self-education and training; effective patient education; imparting coping skill training to patients; and bridging gaps to improve adherence. Moreover, optimum insulinization requires knowledge about the available options for initiation and intensification of insulin therapy; various insulin regimens; dosing and titration; and choosing effective and simple insulin therapy as per patient characteristics. Hence, the objective of this review article is to help build capacity and confidence among general practitioners on optimising insulin therapy.

When basal insulin is not enough: A dose-response relationship between insulin glargine 100 units/mL and glycaemic control

AIMS

A post-hoc analysis to assess the impact in people with type 2 diabetes, of increasing doses of basal insulin on glycaemic measures, body weight and hypoglycaemia.

RESEARCH DESIGN AND METHODS

We included data from prospective, randomized controlled treat-to-target trials of ≥24 weeks' duration in people with type 2 diabetes, uncontrolled on metformin and sulphonylureas, and treated with insulin glargine 100 units/mL (U100), who had at least six fasting plasma glucose (FPG) measurements. The impact of insulin dose on glycated haemoglobin (HbA1c) values, FPG, hypoglycaemia incidence (<3.9 mmol/L [70 mg/dL]), and body weight was analysed. A total of 458 participants from three eligible trials were included.

RESULTS

The observed relationship between higher basal insulin doses and glycaemic control was non-linear, with increasing insulin dose leading to smaller reductions in FPG and HbA1c for doses >0.3 IU/kg/d, with a plateauing effect at 0.5 IU/kg/d. Total daily dose of insulin >0.5 IU/kg/d resulted in greater weight gain, but without higher rates of hypoglycaemia, compared with insulin doses ≤0.5 IU/kg/d.

CONCLUSIONS

This analysis indicates that basal insulin doses >0.5 IU/kg/d have diminishing additional impact on improving glycaemic measures, with the disadvantage of additional weight gain. Clinicians should consider anti-hyperglycaemic treatment intensification at doses approaching 0.5 IU/kg/d.

Integrated Myofibrillar Protein Synthesis in Recovery From Unaccustomed and Accustomed Resistance Exercise With and Without Multi-ingredient Supplementation in Overweight Older Men

Background: We previously showed that daily consumption of a multi-ingredient nutritional supplement increased lean mass in older men, but did not enhance lean tissue gains during a high-intensity interval training (HIIT) plus resistance exercise training (RET) program. Here, we aimed to determine whether these divergent observations aligned with the myofibrillar protein synthesis (MyoPS) response to acute unaccustomed and accustomed resistance exercise. Methods: A sub-sample of our participants were randomly allocated (n = 15; age: 72 ± 7 years; BMI: 26.9 ± 3.1 kg/m2 [mean ± SD]) to ingest an experimental supplement (SUPP, n = 8: containing whey protein, creatine, vitamin D, and n-3 PUFA) or control beverage (CON, n = 7: 22 g maltodextrin) twice per day for 21 weeks. After 7 weeks of consuming the beverage alone (Phase 1: SUPP/CON only), subjects completed 12 weeks of RET (twice per week) + HIIT (once per week) (Phase 2: SUPP/CON + EX). Orally administered deuterated water was used to measure integrated rates of MyoPS over 48 h following a single session of resistance exercise pre- (unaccustomed) and post-training (accustomed). Results: Following an acute bout of accustomed resistance exercise, 0-24 h MyoPS was 30% higher than rest in the SUPP group (effect size: 0.86); however, in the CON group, 0-24 h MyoPS was 0% higher than rest (effect size: 0.04). Nonetheless, no within or between group changes in MyoPS were statistically significant. When collapsed across group, rates of MyoPS in recovery from acute unaccustomed resistance exercise were positively correlated with training-induced gains in whole body lean mass (r = 0.63, p = 0.01). Conclusion: There were no significant between-group differences in MyoPS pre- or post-training. Integrated rates of MyoPS post-acute exercise in the untrained state were positively correlated with training-induced gains in whole body lean mass. Our finding that supplementation did not alter 0-48 h MyoPS following 12 weeks of training suggests a possible adaptive response to longer-term increased protein intake and warrants further investigation. This study was registered at ClinicalTrials.gov. Clinical Trial Registration: www.ClinicalTrials.gov, identifier: NCT02281331.

Prediabetes: An emerging public health concern in adolescents

OBJECTIVES

To identify the presence of risk factors for type 2 diabetes (ethnicity, body mass index, blood glucose tolerance and blood pressure) and to determine the prevalence of prediabetes and type 2 diabetes in Canadian adolescents attending two multicultural urban high schools.

METHODS

A total of 266 multicultural urban high school students who live in a mid-sized Western Canadian city, aged 14-21, were screened for risk factors of prediabetes and type 2 diabetes in March-April 2018. Data with respect to demographics, family history of diabetes, anthropometrics, blood pressure and haemoglobin A1c (HbA1c) were collected. Data analysis was done using descriptive and inferential statistics in addition to chi-square analyses.

RESULTS

Based on body mass index, 38% of the adolescents were classified as either overweight or obese. Overweight rates for females (69.8%) were double than males (30.2%); however, males (52.2%) were more likely to obese than the females (47.8%). Based on HbA1c levels, 29.3% were at high risk to develop either diabetes or prediabetes and 2.6% were classified in the prediabetes range. Prehypertension/hypertension rates of 47% in the sample increased to 51% in those adolescents with elevated HbA1c; the majority of these prehypertensive/hypertensive participants were male.

CONCLUSION

High rates of overweight/obesity and prehypertension/hypertension were found in the adolescents studied and indicated the presence of prediabetes and an increased risk to develop type 2 diabetes and associated complications. Obesity and hypertension are major risk factors for developing type 2 diabetes, resulting in earlier exposure to metabolic consequences and, ultimately, long-term complications. Thus, timely research is needed to identify age-appropriate strategies that address risks and to develop recommendations for routine screening of adolescents for prediabetes.

CANadian CAnagliflozin REgistry: Effectiveness and safety of canagliflozin in the treatment of type 2 diabetes mellitus in Canadian clinical practice

AIM

There is limited information concerning the effects of canagliflozin (CANA), a sodium-glucose co-transporter 2 inhibitor (SGLT2i) in a real-world clinical setting in Canada. CanCARE is a 12-month, prospective, observational analysis to demonstrate the effectiveness and safety of CANA in usual clinical practice in Canada.

MATERIALS AND METHODS

SGLT2i-naïve adult patients with type 2 diabetes mellitus (T2DM) (n = 527) on a stable antihyperglycemic agent (AHA) regimen with glycated hemoglobin (A1C) ≥ 7%, an estimated glomerular filtration rate (eGFR) ≥ 60 mL/min/1.73m2 , were initiated on CANA as part of their usual treatment approach, and were followed for a period of 12 months. The primary effectiveness objective was the mean change in HbA1c from baseline to 6 and 12 months.

RESULTS

Significant improvement from baseline in mean HbA1c levels were observed at 6 months (-0.90%; 95% CI, -1.02, -0.78) and at 12 months (-1.04%; 95% CI, -1.15, -0.92), regardless of duration of diabetes or background AHA treatment regimen. Similarly, significant decreases in systolic blood pressure (-4.65 mm Hg); body weight (-3.24 kg), waist circumference (-2.91 cm) and body mass index (-1.15 kg/m2 ) were observed at 12 months. Additionally, 40.5% of patients achieved the double endpoint (≥0.5% HbA1c reduction and ≥ 3% weight loss), while 24.3% of patients achieved the triple composite endpoint (≥0.5% HbA1c reduction, ≥3% weight loss and ≥ 4 mm Hg systolic blood pressure reduction). No unexpected adverse events were reported.

CONCLUSION

CANA provided sustained clinically meaningful improvements in cardiometabolic parameters in this study in a real-world setting, confirming findings from randomized controlled trials.

Systematic review of community pharmacy-based and pharmacist-led foot care interventions for adults with type 2 diabetes

BACKGROUND

To prevent diabetic foot disease, proper foot care is essential for early detection and treatment. Pharmacists are well suited to provide accessible foot care to adults with type 2 diabetes. Limited research has examined this role.

METHODS

We conducted a systematic review of community pharmacy-based and pharmacist-led foot care interventions for adults with type 2 diabetes compared to usual care. Data sources included MEDLINE, EMBASE, the Cochrane Library, CINAHL, Academic Search Complete and Health Source: Nursing/Academic Edition and Google Scholar, plus Google and hand-searching. Original research studies reported in English, focused on community pharmacy-based or pharmacist-led foot care interventions were eligible for review. Participants were adults with type 2 diabetes. Studies were summarized narratively; pooled data were not possible.

RESULTS

Seven studies were included in this review, 3 focusing on improving foot self-care behaviours and 4 on promoting foot examinations by the health care provider. Only 2 studies were randomized and were assessed as high quality. Six out of 7 studies reported significantly positive findings related to foot care practices.

DISCUSSION

An opportunity to influence foot care exists at each clinical encounter. Pharmacists are accessible health care practitioners and appropriate to provide a range of diabetes foot care interventions.

CONCLUSIONS

Seven studies examined community pharmacy-based and pharmacist-led foot care interventions for people with type 2 diabetes. Community pharmacies and pharmacists are capable of providing a variety of foot care interventions to patients with diabetes, helping detect problems early and leading to prompt intervention.

The effect of a short-term low-carbohydrate, high-fat diet with or without postmeal walks on glycemic control and inflammation in type 2 diabetes: a randomized trial

Lowering carbohydrate consumption effectively lowers glucose, but impacts on inflammation are unclear. The objectives of this study were to: 1) determine whether reducing hyperglycemia by following a low-carbohydrate, high-fat (LC) diet could lower markers of innate immune cell activation in type 2 diabetes (T2D) and 2) examine if the combination of an LC diet with strategically timed postmeal walking was superior to an LC diet alone. Participants with T2D ( n = 11) completed a randomized crossover study involving three 4-day diet interventions: 1) low-fat low-glycemic index (GL), 2) and 3) LC with 15-min postmeal walks (LC+Ex). Four-day mean glucose was significantly lower in the LC+Ex group as compared with LC (-5%, P < 0.05), whereas both LC+Ex (-16%, P < 0.001) and LC (-12%, P < 0.001) conditions were lower than GL. A significant main effect of time was observed for peripheral blood mononuclear cells phosphorylated c-Jun N-terminal kinase ( P < 0.001), with decreases in all three conditions (GL: -32%, LC: -45%, and LC+Ex: -44%). A significant condition by time interaction was observed for monocyte microparticles ( P = 0.040) with a significant decrease in GL (-76%, P = 0.035) and a tendency for a reduction in LC (-70%, P = 0.064), whereas there was no significant change in LC+Ex (0.5%, P = 0.990). Both LC (-27%, P = 0.001) and LC+Ex (-35%, P = 0.005) also led to significant reductions in circulating proinsulin. An LC diet improved 4-day glycemic control and fasting proinsulin levels when compared with GL, with added glucose-lowering benefits when LC was combined with postmeal walking.

The quality of clinical practice guidelines for management of pediatric type 2 diabetes mellitus: a systematic review using the AGREE II instrument

AIMS

Pediatric type 2 diabetes mellitus (T2DM) is a relatively new disease with increasing incidence corresponding to the obesity epidemic among youth. It is important for clinicians to have access to high-quality clinical practice guidelines (CPGs) for appropriate management of pediatric patients with T2DM. The objective of this systematic review was to evaluate overall quality of CPGs for the management of pediatric T2DM using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool.

METHODS

We searched MEDLINE, Embase, CINAHL, Trip, National Guideline Clearinghouse, and grey literature to identify eligible CPGs. We also searched the webpages of national and international diabetes and pediatric organizations globally. We included CPGs from national and international diabetes and pediatric associations that were published as standalone guidelines for T2DM in children and adolescents (2-18 years of age). We also included pediatric and adult guidelines for type 1 diabetes if they included a section addressing T2DM management in children and adolescents. We retrieved the two most recent guidelines from each organization when available to assess change in quality over time. We excluded individual studies and systematic reviews that made treatment recommendations as well as CPGs that were developed for a single institution.

RESULTS

We included 21 unique CPGs in this systematic review. Of the included guidelines, 12 were developed or updated between 2012 and 2014. Five of all included CPGs were specific to pediatric populations. The analysis revealed that "Rigour of Development" (mean 45%, SD 28.68) and "Editorial Independence" (mean 45%, SD 35.19) were the lowest scoring domains on the AGREE II for the majority of guidelines, whereas "Clarity of Presentation" was the highest scoring domain (mean 72%, SD 18.89).

CONCLUSIONS

Overall, two thirds of the pediatric T2DM guidelines were moderate to low quality and the remaining third ranked higher in quality. Low quality was especially due to the scores for the "Rigour of Development" domain, which directly measures guideline development methodology. It is important that future guidelines and updates of existing guidelines improve the methodology of development and quality of reporting in order to appropriately guide physicians managing children and adolescents with T2DM.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42016034187.

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