Amir Hanna

Supplementation of Conventional Therapy with the Novel Grain Salba ( Salvia hispanica L. ) Improves Major and Emerging Cardiovascular Risk Factors in Type 2 Diabetes: Results of a Randomized Controlled Trial

OBJECTIVE—To determine whether addition of Salba (Salvia hispanica L.), a novel whole grain that is rich in fiber, α-linolenic acid (ALA), and minerals to conventional treatment is associated with improvement in major and emerging cardiovascular risk factors in individuals with type 2 diabetes. RESEARCH DESIGN AND METHODS—Using a single-blind cross-over design, subjects were randomly assigned to receive either 37 ± 4 g/day of Salba or wheat bran for 12 weeks while maintaining their conventional diabetes therapies. Twenty well-controlled subjects with type 2 diabetes (11 men and 9 women, aged 64 ± 8 years, BMI 28 ± 4 kg/m2, and A1C 6.8 ± 0.9%) completed the study. This study was set in the outpatient clinic of the Risk Factor Modification Center, St. Michael’s Hospital, Toronto, Canada. RESULTS—Compared with the control treatment, Salba reduced systolic blood pressure (SBP) by 6.3 ± 4 mmHg (P < 0.001), high-sensitivity C-reactive protein (hs-CRP) (mg/l) by 40 ± 1.6% (P = 0.04), and vonWillebrand factor (vWF) by 21 ± 0.3% (P = 0.03), with significant decreases in A1C and fibrinogen in relation to the Salba baseline but not with the control treatment. There were no changes in safety parameters including liver, kidney and hemostatic function, or body weight. Both plasma ALA and eicosapentaenoic polyunsaturated fatty acid levels were increased twofold (P < 0.05) while consuming Salba. CONCLUSIONS—Long-term supplementation with Salba attenuated a major cardiovascular risk factor (SBP) and emerging factors (hs-CRP and vWF) safely beyond conventional therapy, while maintaining good glycemic and lipid control in people with well-controlled type 2 diabetes.

Policies, Guidelines and Consensus Statements: Pharmacologic Management of Type 2 Diabetes-2015 Interim Update.

The initial draft of this commentary was prepared by William Harper MD, FRCPC, Maureen Clement MD, CCFP, Ronald Goldenberg MD, FRCPC, FACE, Amir Hanna MB, BCh, FRCPC, FACP, Andrea Main BScPhm, CDE, Ravi Retnakaran MD, MSc, FRCPC, Diana Sherifali RN, PhD, CDE, Vincent Woo MD, FRCPC, Jean-François Yale MD, CSPQ, FRCPC, and Alice Y.Y. Cheng MD, FRCPC on behalf of the Steering Committee for the Canadian Diabetes Association 2013 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada

A Portable System for Continuous Intravenous Insulin Delivery: Characteristics and Results in Diabetic Patients

A portable insulin delivery system for clinical use has been developed, with the aim of improving glycemic control for prolonged periods for individuals with insulin-dependent diabetes. It weighs 1.5 kg and measures 8 × 11 × 20 cm. A plastic case contains two insulin reservoirs, two peristaltic pumps (flow variability ± 3%), a battery pack, and voltage regulator. Silastic tubes connect the reservoirs to an indwelling intravenous catheter inserted into the arm. The system is carried by a strap over the shoulder. One pump operates continuously, giving insulin at a “basal” rate, and the other is activated during meals to give a preprogrammed waveform of insulin, the latter controlled by a small bedside unit. Twelve insulin-dependent diabetic patients were infused with insulin by this system for 4–60 days (mean 18 days), for a total of 199 patient days. Insulin delivery rates were modified according to data obtained by intermittent glycemic monitoring, and on one and in some cases two days glycemia was continuously monitored (N = 10). With a basal infusion rate of 18 ± 2 mU/min (mean ± SEM), fasting glycemia was 99 ± 7 mg/dl. The mean insulin delivered with meals was 12 ± 2 U for breakfast, 9 ± 2 U for lunch, and 11 ± 2 U for dinner. Mean glycemia before lunch and supper was 102 ± 6 and 121 ± 11 mg/dl, respectively. The lowest mean glycemia occurred after lunch (88 ± 7 mg/dl) and the mean peak postprandial glycemia was 136 ± 8 mg/dl (2 h after supper). The range from lowest to highest observed value was 47–189 mg/dl. This system is capable of maintaining glycemia within the normal range for periods up to 60 days. Further refinement of the waveforms of insulin delivery may allow for total glycemic normalization. The future refinement of such a system will allow for longer-term studies addressing the relationship between glycemic control and complications.

Self-Monitoring of Blood Glucose in People with Type 2 Diabetes: Canadian Diabetes Association Briefing Document for Healthcare Providers

BaCKGroUnD The Canadian Diabetes Association (CDA) believes that self-monitoring of blood glucose (SMBG) is an important and essential tool for the care of individuals with diabetes. The Canadian Diabetes Association 2008 clinical practice guidelines for the prevention and management of diabetes in Canada (1) recommend that SMBG be individualized for each person with diabetes based on their circumstances and needs. It is the intent of the CDA to inform Canadian healthcare providers of its position concerning SMBG, to respect the CDA guidelines (1) and to proactively influence public policy concerning SMBG, while at the same time addressing issues concerning cost-effectiveness raised by the Canadian Optimal Medication Prescribing and Utilization Service (COMPUS) (2-7). To do this, a working group of members of the Clinical & Scientific Section (C&SS), Diabetes Educator Section (DES) and National Advocacy Committee (NAC) of the CDA was formed to draft a briefing document regarding SMBG. This document has been accepted by the executive committees of both the C&SS and DES. The SMBG working group believes that some level of SMBG is appropriate for many people with type 2 diabetes, where clinically indicated. The frequency of SMBG will vary depending on the clinical situation. This document was developed by the SMBG working group as a briefing document and not as a guidelines statement. The purpose of this document is as follows: 1. To make recommendations on SMBG in the management of type 2 diabetes, following a review of current data on its efficacy and cost-effectiveness. 2. To address the allocation of healthcare funding in an environment of limited fiscal resources. 3. To provide support for people with diabetes who, based on certain circumstances, will benefit from structured SMBG as a way to self-manage their disease. This document provides general comments on all 5 COMPUS recommendations, and presents specific information and comments for patients with type 2 diabetes, so that the CDA’s perspective on SMBG is shared with healthcare providers and stakeholders alike. To complement this document and provide practical education, the CDA has developed an SMBG tool for healthcare providers and 2 tools for people with diabetes, to identify optimal self-management and best practices regarding individualized requirements for SMBG (8,9), including optimal frequency and timing. These tools will be disseminated to physicians, diabetes educators and other healthcare professionals who work with people with diabetes and will be available on the CDA website, www.diabetes.ca. Self-management of diabetes remains the cornerstone of diabetes care. Every effort should be made by all involved with diabetes care in the Canadian healthcare system to support SMBG as part of an overall self-management strategy. This would be greatly beneficial to people with diabetes and their families. SMBG should be considered and evaluated in conjunction with all other aspects of diabetes self-management and care within the Canadian healthcare system.

The metabolic syndrome in healthy, multiethnic adolescents in Toronto, Ontario: The use of fasting blood glucose as a simple indicator

BACKGROUNDnThe prevalence of the metabolic syndrome (MetS) is increasing worldwide and prevention represents a major challenge. Usually identified in middle age, the MetS has pediatric roots and there are variable incidence rates between ethnic groups. Due to the difficulty of diagnosis, it remains largely undetected in adolescents.nnnOBJECTIVESnTo assess the presence of the MetS features in healthy, normal-weight, multiethnic adolescents and to determine whether fasting blood glucose (FBG) could function as a simple indicator of its presence.nnnMETHODSnA convenience sample of secondary school students was used in a cross-sectional study. General linear model ANCOVA adjusted for multiple pairwise comparisons by the post hoc Tukey-Kramer test was used to assess differences among the tertiles of FBG.nnnRESULTSnA total of 182 adolescents from 62 Greater Toronto Area secondary schools in Ontario were recruited (44% Caucasian, 34% South Asian and 22% Chinese), with a mean (+/- SD) age of 17.4+/-0.9 years, a mean body mass index of 22.1+/-3.4 kg/m2 and a mean FBG of 4.92+/-0.4 mmol/L. Analysis with general linear model ANCOVA across the tertiles of FBG (3.83 mmol/L to 4.78 mmol/L, 4.79 mmol/L to 5.08 mmol/L, and 5.09 mmol/L to 6.45 mmol/L) showed significant linear increases of body mass index (P<0.005), waist circumference (P<0.001), systolic blood pressure (P<0.001) and diastolic blood pressure (P<0.05) with increasing FBG. Stepwise multiple regression analysis indicated systolic blood pressure (beta=0.0078, partial R2=0.039, P=0.007) and waist circumference (beta=0.0081, partial R2=0.025, P=0.035) were independent predictors of the increased FBG level.nnnCONCLUSIONSnMetS markers were present in a sample of healthy multiethnic adolescents in the Greater Toronto Area. FBG could be used as a simple indicator of the MetS to allow for early detection of the presence of the MetS and the introduction of preventive lifestyle measures. Further studies with larger sample sizes should address the accuracy of FBG for diagnosing the MetS.

The non-glycemic effects of incretin therapies on cardiovascular outcomes, cognitive function and bone health

The incretin therapies, glucagon-like peptide-1 receptor agonists and dipeptidyl-peptidase-4 inhibitors, have been developed to lower blood glucose levels in patients with Type 2 diabetes. However, in addition to being a treatment strategy to improve metabolic control, incretin therapies have shown effects independent of glycemic control, including the potential to positively impact cardiovascular events, cognitive deficits and bone mineral density. This paper outlines the non-glycemic effects of incretin therapies on cardiovascular disease, cognitive function and bone health.