Ellen L. Toth

Oat bran concentrate bread products improve long-term control of diabetes : A pilot study

OBJECTIVE To evaluate the long-term effects oat bran concentrate bread products in the diet of free-living subjects with non-insulin-dependent diabetes (NIDDM) via dietary, clinical, and biochemical methods. DESIGN A 24-week crossover study consisting of two 12-week periods. SUBJECTS/SETTING Eight men with NIDDM (mean age = 45 years) who lived in the community. Glucose and insulin profiles were conducted in a clinical investigation unit. INTERVENTION Palatable, high-fiber, oat bran concentrate (soluble fiber [beta-glucan] content = 22.8%) bread products were developed. Four randomly chosen subjects ate oat bran concentrate breads first; the other subjects ate control white bread first. MAIN OUTCOME MEASURES Dietary intake (four 48-hour dietary recalls per period) was assessed. Blood glucose and insulin (8-hour profiles) and lipid parameters after fasting were measured (at 0, 12, and 24 weeks). STATISTICAL ANALYSES PERFORMED Analysis of variance and repeated-measures analysis of variance. RESULTS Total energy and macronutrient intakes were similar in both periods. Mean total dietary fiber intake was 19 g/day in the white bread period and 34 g/day (9 g soluble fiber per day from oat bran concentrate) in the oat bran concentrate period. Body weight remained stable. Mean glycemic and insulin response areas (area under the curve) were lower (P < or = .05 and not significant, respectively) for the oat bran concentrate period than the white bread period. After breakfast, area under the curve for the oat bran concentrate period was lower for glucose (P < or = .01) and insulin (P < or = .05); insulin peak was reached earlier (P < or = .05) than in the white bread period. Dietary fiber intake was correlated negatively with insulin area under the curve (P < or = .05). Mean total plasma cholesterol and low-density lipoprotein cholesterol levels were lower (P < or = .01) in the oat bran concentrate period than in the white bread period. In the oat bran concentrate period, the mean ratio of low-density lipoprotein cholesterol to high-density lipoprotein cholesterol was reduced by 24% (P < or = .05). CONCLUSIONS The well-accepted oat bran concentrate bread products improved glycemic, insulinemic, and lipidemic responses.

Reduced cardiovascular morbidity and mortality associated with metformin use in subjects with Type 2 diabetes

Aim  Metformin therapy reduces microvascular complications in Type 2 diabetes; questions remain, however, regarding its impact on macrovascular events. This study examined metformin use in relation to risk of cardiovascular‐related hospitalization and mortality.

Compliance with Clinical Practice Guidelines for Type 2 Diabetes in Rural Patients: Treatment Gaps and Opportunities for Improvement

The level of compliance with clinical practice guidelines for patients with type 2 diabetes was evaluated in 368 patients from two health regions in rural northern Alberta, Canada. Data were collected from patient interviews, drug histories, physical and laboratory assessments, and a self‐report questionnaire to assess clinical status, indicators of diabetes management, and health care utilization. Treatment of three clinical indicators of diabetes—hemoglobin A1c (A1C), blood pressure, and low‐density lipoprotein cholesterol (LDL)—has been shown to reduce the morbidity and mortality associated with type 2 diabetes. Mean ± SD values for this cohort of patients were as follows: A1C 7.25% ± 1.54%, blood pressure 131.7 ± 18.2/76.2 ± 12.7 mm Hg, and LDL 105.2 ± 32 mg/dl. Despite these results, only 10.4% of the patients met all three recommended targets for control of glycemia: A1C below 7%, blood pressure below 130/85 mm Hg, and LDL below 100 mg/dl. Of patients not at target levels, 14.4%, 27.5%, and 86.7% reported receiving no therapy for hyperglycemia, hypertension, and dyslipidemia, respectively. Of those taking oral hypoglycemic agents who were not at target levels, only 35% were receiving combination therapy. Of patients at or above LDL target levels, 87% were not receiving any therapy. Only 22% of patients were taking aspirin, although this therapy would be recommended for the entire cohort according to clinical practice guidelines. Despite the availability of proved effective therapies, treatment gaps were present for this cohort of patients.

hIGh RATES OF ThE METABOLIc SYNDROME IN A FIRST NATIONS cOMMUNITY IN WESTERN cANADA: PREVALENcE AND DETERMINANTS IN ADULTS AND chILDREN

Objectives. Increasing type 2 diabetes in Aboriginal communities across North America raisesconcerns about metabolic syndrome in these populations. Some prevalence information for AmericanIndians exists, but little has been available for Canada’s First Nations. Study Design. Wescreened 60 % of the eligible population of a single First Nation in Alberta for diabetes, prediabetes, cardiovascular risk, and metabolic syndrome. Methods. NCEP/ATP III and IDF criteria were used to identify metabolic syndrome in participantsaged ≥ 18; modified NCEP/ATP III criteria were used for participants aged < 18. Logisticregression identified factors associated with the metabolic syndrome. Results. 297 individuals were screened (176 adults, 84 children/adolescents, with complete data).52.3 % of adults had metabolic syndrome using NCEP/ATP III criteria, and 50 % using IDFcriteria. 40.5 % of individuals aged < 18 had the condition. Waist circumference was the mostprevalent correlate. Bivariate analysis suggested that age, BMI, weight, A1c, LDL-C, ADA riskscore and activity pattern were associated with metabolic syndrome. Conclusions. Our data represent the first available for Western Cree and are consistent withprevalence reported for Aboriginal populations in Ontario and Manitoba. High rates of obesity, pre-diabetes and metabolic syndrome for participants aged < 18 raise concerns about future prevalenceof diabetes and cardiovascular disease.

Health-related quality of life deficits associated with varying degrees of disease severity in type 2 diabetes

BackgroundDiabetes is a chronic medical condition accompanied by a considerable health-related quality of life (HRQL) burden. The purpose of this analysis was to use generic measures of HRQL to describe HRQL deficits associated with varying degrees of severity of type 2 diabetes.MethodsThe RAND-12 physical and mental health composites (PHC and MHC, respectively) and Health Utilities Index Mark 3 (HUI3) were self-completed by 372 subjects enrolled in a prospective, controlled study of an intervention to improve care for individuals with type 2 diabetes in rural communities. Analysis of covariance was used to assess differences in HRQL according to disease severity and control of blood glucose. Disease severity was defined in terms of treatment intensity, emergency room visits and absenteeism from work specifically attributable to diabetes. To control for potential confounding, the analysis was adjusted for important sociodemographic and clinical characteristics.ResultsThe PHC and MHC were significantly lower for individuals treated with insulin as compared to diet alone (PHC: 41.01 vs 45.11, MHC: 43.23 vs 47.00, p < 0.05). Individuals treated with insulin had lower scores on the vision, emotion and pain attributes of the HUI3 than individuals managed with oral medication or diet. The PHC, MHC, pain attribute and overall score on the HUI3 captured substantial decrements in HRQL associated with absenteeism from work due to diabetes, while the burden associated with emergency room utilization for diabetes was seen in the PHC and HUI3 pain attribute.ConclusionsWe concluded that generic measures of HRQL captured deficits associated with more severe disease in type 2 diabetes.

Effect of enteral nutritional products differing in carbohydrate and fat on indices of carbohydrate and lipid metabolism in patients with NIDDM

Non-insulin dependent diabetes mellitus (NIDDM) is associated with chronic hyperglycemia, which increases the risk of developing microvascular and macrovascular complications. Elevated triglyceride (TG) and VLDL cholesterol levels and low levels of HDL cholesterol have also been frequently reported in NIDDM patients. A diet high in complex carbohydrate and low in fat is typically recommended for management of NIDDM, however, this has recently been challenged by scientific reports of the benefits of dietary intakes high in monounsaturated fat. Thirty-two individuals with NIDDM were randomized to receive either Ensure with Fibre® (30% fat) or a high monounsaturated fatty acid product, Glucerna® (50% fat). These products were consumed for 28 days at 280% of daily energy intake. Post-treatment, dietary compliance was verified by a higher plasma TG 18:1 n-9 (p < 0.001) in the Glucerna® group and a higher plasma TG 18:2 n-6 (p < 0.001) in the Ensure with Fibre® group. The postprandial rise in blood glucose levels, determined by fingerprick samples, was significantly lower (p < 0.01) in the Glucerna® group. Trends of clinical interest were greater mean decreases in the Glucerna® group compared to the Ensure with Fibre® group in: fructosamine, 9.13 umol/L vs 0.14 umol/L; glucose, 1.61 mmol/L vs 0.63 mmol/L; and insulin, 46.0 pmol/L vs 12.6 pmol/L; respectively. However, overall, fasting plasma glucose, fructosamine, TG and cholesterol levels were not significantly different between groups. Thus, in these patients, the high monounsaturated fat diet and the standard diet were similar with regard to usual indicators of carbohydrate and lipid metabolism. A high monounsaturated fat diet appears to pose no risk to lipoprotein metabolism in NIDDM patients.

Lack of insurance coverage for testing supplies is associated with poorer glycemic control in patients with type 2 diabetes

Background: Public insurance for testing supplies for self-monitoring of blood glucose is highly variable across Canada. We sought to determine if insured patients were more likely than uninsured patients to use self-monitoring and whether they had better glycemic control. Methods: We used baseline survey and laboratory data from patients enrolled in a randomized controlled trial examining the effect of paying for testing supplies on glycemic control. We recruited patients through community pharmacies in Alberta and Saskatchewan from Nov. 2001 to June 2003. To avoid concerns regarding differences in provincial coverage of self-monitoring and medications, we report the analysis of Alberta patients only. Results: Among our sample of 405 patients, 41% had private or public insurance coverage for self-monitoring testing supplies. Patients with insurance had significantly lower hemoglobin A1c concentrations than those without insurance coverage (7.1% v. 7.4%, p = 0.03). Patients with insurance were younger, had a higher income, were less likely to have a high school education and were less likely to be married or living with a partner. In multivariate analyses that controlled for these and other potential confounders, lack of insurance coverage for self-monitoring testing supplies was still significantly associated with higher hemoglobin A1c concentrations (adjusted difference 0.5%, p = 0.006). Interpretation: Patients without insurance for self-monitoring test strips had poorer glycemic control.

Self-monitoring in Type 2 diabetes : a randomized trial of reimbursement policy

Aim  Self‐monitoring of blood glucose is often considered a cornerstone of self‐care for patients with diabetes. We assessed whether provision of free testing strips would improve glycaemic control in non‐insulin‐treated Type 2 diabetic patients.

Underuse of aspirin in type 2 diabetes mellitus: prevalence and correlates of therapy in rural Canada.

BACKGROUND Patients with type 2 diabetes mellitus (DM) have a markedly increased risk of cardiovascular morbidity and mortality. Guidelines of both the American and Canadian Diabetes Associations recommend the use of aspirin as antiplatelet therapy for all adults with type 2 DM. OBJECTIVES The aims of this study were to assess the rate of adherence to guidelines for aspirin use in DM patients in rural Canadian communities and to describe the independent correlates of aspirin use in this population. METHODS We collected information from a cohort of patients with type 2 DM living in 2 rural regions of northern Alberta, Canada, at the time of their enrollment in a multidisciplinary outreach program designed to improve their quality of care. Our primary outcome was self-reported use of antiplatelet therapy (aspirin or others). We use multivariate logistic regression analyses to examine the independent association between sociodemographic and clinical characteristics and self-reported use of antiplatelet agents. RESULTS Among 342 patients included in the study (who were typical of rural Canadian patients with type 2 DM), the mean age was 62.9 years; 149 (44%) were men, 84 (25%) were of indigenous origin, and the median time since diagnosis of DM was 8 years. Despite guideline recommendations, only 23% of the cohort (78 patients) were regularly taking aspirin alone or in combination with a thienopyridine (n = 74 and n = 2, respectively) or a thienopyridine alone (n = 2). The results of them ultivariate analyses showed that the only factors independently associated with the use of antiplatelet therapy were symptomatic coronary artery disease (adjusted odds ratio [AOR], 3.1; 95% CI, 1.1-8.7; P=0.033 ), older age (AOR, 2.0 per 10-year interval; 95% CI, 1.7-2.2; P<0.001 ); and male sex (AOR, 1.9; 95% CI, 1.1-3.5; P=0.026 ). CONCLUSIONS Aspirin is a safe, inexpensive, and readily available therapy that is effective for preventing cardiovascular disease, and patients with type 2 DM are particularly likely to benefit from such preventive therapy. However, we found significant underuse of aspirin therapy among our study population. Aspirin should be included and better promoted as a factor in high-quality, evidence-based DM management.

Treatment gaps for hypertension management in rural Canadian patients with type 2 diabetes mellitus

BACKGROUND There were a reported 2.2 million Canadians living with diabetes mellitus (DM) in 2002, of whom 1.98 million (90.0%) had type 2 DM. In addition, there are approximately 60,000 new cases of type 2 DM diagnosed in Canada each year. However, the research shows that evidence and guidelines for management of hypertension in DM are not always translated into clinical practice. In rural areas, factors affecting implementation of recommendations and/or guidelines are less well understood, although some studies suggest that urban practices provide higher quality of care overall than rural areas. OBJECTIVE The goal of this study was to describe the patterns of medication use for hypertension for patients with type 2 DM in rural northern Alberta, Canada. We also tried to identify treatment gaps and opportunities for prescribing antihypertensives relative to the Canadian Diabetes Associations 1998 Clinical Practice Guidelines for the Management of Diabetes in Canada and the Canadian Hypertension Society Recommendations Working Groups 2003 Canadian Recommendations for the Management of Hypertension: Therapy. METHODS This study was conducted at the Institute of Health Economics and the University of Alberta (Edmonton, Alberta, Canada). We collected information from a cohort of patients aged >or =20 years with type 2 DM living in 2 adjacent rural regions of northern Alberta, Canada, at the time of enrollment in a diabetes care quality-improvement program as part of the Diabetes Outreach Van Enhancement (DOVE) study. Treatment gaps were determined by comparing antihypertensive pharmacotherapy with a blood pressure (BP) target of < or =130/< or =85 mm Hg. We used multivariate regression analyses to determine the associations between sociodemographic and clinical characteristics and treatment gaps. RESULTS A total of 392 patients (229 women, 164 men; mean [SD] age, 62.3 [12.5] years) with type 2 DM were included in this analysis. Patients had a mean (SD) duration of diabetes of 8.3 (8.5) years. A total of 75.8% (297/392) of the study population had hypertension, and most (236/392[60.2%]) were receiving some pharmacotherapy. Treatment gaps were present; 42.7% (n = 67) of patients not receiving pharmacotherapy for hypertension were above the established BP targets. For patients receiving monotherapy, 70% were not at BP targets. For patients receiving dual, triple, and > or =4 medications, 65%, 66%, and 46%, respectively, were not at BP targets. After controlling for systolic blood pressure, male sex (adjusted odds ratio [aOR], 2.17; 95% CI, 1.17-4.03), older age (aOR, 1.80 per decade; 95% CI, 1.51-2.09), lower self-reported physical health (aOR, 0.68; 95% CI, 0.41-0.96), higher body mass index (aOR, 1.05; 95% CI, 1.01-1.10), and past/current smoking (aOR, 1.95; 95% CI, 1.01-3.76) were all significantly associated with a lack of treatment for hypertension. CONCLUSIONS Treatment maps in the management of hypertension exist in these rural Canadian patients with type 2 DM. Cardiovascular risk may be underestimated in these patients, particularly among younger patients and women, and those with multiple non-DM risk factors. These are patient subgroups that should be targeted as opportunities to improve hypertension management at the population level.