Lori Berard

Dietary determinants of hepatic steatosis and visceral adiposity in overweight and obese youth at risk of type 2 diabetes

BACKGROUND Dietary determinants of hepatic steatosis, an important precursor for nonalcoholic fatty liver disease, are undefined. OBJECTIVE We explored the roles of sugar and fat intake as determinants of hepatic steatosis and visceral obesity in overweight adolescents at risk of type 2 diabetes. DESIGN This was a cross-sectional study of dietary patterns and adipose tissue distribution in 74 overweight adolescents (aged: 15.4 ± 1.8 y; body mass index z score: 2.2 ± 0.4). Main outcome measures were hepatic steatosis (≥5.5% fat:water) measured by magnetic resonance spectroscopy and visceral obesity (visceral-to-subcutaneous adipose tissue ratio ≥0.25) measured by magnetic resonance imaging. Main exposure variables were dietary intake and habits assessed by the Harvard Youth Adolescent Food Frequency Questionnaire. RESULTS Hepatic steatosis and visceral obesity were evident in 43% and 44% of the sample, respectively. Fried food consumption was more common in adolescents with hepatic steatosis than in adolescents without hepatic steatosis (41% compared with 18%; P = 0.04). Total fat intake (β = 0.51, P = 0.03) and the consumption of >35% of daily energy intake from fat (OR: 11.8; 95% CI: 1.6, 86.6; P = 0.02) were both positively associated with hepatic steatosis. Available carbohydrate (β = 0.54, P = 0.02) and the frequent consumption of soda were positively associated with visceral obesity (OR: 6.4; 95% CI: 1.2, 34.0; P = 0.03). Daily fiber intake was associated with reduced odds of visceral obesity (OR: 0.82; 95% CI: 0.68, 0.98; P = 0.02) but not hepatic steatosis. CONCLUSION Hepatic steatosis is associated with a greater intake of fat and fried foods, whereas visceral obesity is associated with increased consumption of sugar and reduced consumption of fiber in overweight and obese adolescents at risk of type 2 diabetes.

Self-Management Education

Offer collaborative and interactive self-management education (SME) interventions as they are more effective than didactic SME. Incorporate problem-solving skills for ongoing self-management of medical, social and emotional aspects of care into the traditional knowledge and technical skills content of educational interventions. Design patient-centred learning to empower individuals to make informed decisions toward achievement of patient-chosen goals. Individualize SME interventions according to type of diabetes and recommended therapy, the patient’s ability and motivation for learning and change, and his or her culture and literacy level. Provide ongoing SME and comprehensive healthcare collaboratively to make SME most effective.

Vigorous intensity exercise for glycemic control in patients with type 1 diabetes.

Regular physical activity has substantial health benefits in persons with type 1 diabetes, including reduced risk of complications and cardiovascular mortality as well as improved self-rated quality of life. Despite these benefits, individuals with type 1 diabetes are often less active than their peers without diabetes. When factors such as time constraints, work pressure and environmental conditions are often cited as barriers to physical activity in the general population, 2 additional major factors may also explain the low rates of physical activity in young people with type 1 diabetes: (1) fear of hypoglycemia both during and after (particularly overnight) exercise and (2) a lack of empiric evidence for the efficacy of physical activity for achieving optimal glycemic control. A number of acute exercise trials recently showed that the inclusion of vigorous intensity physical activity in conventional moderate intensity (i.e. walking and light cycling) exercise sessions may overcome these barriers. No studies have tested the efficacy of high-intensity physical activity on glycemic control (A1C) or post-exercise hypoglycemia in a randomized controlled trial. This article summarizes the literature related to the role of physical activity for the management of blood glucose levels in individuals with type 1 diabetes and provides a rationale for the need of a randomized controlled trial examining the effects of vigorous-intensity physical activity on blood glucose control.

SGLT2 Inhibitor–associated Diabetic Ketoacidosis: Clinical Review and Recommendations for Prevention and Diagnosis

PURPOSE Sodium-glucose cotransporter 2 (SGLT2) inhibitors are the newest class of antihyperglycemic agents available on the market. Regulator warnings and concerns regarding the risk of developing diabetic ketoacidosis (DKA), however, have dampened enthusiasm for the class despite the combined glycemic, blood pressure, and occasional weight benefits of SGLT2 inhibitors. With the goal of improving patient safety, a cross-Canada expert panel and writing group were convened to review the evidence to-date on reported SGLT2 inhibitor-related DKA incidents and to offer recommendations for preventing and recognizing patients with SGLT2 inhibitor-associated DKA. METHODS Reports covering DKA events in subjects taking SGLT2 inhibitors that were published in PubMed, presented at professional conferences, or in the public domain from January 2013 to mid-August 2016 were reviewed by the group independently and collectively. Practical recommendations for diagnosis and prevention were established by the panel. FINDINGS DKA is rarely associated with SGLT2 inhibitor therapy. Patients with SGLT2 inhibitor-associated DKA may be euglycemic (plasma glucose level <14 mmol/L). DKA is more likely in patients with insulin-deficient diabetes, including those with type 2 diabetes, and is typically precipitated by insulin omission or dose reduction, severe acute illness, dehydration, extensive exercise, surgery, low-carbohydrate diets, or excessive alcohol intake. SGLT2 inhibitor-associated DKA may be prevented by withholding SGLT2 inhibitors when precipitants develop, avoiding insulin omission or inappropriate insulin dose reduction, and by following sick day protocols as recommended. IMPLICATIONS Preventive strategies should help avoid SGLT2 inhibitor-associated DKA. All SGLT2 inhibitor-treated patients presenting with signs or symptoms of DKA should be suspected to have DKA and be investigated for DKA, especially euglycemic patients. If DKA is diagnosed, SGLT2 inhibitor treatment should be stopped, and the DKA should be treated with a traditional treatment protocol.

Does a Patient-Managed Insulin Intensification Strategy With Insulin Glargine and Insulin Glulisine Provide Similar Glycemic Control as a Physician-Managed Strategy? Results of the START (Self-Titration With Apidra to Reach Target) Study A Randomized Noninferiority Trial

OBJECTIVE Diabetes self-management is universally regarded as a foundation of diabetes care. We determined whether comparable glycemic control could be achieved by self-titration versus physician titration of a once-daily bolus insulin dose in patients with type 2 diabetes who are unable to achieve optimal glycemia control with a basal insulin. RESEARCH DESIGN AND METHODS Patients with type 2 diabetes, an HbA1c level >7% (53 mmol/mol), and either nocturnal hypoglycemia episodes or an insufficient basal insulin glargine level (with or without oral agents) to achieve a fasting plasma glucose level ≤6 mmol/L (108 mg/dL) were studied. Participants all had bolus insulin glulisine added at breakfast and were allocated to either algorithm-guided patient self-titration or physician titration. The primary outcome was an HbA1c level ≤7% (53 mmol/mol) without severe hypoglycemia. RESULTS After a mean (SD) follow-up of 159.4 days (36.2 days), 28.4% of participants in the self-titration arm vs. 21.2% in the physician titration arm achieved an HbA1c level of ≤7% (53 mmol/mol) without severe hypoglycemia (between-group absolute difference 7.2%; 95% CI −3.2 to 17.7). The lower end of this 95% confidence interval was within the predetermined noninferiority boundary of −5% (P noninferiority = 0.011). CONCLUSIONS In stable patients with type 2 diabetes who are receiving doses of basal insulin glargine who require bolus insulin, a simple bolus insulin patient-managed titration algorithm is as effective as a physician-managed algorithm.

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.

Can community retail pharmacist and diabetes expert support facilitate insulin initiation by family physicians? Results of the AIM@GP randomized controlled trial

BackgroundLimited evidence exists on the effectiveness of external diabetes support provided by diabetes specialists and community retail pharmacists to facilitate insulin-prescribing in family practice.MethodsA stratified, parallel group, randomized control study was conducted in 15 sites across Canada. Family physicians received insulin initiation/titration education, a physician-specific ‘report card’ on the characteristics of their type 2 diabetes (T2DM) population, and a registry of insulin-eligible patients at a workshop. Intervention physicians in addition received: (1) diabetes specialist/educator consultation support (active diabetes specialist/educator consultation support for 2 months [the educator initiated contact every 2 weeks] and passive consultation support for 10 months [family physician initiated as needed]); and (2) community retail pharmacist support (option to refer patients to the pharmacist(s) for a 1-hour insulin-initiation session). The primary outcome was the insulin prescribing rate (IPR) per physician defined as the number of insulin starts of insulin-eligible patients during the 12-month strategy.ResultsConsenting, eligible physicians (n = 151) participated with 15 specialist sites and 107 community pharmacists providing the intervention. Most physicians were male (74%), and had an average of 81 patients with T2DM. Few (9%) routinely initiated patients on insulin. Physicians were randomly allocated to usual care (n = 78) or the intervention (n = 73). Intervention physicians had a mean (SE) IPR of 2.28 (0.27) compared to 2.29 (0.25) for control physicians, with an estimated adjusted RR (95% CI) of 0.99 (0.80 to 1.24), p = 0.96.ConclusionsAn insulin support program utilizing diabetes experts and community retail pharmacists to enhance insulin prescribing in family practice was not successful. Too few physicians are appropriately intensifying diabetes management through insulin initiation, and aggressive therapeutic treatment is lacking.Trial registrationClinicalTrial.gov: NCT00593489

Understanding adherence to medications in type 2 diabetes care and clinical trials to overcome barriers: a narrative review.

Abstract Aim: To identify factors affecting adherence to medications in type 2 diabetes (T2D) care and clinical trials. Background: Adherence to medication is associated with better patient outcomes, lower healthcare costs, and improved quality and robustness of trial data. In T2D, non-adherence to regimens may compromise glycemic, blood pressure and lipid control, which can, in turn, increase morbidity and mortality rates. Design: A literature search was performed to identify studies reporting adherence to medications and highlighting specific adherence challenges/approaches in T2D. The search was limited to clinical trials, comparative studies or meta-analyses, reported in English with a freely available abstract. Data source: MEDLINE (31 December 2008 to 31 December 2013). Review methods: Studies not reporting adherence to medications or highlighting adherence challenges/approaches in T2D, presenting only self-reported adherence or including fewer than 100 patients were excluded. Eligible reports are discussed narratively. Results: Factors identified as having a detrimental impact on adherence were smoking, depression and polypharmacy. Conversely, increased convenience (e.g. pen compared with vial and syringe; medication supplied by mail order vs. retail pharmacy) was associated with better patient adherence, as were interventions that increased patient motivation (e.g. individualized, nurse-led consultation) and education. Conclusions: Medication adherence is influenced by complex and multifactorial issues, which can include smoking, depression, polypharmacy, convenience of obtaining and administering the medication, patient motivation and education. We recommend simplifying treatment regimens, where possible, improving provider–patient communication, and providing support and education to increase medication adherence, with a view to improving patient outcomes and clinical trial data quality.

Insights into optimal basal insulin titration in type 2 diabetes: results of a quantitative survey

Basal insulin (BI) treatment initiation and dose titration in type 2 diabetes (T2DM) are often delayed. Such “clinical inertia” results in poor glycaemic control and high risk of long‐term complications. This survey aimed to determine healthcare professional (HCP) and patient attitudes to BI initiation and titration.

Diabetes and driving: 2015 Canadian Diabetes Association updated recommendations for private and commercial drivers.

a Division of Endocrinology and Metabolism, Department of Medicine, Queen’s University, Kingston, Ontario, Canada b Winnipeg Regional Health Authority, Health Sciences Centre Winnipeg, Winnipeg, Manitoba, Canada c Division of Endocrinology and Metabolism, Department of Medicine, University of Toronto, Mississauga, Ontario, Canada d Medicine and Obstetrics and Gynecology, University of Toronto, Toronto, Ontario, Canada e Division of Endocrinology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada f Section of Endocrinology and Metabolism, John Buhler Research Centre, University of Manitoba, Winnipeg, Manitoba, Canada g McGill Nutrition and Food Science Centre, McGill University, Montreal, Quebec, Canada