Canadian Diabetes Association Clinical Practice Research Articles

Exploring Clinical Care Among Adults With Diabetes Mellitus: Alignment With Recommended Statin and Sulfonylureas Treatment.

The care of patients with diabetes mellitus (DM), compiled in the 2008 Canadian Diabetes Association clinical practice guidelines and in recommendations from the Choosing Wisely Canada program, is informed by a large body of evidence. This study sought to assess to what extent primary care providers (PCPs) incorporate recommended statin and sulfonylureas treatment in their care of patients with DM, and to identify the association between use of recommended care and PCP characteristics. This retrospective cohort study (2007-2017) used electronic medical records of 21,149 patients with DM receiving care from 240 PCPs participating in the Manitoba Primary Care Research Network. PCPs prescribed statins to patients newly diagnosed with DM who were ≥40years of age 41% of the time, with 45% of the prescriptions occurring ≤180days after a new diagnosis (early treatment). PCPs least likely to prescribe recommended statin treatment had higher odds of being older (adjusted odds ratio [aOR], 1.05; 95% confidence interval [CI], 1.01 to 1.09) and fee-for-service funded (aOR, 4.36; 95% CI, 1.47 to 12.91). In addition, older PCPs (aOR, 1.06; 95% CI, 1.02 to 1.10) and women (aOR, 2.42; 95% CI, 1.11 to 5.28) were less likely to prescribe statin treatment early. Seventy-four percent of PCPs prescribed sulfonylureas to adults ≥65years of age. No PCP characteristics were associated with prescription of sulfonylureas in the lower implementation quartile in the fully adjusted model. Results suggest that PCPs' practice does not always align with current evidence-based clinical guidelines or Choosing Wisely Canada recommendations for patients with DM. Some PCP's characteristics were associated with lower implementation of recommended evidence-based care. This information can help guide future targeted medical education.

British Columbian Healthcare Providers' Perspectives on Facilitators and Barriers to Adhering to Pediatric Diabetes Treatment Guidelines.

There are few studies exploring why adherence to clinical practice guidelines for the treatment of childhood type 1 diabetes is suboptimal. Our objective was to describe healthcare providers' perspectives on the facilitators of and barriers to adhering to pediatric diabetes treatment guidelines. We fielded an electronic survey to 260 pediatric diabetes healthcare providers (physicians, nurses, dietitians) in British Columbia, Canada, followed by qualitative interviews with a purposeful sample (N=15) of physicians and allied healthcare providers. Descriptive statistics and directed content analysis were used. We received 95 of 260 survey responses(37%). Of the 260 healthcare providers who received the survey, 116 were known to be working in a pediatric diabetes centre, and 71 of 116 (61%) responded. Almost all providers were aware of (92%) and familiar with (77%) the Canadian Diabetes Association clinical practice guidelines, and most were in agreement with the recommendations. Patient-level factors, such as poor adherence and patient/family preferences for higher glycemic targets, as well as inadequate resources (i.e. funding, mental health support), were identified as significant barriers. Qualitative interviews identified 3 key themes: 1) working collectively provincially; 2) supporting emotional and mental health and 3) frequent interactions with patients. A provincial health delivery and communication model, as well as mental health support integrated into routine patient care, were recommended. The results of this study can guide resource allocation toward key priorities, such as increased investment in mental health support for children with diabetes. The next steps include collecting patient and family perspectives on improving guideline adherence.

117 Adherence of Primary Care Physicians to the Canadian Diabetes Association Clinical Practice Guidelines for Erectile Dysfunction and Hypogonadism

117 Adherence of Primary Care Physicians to the Canadian Diabetes Association Clinical Practice Guidelines for Erectile Dysfunction and Hypogonadism

Review of Dietary Practices of the 21st Century: Facts and Fallacies.

The prevalence of chronic metabolic diseases, such as diabetes, cardiovascular diseases and cancer, is increasing around the world. Nutritional interventions can reduce the prevalence and provide effective treatment, even when weight loss is not dramatic. The 2013 Canadian Diabetes Association Clinical Practice Guidelines concluded that certain dietary patterns and popular weight-loss diets had sufficient evidence to suggest their use by individuals with diabetes, but many other diet patterns and diets exist. Our specific objectives were to review the nutritional quality of various dietary patterns and diets, with emphasis on the evidence that they are efficacious for weight loss, glycemic control and cardiovascular risk factors.

Impact of Current and Emerging Glucose-Lowering Drugs on Body Weight in Type 2 Diabetes.

Type 2 diabetes is a progressive disease, and most people with diabetes will eventually require adjunctive pharmacotherapy to optimize their glycemic control. As the majority of people with type 2 diabetes are overweight or obese, weight management is an essential component of diabetes management to improve their overall health and quality of life. Many of the currently available glucose-lowering drugs are associated with weight gain, which makes it challenging for both prescribing clinicians and patients. The 2015 Canadian Diabetes Association Clinical Practice Guidelines interim update on the pharmacologic management of type 2 diabetes recommend individualization of therapy and glycemic targets. Clinicians should take into consideration not only the drug's efficacy and safety profiles but also its propensity for causing hypoglycemia and weight gain. Given that the number of glucose-lowering drugs is expanding rapidly, a better understanding of the impacts of current and emerging therapies on body weight will serve as a useful guide. Metformin remains the first-line drug after diet and exercise therapy. The next add-on agent could be selected from the incretin or sodium-glucose cotransporter-2 inhibitor class because these drugs rarely cause hypoglycemia and may lead to modest weight loss. When insulin therapy is considered, choosing a basal insulin that is associated with less nocturnal hypoglycemia and weight gain is recommended. Emerging therapies using combination therapy of an incretin-sodium-glucose cotransporter 2 inhibitor or glucagon-like peptide-1 agonist-basal insulin hold promise to achieve robust glycemic control with weight loss and low risk for hypoglycemia.

Kidney Paired Donation Protocol for Participating Donors 2014.

Kidney Paired Donation Protocol for Participating Donors 2014.

Testing for albuminuria in 2014.

Routine quantification of urinary albumin levels is recommended for all Canadians with diabetes, yet many controversies remain when interpreting these tests. Elevated levels of albuminuria have traditionally been labeled as either microalbuminuria, representing 30 to 300 mg of albuminuria per day (a range not reliably picked up by conventional urine dipsticks), or as overt nephropathy, representing more than 300 mg per day and usually identifiable by dipstick. The random urine albumin-to-creatinine ratio is a convenient test that can predict reliably the total daily protein excretion. The 30 mg per day upper limit of normal was selected to be a threshold far above the normal albumin excretion seen in healthy people. However, recent studies have shown that elevations of albumin excretion below the microalbuminuria threshold are associated with increased cardiorenal risk, suggesting that the 30 mg per day level may be set too high. Recently, the Canadian Diabetes Association Clinical Practice Guidelines changed the threshold for abnormal urine albumin-to-creatinine ratios to be 2.0 mg/mmol for both men and women. As a result, more women will be identified as having abnormal levels of albuminuria. However, these women will be correctly identified as having increased cardiorenal risk. It is important to note that people with diabetes who have abnormal levels of albuminuria are among patients at the highest risk for cardiorenal disease. These risks can be reduced by using the strategies outlined in the guidelines put forth by the Canadian Diabetes Association.

Our Mandate to Optimize Diabetes Care and Management

One of the Canadian Journal of Diabetes's mandates is to focus on relevant current issues in an attempt to improve and optimize diabetes care and management. Thematic issues have been published since 2012 to highlight topics that are of interest to the diabetes community at large and at the same time relevant to best practice. Several themes have been identified by our editorial board as areas in which knowledge translation to best clinical practice has been lagging, and that could be addressed. This first such theme, the in-hospital management of patients with diabetes, is presented in this issue. Significant gaps exist between current standards of care, as recommended by 2013 evidence-based Canadian Diabetes Association clinical practice guidelines (http://guidelines.diabetes.ca/), and successful implementation of point-of-care tools, such as order sets and protocols, in optimizing glycemic control and overall diabetes management. The guest editors for this issue, led by Dr. Alice Cheng, have admirably assembled articles that address a wide array of topics, from glycemic targets and barriers to implementation, to practical perspectives and point-of-care tools, including clinical templates and protocols, so as to promote optimal management of hospitalized patients with diabetes in Canada. The next issue's theme will focus on the primary-care management of diabetes. Because most of the Canadian provincial and territorial health authorities fully embrace and implement the chronic care model as part of their long-term healthcare objectives, diabetes has become a prototypical model of a complex chronic disease. It follows naturally that the management of diabetes should gradually transition from a shared-care model between specialists and family physicians to one that is delivered mainly by primary care practitioners, which in many provinces are composed of a team of interprofessional healthcare workers. The primary care management issue will provide insights into diabetes surveillance in primary care settings and how well diabetes management is integrated in primary care models. As the prevalence of diabetes is rising not only in adults but also in children and youths, new challenges arise for the management and prevention of diabetes in the pediatric population. This subject will be addressed in greater depth in a future issue devoted to pediatric diabetes. Another area that merits greater attention in clinical practice is the rising prevalence of chronic kidney disease in diabetes. Management of patients with diabetic kidney disease is complex and challenging from multiple perspectives. Providing guidance for primary care practitioners with respect to glycemia, blood pressure and lipid management in people with early to advanced diabetic chronic kidney disease, as well as management and prevention of diabetic nephropathy, will be the focus of a theme issue devoted to diabetes and the kidney. CJD aspires to become the “go-to” authoritative and reliable source of information for the diabetes community in Canada and abroad. We just launched the Clinical Resource Centre, a new feature that is now available at our website (http://www.canadianjournalofdiabetes.com/). This initiative attempts to interact with our readers by providing innovative and interactive educational resource materials in a variety of formats (video clips, slides, research and review articles, case studies and point-of-care tools) to assist healthcare professionals to update their best practices. The role of the kidney in glucose homeostasis is the first topic selected for the launch. We introduce our readers to a novel mechanism of insulin-independent glucose lowering by inhibiting glucose reabsorption in the proximal renal tubules, resulting in increased urinary glucose excretion. Inhibitors of sodium-coupled glucose co-transporter-2 (SGLT2 inhibitors) belong to a new class of oral antihyperglycemic drugs, which will soon become available for the management of type 2 diabetes in Canada. In countries where they have been approved, such as the United States and the European Union, SGLT2 inhibitors have become popular second-line glucose-lowering agents after metformin. As always, we welcome suggestions and comments from our readers on “hot” and controversial topics that are relevant to clinical and best practices.

Glycemic Targets in Hospital and Barriers to Attaining Them

The importance of glycemic control in hospitalized patients has been a relatively recent revelation. There is somewhat contradictory evidence concerning the optimal glycemic target in critically ill patients. There is only indirect evidence in non-critically ill patients. This article reviews the evidence for glycemic targets in hospitalized patients. It also investigates which hospital-based treatments can act as barriers to attaining optimal blood glucose levels in hospital and system barriers to attaining those optimal levels. The systematic approach to and evaluation of in-hospital diabetes management has a short history. The first large clinical trial, the DIGAMI trial of peri-myocardial infarction insulin therapy, was published in 1995 (1). The first guideline discussion of in-hospital diabetes management occurred briefly in 2003, more fully in 2008 and 2013 (2-4) by the Canadian Diabetes Association; in 2005 and annually since then by the American Diabetes Association (5,6). Recently, there have been many more publications on the topic. A recent PubMed search, limited to the last 5 years, "hospital" and "diabetes" as a Medical Subject Headings (MeSH) major topic, revealed more than 5000 English-language clinical trials (PubMed.gov; accessed 6 Oct 2013). Still, relatively little is certain about appropriate glycemic targets in hospital. This has left us, in 2014, with consensus recommendations only for glycemic targets in non-critically ill patients from both the Canadian Diabetes Association Clinical Practice Guidelines (4) and the American Diabetes Association Standards of Medical Care in Diabetes (6). This article reviews recommended glycemic targets in various in-hospital populations and the barriers to obtaining them.

Snapshots of Diabetes Care in Canada

Snapshots of Diabetes Care in Canada

Letter to the Editor

I thank Dr. Snyman for his thoughtful comments and perspective on diabetes as a risk factor for cardiovascular (CV) disease. Diabetes is associated with excessive CV morbidity and mortality (1Lau D.C.W. Shen G.X. Cardiovascular Complications of Diabetes.Can J Diabetes. 2013; 37: 279-281Abstract Full Text Full Text PDF Scopus (3) Google Scholar). The widely cited Finnish cohort study heralded the notion that diabetes can be considered a coronary heart disease risk equivalent (2Haffner S.M. Lehto S. Rönnemaa T. et al.Mortality from coronary heart disease in subjects with type 2 diabetes and in nondiabetic subjects with and without prior myocardial infarction.N Engl J Med. 1998; 339: 229-234Crossref PubMed Scopus (5902) Google Scholar). The 7-year risk for myocardial infarction in people with diabetes was found to be almost the same as in nondiabetic subjects having a history of previous myocardial infarction (2Haffner S.M. Lehto S. Rönnemaa T. et al.Mortality from coronary heart disease in subjects with type 2 diabetes and in nondiabetic subjects with and without prior myocardial infarction.N Engl J Med. 1998; 339: 229-234Crossref PubMed Scopus (5902) Google Scholar). Several studies have since refuted this tenet. A Scottish cross-sectional and cohort study reported that people with type 2 diabetes were at a lower risk for cardiovascular events than people with established coronary heart disease (3Evans J.M. Wang J. Morris A.D. Comparison of cardiovascular risk between patients with type 2 diabetes and those who had had a myocardial infarction: cross-sectional and cohort studies.Br Med J. 2002; 324: 939-943Crossref PubMed Google Scholar). A systematic review and meta-analysis of 13 studies with 45108 patients followed for a mean of 13.4 years reported significantly lower risk for fatal or nonfatal myocardial infarction, with an overall odds ratio of 0.56 (95% CI 0.53 to 0.60) when compared with nondiabetic individuals with previous myocardial infarction (4Bulugahapitiya U. Siyambalapitiya S. Sithole J. et al.Is diabetes a coronary risk equivalent? systematic review and meta-analysis.Diabetic Med. 2009; 26: 142-148Crossref PubMed Scopus (264) Google Scholar). It is important to note that the landmark Steno-2 study has provided compelling evidence that mortality resulting from CV disease can be drastically reduced in type 2 diabetes by aggressive multifactorial interventions-to-treat so as to target lipid level, blood pressure and glycemic goals (5Gaede P. Lund-Andersen H. Parving H.H. et al.Effect of a multifactorial intervention on mortality in type 2 diabetes.N Engl J Med. 2008; 358: 580-591Crossref PubMed Scopus (2780) Google Scholar). Vascular protection and CV disease-risk reduction have become a major focus in the management of people with diabetes, as emphasized by the evidence-based 2013 Canadian Diabetes Association clinical practice guidelines (6Canadian Diabetes Association Clinical Practice Guidelines Expert CommitteeVascular protection in people with diabetes.Can J Diabetes. 2013; 37: S100-S104Abstract Full Text Full Text PDF Scopus (31) Google Scholar). The alarming concern that glucose-lowering drugs may be associated with increased CV deaths was first raised by Nissen in 2007 (7Nissen S. Wolski K. Effect of rosiglitazone on the risk of myocardial infarction and death from cardiovascular causes.N Engl J Med. 2007; 356: 2457-2471Crossref PubMed Scopus (4092) Google Scholar), and it has subsequently led the Food and Drug Administration (FDA) to mandate that all novel antihyperglycemic drugs demonstrate no increase in CV safety signals before they are approved. Further, a compulsory requirement of the FDA approval process for all glucose-lowering drugs involves the conduct of long-term CV outcome trials. The first 2 neutral CV outcomes studies, both oral incretins (saxagliptin and alogliptin), have been published (8Scirica B.M. Bhatt D.L. Braunwald E. et al.Saxagliptin and cardiovascular outcomes in patients with type 2 diabetes mellitus.New Engl J Med. 2013; 369: 1317-1326Crossref PubMed Scopus (2721) Google Scholar, 9White W.B. Cannon C.P. Heller S.R. et al.Alogliptin after acute coronary syndrome in patients with type 2 diabetes.New Engl J Med. 2013; 369: 1327-1335Crossref PubMed Scopus (2037) Google Scholar). Over the next several years, we will learn more about the cardiovascular safety of novel glucose-lowering agents from no fewer than 15 ongoing CV-outcome clinical trials (http://www.ClinicalTrials.gov/). Because diabetes confers excessive CV risk, it could be predicted that few, if any, of the ongoing CV outcome trials involving glucose-lowering agents, will be able to demonstrate superiority during the relatively short study period of 6 to 8 years in people with type 2 diabetes enrolled in these trials, most of whom are already at high CV risk. In any case, prospective clinical trials will provide much more robust and insightful information concerning CV risk in people with diabetes than does a comprehensive retrospective analysis of Canadian CV mortality attributable to diabetes, as suggested by Dr. Snyman.

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

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. Canadian Diabetes Association Clinical Practice Guidelines Expert Committee Canadian Diabetes Association 2008 clinical practice guidelines for the prevention and management of diabetes in Canada. Can J Diabetes. 2008; 32: S1-S201 Google Scholar ) recommend that SMBG be individualized for each person with diabetes based on their circumstances and needs. No funding sources were used by the CDA for the development or launch of this document on SMBG

Type 2 diabetes in the First Nations population: a case example of clinical practice guidelines

Type 2 diabetes (T2D) is a major public health concern and has reached epidemic proportions in the Canadian First Nation population. Reasons for this epidemic are the consequences of low socioeconomic status, and challenges to screening, primary prevention, management and access to care. This article presents the authors' opinions of the healthcare needs specific to the First Nation population in Canada with respect to management of T2D. The authors argue that the current Canadian Diabetes Association Clinical Practice Guidelines are insufficient to provide a basis for health care and funding policies related to T2D management in the First Nation population. The authors present their own recommendations in relation to funding policies and the appropriateness of services for the First Nation population.

Is there a relationship between type of insulin regimen and dietary intake in adolescents with type 1 diabetes?

ABSTRACT OBJECTIVE: The literature indicates that adolescents with type 1 diabetes consume a diet high in fat, saturated fat and cholesterol, and low in fruit, vegetables and fibre. Information describing the relationship between insulin regimen and dietary intake is scarce. This study aimed to investigate and compare the impact of 3 insulin therapies— 3 times daily insulin (tid), multiple daily injections (MDI) and continuous subcutaneous insulin infusion (CSII)—on dietary intake of teens with type 1 diabetes. METHOD: Ninety-seven subjects aged 14 to 18 years were recruited during outpatient diabetes clinics at SickKids Hospital. Group distribution was as follows: tid (n=34), MDI (n=29) and CSII (n=34). Dietary intake information was collected using the validated Youth/Adolescent Food Frequency Questionnaire and analyzed for energy, carbohydrate, sucrose, fibre, protein, total fat and saturated fat. RESULTS: Using analysis of variance, no significant differences were found in any of the nutrients studied. Univariate and multiregression analyses also failed to reveal significant differences. All groups fell within the acceptable distribution ranges for all macronutrients, above the recommendation for saturated fat according to the 2008 Canadian Diabetes Association clinical practice guidelines and below the adequate intake for fibre. CONCLUSION: These data indicate that the choice of insulin regimen is not a major factor in predicting dietary intake.

Acute hyperglycemic emergencies in children with type 2 diabetes

Acute hyperglycemic emergencies in children with type 2 diabetes

CIHR's New Guidelines for Aboriginal Health Research: Setting the Ground Rules

Diabetes in Aboriginal communities has often been described as having reached epidemic proportions over the past several decades. Among the things we know about Aboriginal people and diabetes are that they have a 3 to 5 times greater risk of developing type 2 diabetes than other Canadians, and that Aboriginal children as young as 5 years of age have been diagnosed with diabetes ( 1. Canadian Diabetes Association Clinical Practice Guidelines Expert Committee Canadian Diabetes Association 2003 clinical practice guidelines for the prevention and management ofdiabetes in Canada. Can J Diabetes. 2003; 27: S1-S152 Google Scholar ).We know that prior to the 1950s there was virtually no diabetes in the Aboriginal community.

Rationale and Implementation of the SLICK Project

Objective: Identifying diabetes complications through screening using portable laboratory equipment in Aboriginal communities, and providing education and client empowerment for improved follow-up care and self-care. Participants: First Nations people with known diabetes. Setting: Screening was carried out in temporary clinics and laboratories set up at the local health centre in each of Alberta’s 44 First Nations. Intervention: Two mobile units (“SLICK vans”), equipped with professionally trained staff, portable lab instruments and a retinal camera, travelled to all 44 Alberta First Nations communities to facilitate implementation of the Canadian Diabetes Association Clinical Practice Guidelines (CPGs). The project provided relevant education and counselling in conjunction with screening activities. Outcomes: SLICK screened 1,151 clients between December 2001 and July 2003, and the project remains ongoing. A preliminary evaluation of the project’s 19-month implementation period showed screening activities and satisfaction with diabetes services were low prior to SLICK. There were modest improvements in some program outcomes at 6–12 months follow-up. Conclusion: The SLICK project is designed to address the impact of diabetes by utilizing evidence-based CPGs with respect to screening for complications at the community level. It had a successful implementation period facilitated by community acceptance.

Rationale and implementation of the SLICK project: Screening for Limb, I-Eye, Cardiovascular and Kidney (SLICK) complications in individuals with type 2 diabetes in Alberta's First Nations communities.

Identifying diabetes complications through screening using portable laboratory equipment in Aboriginal communities, and providing education and client empowerment for improved follow-up care and self-care. First Nations people with known diabetes. Screening was carried out in temporary clinics and laboratories set up at the local health centre in each of Alberta's 44 First Nations. Two mobile units ("SLICK vans"), equipped with professionally trained staff, portable lab instruments and a retinal camera, travelled to all 44 Alberta First Nations communities to facilitate implementation of the Canadian Diabetes Association Clinical Practice Guidelines (CPGs). The project provided relevant education and counselling in conjunction with screening activities. SLICK screened 1,151 clients between December 2001 and July 2003, and the project remains ongoing. A preliminary evaluation of the project's 19-month implementation period showed screening activities and satisfaction with diabetes services were low prior to SLICK. There were modest improvements in some program outcomes at 6-12 months follow-up. The SLICK project is designed to address the impact of diabetes by utilizing evidence-based CPGs with respect to screening for complications at the community level. It had a successful implementation period facilitated by community acceptance.