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1.  Stigma and Its Impact on Glucose Control Among Youth With Diabetes: Protocol for a Canada-Wide Study 
JMIR Research Protocols  2016;5(4):e242.
Background
Stigma in chronic disease involves unwarranted rejection, judgement, or exclusion by others based on the chronic disease itself.
Objective
We aim to determine the prevalence of stigma among youth and young adults with type 1 diabetes in Canada, to assess associations between stigma and glycemic control, and to explore ways to address stigma related to type 1 diabetes.
Methods
The study includes 3 distinct phases: (1) refinement of survey questions, (2) assessment of test-retest reliability, and (3) a data collection and analysis phase (online survey and mailed-in capillary blood sample to assess hemoglobin A1c). A total of 380 youth and young adults (14 to 24 years old) with type 1 diabetes are being recruited through social media and clinic posters.
Results
Phases 1 and 2 are complete, and phase 3 is in progress. Thirty participants completed phase 2. The survey includes the Barriers to Diabetes Adherence in adolescent scale (intraclass correlation [ICC]=0.967, 95% CI 0.931-0.984), the Self-Efficacy for Diabetes Self-Management measure (ICC=0.952, 95% CI 0.899-0.977), the World Health Organization-5 Well-Being Index (ICC=0.860, 95% CI 0.705-0.933), 12 closed-ended questions, and an additional 5 open-ended questions to explore challenges and solutions developed by the team of experts, including a patient representative.
Conclusions
This will be the first large-scale survey to estimate the prevalence of stigma in young people with type 1 diabetes. The results of this study will allow for an appreciation of the magnitude of the problem and the need for developing and implementing solutions. This work is intended to provide an initial understanding of youth perspectives on the challenges of living with type 1 diabetes and will serve as a foundation for future research and action to help youth improve their experience of living with diabetes.
Trial Registration
ClinicalTrials.gov NCT02796248, https://clinicaltrials.gov/ct2/show/NCT02796248 (Archived at http://www.webcitation.org/6mhenww3o).
doi:10.2196/resprot.6629
PMCID: PMC5200843  PMID: 27979791
type 1 diabetes; youth; stigma; perception; well-being
2.  Neighbourhood walkability and home neighbourhood-based physical activity: an observational study of adults with type 2 diabetes 
BMC Public Health  2016;16(1):957.
Background
Converging international evidence suggests that diabetes incidence is lower among adults living in more walkable neighbourhoods. The association between walkability and physical activity (PA), the presumed mediator of this relationship, has not been carefully examined in adults with type 2 diabetes. We investigated the associations of walkability with total PA occurring within home neighbourhoods and overall PA, irrespective of location.
Methods
Participants (n = 97; 59.5 ± 10.5 years) were recruited through clinics in Montreal (QC, Canada) and wore a GPS-accelerometer device for 7 days. Total PA was expressed as the total Vector of the Dynamic Body Acceleration. PA location was determined using a Global Positioning System (GPS) device (SIRF IV chip). Walkability (street connectivity, land use mix, population density) was assessed using Geographical Information Systems software. The cross-sectional associations between walkability and location-based PA were estimated using robust linear regressions adjusted for age, body mass index, sex, university education, season, car access, residential self-selection, and wear-time.
Results
A one standard deviation (SD) increment in walkability was associated with 10.4 % of a SD increment in neighbourhood-based PA (95 % confidence interval (CI) 1.2, 19.7) – equivalent to 165 more steps/day (95 % 19, 312). Car access emerged as an important predictor of neighbourhood-based PA (Not having car access: 38.6 % of a SD increment in neighbourhood-based PA, 95 % CI 17.9, 59.3). Neither walkability nor car access were conclusively associated with overall PA.
Conclusions
Higher neighbourhood walkability is associated with higher home neighbourhood-based PA but not with higher overall PA. Other factors will need to be leveraged to facilitate meaningful increases in overall PA among adults with type 2 diabetes.
Electronic supplementary material
The online version of this article (doi:10.1186/s12889-016-3603-y) contains supplementary material, which is available to authorized users.
doi:10.1186/s12889-016-3603-y
PMCID: PMC5017036  PMID: 27613233
Type 2 diabetes; Physical activity; Accelerometry; Global Positioning Systems; Physical activity locations; Neighbourhood walkability; Environmental epidemiology; Health geography
3.  Neighbourhood Walkability and Daily Steps in Adults with Type 2 Diabetes 
PLoS ONE  2016;11(3):e0151544.
Introduction
There is evidence that greater neighbourhood walkability (i.e., neighbourhoods with more amenities and well-connected streets) is associated with higher levels of total walking in Europe and in Asia, but it remains unclear if this association holds in the Canadian context and in chronic disease populations. We examined the relationships of different walkability measures to biosensor-assessed total walking (i.e., steps/day) in adults with type 2 diabetes living in Montreal (QC, Canada).
Materials and Methods
Participants (60.5±10.4 years; 48.1% women) were recruited through McGill University-affiliated clinics (June 2006 to May 2008). Steps/day were assessed once per season for one year with pedometers. Neighbourhood walkability was evaluated through participant reports, in-field audits, Geographic Information Systems (GIS)-derived measures, and the Walk Score®. Relationships between walkability and daily steps were estimated using Bayesian longitudinal hierarchical linear regression models (n = 131).
Results
Participants who reported living in the most compared to the least walkable neighbourhoods completed 1345 more steps/day (95% Credible Interval: 718, 1976; Quartiles 4 versus 1). Those living in the most compared to the least walkable neighbourhoods (based on GIS-derived walkability) completed 606 more steps per day (95% CrI: 8, 1203). No statistically significant associations with steps were observed for audit-assessed walkability or the Walk Score®.
Conclusions
Adults with type 2 diabetes who perceived their neighbourhoods as more walkable accumulated more daily steps. This suggests that knowledge of local neighborhood features that enhance walking is a meaningful predictor of higher levels of walking and an important component of neighbourhood walkability.
doi:10.1371/journal.pone.0151544
PMCID: PMC4798718  PMID: 26991308
5.  Neighbourhood walkability, daily steps and utilitarian walking in Canadian adults 
BMJ Open  2015;5(11):e008964.
Objectives
To estimate the associations of neighbourhood walkability (based on Geographic Information System (GIS)-derived measures of street connectivity, land use mix, and population density and the Walk Score) with self-reported utilitarian walking and accelerometer-assessed daily steps in Canadian adults.
Design
A cross-sectional analysis of data collected as part of the Canadian Health Measures Survey (2007–2009).
Setting
Home neighbourhoods (500 m polygonal street network buffers around the centroid of the participant's postal code) located in Atlantic Canada, Québec, Ontario, the Prairies and British Columbia.
Participants
5605 individuals participated in the survey. 3727 adults (≥18 years) completed a computer-assisted interview and attended a mobile clinic assessment. Analyses were based on those who had complete exposure, outcome and covariate data (n=2949).
Main exposure measures
GIS-derived walkability (based on land use mix, street connectivity and population density); Walk Score.
Main outcome measures
Self-reported utilitarian walking; accelerometer-assessed daily steps.
Results
No important relationship was observed between neighbourhood walkability and daily steps. Participants who reported more utilitarian walking, however, accumulated more steps (<1 h/week: 6613 steps/day, 95% CI 6251 to 6975; 1 to 5 h/week: 6768 steps/day, 95% CI 6420 to 7117; ≥6 h/week: 7391 steps/day, 95% CI 6972 to 7811). There was a positive graded association between walkability and odds of walking ≥1 h/week for utilitarian purposes (eg, Q4 vs Q1 of GIS-derived walkability: OR=1.66, 95% CI 1.31 to 2.11; Q3 vs Q1: OR=1.41, 95% CI 1.14 to 1.76; Q2 vs Q1: OR=1.13, 95% CI 0.91 to 1.39) independent of age, sex, body mass index, married/common law status, annual household income, having children in the household, immigrant status, mood disorder, perceived health, ever smoker and season.
Conclusions
Contrary to expectations, living in more walkable Canadian neighbourhoods was not associated with more total walking. Utilitarian walking and daily steps were, however, correlated and walkability demonstrated a positive graded relationship with utilitarian walking.
doi:10.1136/bmjopen-2015-008964
PMCID: PMC4679838  PMID: 26603246
EPIDEMIOLOGY; PUBLIC HEALTH; PREVENTIVE MEDICINE
6.  Correlates of sitting time in adults with type 2 diabetes 
BMC Public Health  2015;15:793.
Background
Studies suggest a relationship between sitting time and cardiovascular disease mortality. Our aim was to identify socio-demographic, contextual, and clinical (e.g., body composition, diabetes duration) correlates of self-reported sitting time among adults with type 2 diabetes, a clinical population at high risk for cardiovascular disease. We sought to determine if there was an inverse relationship between sitting and step counts in a diabetes cohort in whom we had previously identified low step counts with further lowering in fall/winter.
Methods
The cohort included 198 adults (54 % men; age 60.0 SD 11.5 years; Body mass index 30.4 SD 5.6 kg/m2) (Montréal, Canada). Socio-demographic, contextual and clinical factors were assessed using standardized questionnaires and step counts with a pedometer over 14 days (concealed viewing windows). Total sitting time was estimated once per season (up to 4 times per year at –month intervals) using the International Physical Activity Questionnaire-Short version. Potential sitting time correlates were evaluated using Bayesian longitudinal hierarchical linear regression models in participants with sitting time data (n = 191).
Results
The average sitting time was 308 (SD 161) minutes/day without variation across seasons. Sitting time correlates were being an immigrant (56 fewer minutes/day spent sitting compared to non- immigrants, 95 % credible interval, CrI: −100, −11) and having a university degree (55 more minutes/day spent sitting compared to those without a university degree, 95 % CrI: 10, 100) after adjustment for potential correlates observed in univariate analyses (sex, age, job status, waist circumference, depressed mood, steps). Correlation between sitting and steps, adjusted for age and sex, was −0.144 (95 % CI: −0.280, 0.002).
Conclusion
There was low correlation between sitting time and step counts. Therefore, high sitting time and low step counts are behaviours that may need to be independently targeted. Interventions to reduce sitting time in adults with type 2 diabetes may need to target non-immigrants and those with a university degree.
doi:10.1186/s12889-015-2086-6
PMCID: PMC4541749  PMID: 26285581
Sedentary behaviors; Seasons; Steps; Socio-demographic factors
7.  Utility of current obesity thresholds in signaling diabetes risk in the James Bay Cree of Eeyou Istchee 
Objective
The anthropometric thresholds signaling type 2 diabetes risk have not been well defined for Aboriginal communities. This study examined current thresholds in terms of ability to capture diabetes risk in the Cree of Eeyou Istchee in northern Quebec, Canada.
Research design and methods
The study cohort for this analysis included adult participants from the Nituuchischaayihtitaau Aschii Multi-Community Environment and Health Study with complete data on anthropometric measures, fasting glucose, and insulin. Diabetes risk was defined as Homeostatic Model Assessment of Insulin Resistance (HOMA-IR) value >2. Positive and negative likelihood ratios (PLR, NLR) of existing obesity thresholds were evaluated (WHO; International Diabetes Federation, IDF; Adult Treatment Panel III, ATP III). Receiver operating curves were examined to estimate optimal thresholds. In a sensitivity analysis, diabetes risk was defined as HOMA-IR >2.7.
Results
The WHO 30 kg/m2 body mass index (BMI) threshold performed well in women (PLR 5.56, 95% CI 1.95 to 15.9; NLR 0.24, 95% CI 0.19 to 0.31) and men (PLR 7.51, 95% CI 2.94 to 19.2; NLR 0.33, 95% CI 0.27 to 0.41). It was close to the estimated optimal threshold (28.5 kg/m2). The ATP III waist circumference threshold (102 cm) performed well in men (PLR 4.64, 95% CI 2.47 to 8.71; NLR 0.21, 95% CI 0.16 to 0.28) and was close to the estimated optimal threshold (101 cm). With diabetes risk defined at HOMA-IR >2.7, PLR values were slightly lower with narrower 95% CIs and optimal thresholds were slightly higher; PLR values remained above 3. For other current thresholds, estimated optimal values were higher and none had a PLR above 2.
Conclusions
A BMI of 30 kg/m2 in women and men, and a 102 cm waist circumference in men, are meaningful obesity thresholds in this Aboriginal population. Other thresholds require a further evaluation.
doi:10.1136/bmjdrc-2015-000114
PMCID: PMC4537917  PMID: 26301098
Aboriginal Health; Obesity and Type 2; Type 2 Diabetes
8.  Associations between neighbourhood walkability and daily steps in adults: a systematic review and meta-analysis 
BMC Public Health  2015;15:768.
Background
Higher street connectivity, land use mix and residential density (collectively referred to as neighbourhood walkability) have been linked to higher levels of walking. The objective of our study was to summarize the current body of knowledge on the association between neighbourhood walkability and biosensor-assessed daily steps in adults.
Methods
We conducted a systematic search of PubMed, SCOPUS, and Embase (Ovid) for articles published prior to May 2014 on the association between walkability (based on Geographic Information Systems-derived street connectivity, land use mix, and/or residential density) and daily steps (pedometer or accelerometer-assessed) in adults. The mean differences in daily steps between adults living in high versus low walkable neighbourhoods were pooled across studies using a Bayesian hierarchical model.
Results
The search strategy yielded 8,744 unique abstracts. Thirty of these underwent full article review of which six met the inclusion criteria. Four of these studies were conducted in Europe and two were conducted in Asia. A meta-analysis of four of these six studies indicates that participants living in high compared to low walkable neighbourhoods accumulate 766 more steps per day (95 % credible interval 250, 1271). This accounts for approximately 8 % of recommended daily steps.
Conclusions
The results of European and Asian studies support the hypothesis that higher neighbourhood walkability is associated with higher levels of biosensor-assessed walking in adults. More studies on this association are needed in North America.
doi:10.1186/s12889-015-2082-x
PMCID: PMC4532296  PMID: 26260474
Neighbourhood walkability; Daily step count; Walking; Environments; Physical activity
9.  Participants’ Perceptions of a Group Based Program Incorporating Hands-On Meal Preparation and Pedometer-Based Self-Monitoring in Type 2 Diabetes 
PLoS ONE  2014;9(12):e114620.
Background
Nutrition education (portion sizes, balanced meals) is a cornerstone of diabetes management; however, moving from information to behavior change is challenging. Through a single arm intervention study, we recently demonstrated that combining education with group-based meal preparation training has measureable effects on weight, eating behaviour, and glycemic control in adults with type 2 diabetes. In the present study, we conducted an in-depth examination of participants’ perceptions of this strategy, through focus group discussion, to delineate effective elements of the strategy from participants’ perspectives.
Methods
Participants who had completed the nutrition education/meal preparation training program were invited to attend one of four focus group discussions. These were led by experienced facilitators and guided by questions addressing experiences during the intervention and their perceived impact. Audiotapes were transcribed and qualitative content analysis of transcripts was performed. We report herein themes that achieved saturation across the four discussions.
Results
Twenty-nine (80.6%, 29/36) attended a focus group discussion. The program elements perceived as effective by participants included the hands-on interactive learning approach to meal preparation, the grocery store tour, pedometer-based self-monitoring, experiencing the link between food consumption/physical activity and glucose changes during the program, and peer support. Discussants reported changes in eating and walking behaviour, greater confidence in ability to self-manage diabetes, reductions in glucose levels and/or need for glucose-lowering medications, and, in some cases, weight loss. Family members and friends were facilitators for some and barriers for others in terms of achieving health behavior changes.
Conclusions
Among adults with type 2 diabetes, a group based program that included hands-on meal preparation and pedometer-based self-monitoring was perceived as effective in conveying information, developing skills, building confidence, and changing health behaviors.
doi:10.1371/journal.pone.0114620
PMCID: PMC4275207  PMID: 25536068
10.  Sex-based disparities in cardioprotective medication use in adults with diabetes 
Objective
The identification of sex-based disparities in the use of effective medications in high-risk populations can lead to interventions to minimize disparities in health outcomes. The objective of this study was to determine sex-specific rates of cardioprotective medication use in a large population-level administrative-health database from a universal-payer environment.
Research design and methods
This observational, population-based cohort study used provincial administrative data to compare the utilization of cardioprotective medications between women and men in the first year following a diabetes diagnosis. Competing risks regression was used to calculate crude and adjusted sub-hazard ratios for time-to-first angiotensin-converting-enzyme inhibitor, angiotensin receptor blocker, or statin dispensations.
Results
There were 15,120 (45.4%) women and 18,174 (54.6%) men with diabetes in the study cohort. Overall cardioprotective medication use was low for both primary and secondary prevention for both women and men. In the year following a diabetes diagnosis, women were less likely to use a statin relative to men (adjusted sub-hazard ratio [aSHR] 0.90, 95% confidence interval [CI] 0.85 to 0.96), angiotensin-converting-enzyme inhibitors (aSHR 0.90, 95% CI 0.86 to 0.94), or any cardioprotective medication (aSHR 0.93, 95% CI 0.90 to 0.97).
Conclusions
Cardioprotective medication use was not optimal in women or men. We also identified a health care gap with cardioprotective medication use being lower in women with diabetes compared to men. Closing this gap has the potential to reduce the impact of cardiovascular disease in women with diabetes.
Electronic supplementary material
The online version of this article (doi:10.1186/1758-5996-6-117) contains supplementary material, which is available to authorized users.
doi:10.1186/1758-5996-6-117
PMCID: PMC4240896  PMID: 25419242
11.  Estimating the Population Prevalence of Diagnosed and Undiagnosed Diabetes 
Diabetes Care  2013;36(10):3002-3008.
OBJECTIVE
Health administrative data are frequently used for diabetes surveillance, but validation studies are limited, and undiagnosed diabetes has not been considered in previous studies. We compared the test properties of an administrative definition with self-reported diabetes and estimated prevalence of undiagnosed diabetes by measuring glucose levels in mailed-in capillary blood samples.
RESEARCH DESIGN AND METHODS
A stratified random sample of 6,247 individuals (Quebec province) was surveyed by telephone and asked to mail in fasting blood samples on filter paper to a central laboratory. An administrative definition was applied (two physician claims or one hospitalization for diabetes within a 2-year period) and compared with self-reported diabetes alone and with self-reported diabetes or elevated blood glucose level (≥7 mmol/L). Population-level prevalence was estimated with the use of the administrative definition corrected for its sensitivity and specificity.
RESULTS
Compared with self-reported diabetes, sensitivity and specificity were 84.3% (95% CI 79.3–88.5%) and 97.9% (97.4–98.4%), respectively. Compared with diabetes by self-report and/or glucose testing, sensitivity was lower at 58.2% (52.2–64.6%), whereas specificity was similar at 98.7% (98.0–99.3%). Adjusted for sampling weights, population-level prevalence of physician-diagnosed diabetes was 7.2% (6.3–8.0%). Prevalence of total diabetes (physician-diagnosed and undiagnosed) was 13.4% (11.7–15.0%), indicating that ∼40% of diabetes cases are undiagnosed.
CONCLUSIONS
A substantial proportion of diabetes cases are missed by surveillance methods that use health administrative databases. This finding is concerning because individuals with undiagnosed diabetes are likely to have a delay in treatment and, thus, a higher risk for diabetes-related complications.
doi:10.2337/dc12-2543
PMCID: PMC3781536  PMID: 23656982
12.  Group-based activities with on-site childcare and online support improve glucose tolerance in women within 5 years of gestational diabetes pregnancy 
Background
Women with gestational diabetes history are at increased risk for type 2 diabetes. They face specific challenges for behavioural changes, including childcare responsibilities. The aim of this study is to test a tailored type 2 diabetes prevention intervention in women within 5 years of a pregnancy with gestational diabetes, in terms of effects on weight and cardiometabolic risk factors.
Methods
The 13-week intervention, designed based on focus group discussions, included four group sessions, two with spousal participation and all with on-site childcare. Web/telephone-based support was provided between sessions. We computed mean percentage change from baseline (95% confidence intervals, CI) for anthropometric measures, glucose tolerance (75 g Oral glucose tolerance test), insulin resistance/sensitivity, blood pressure, physical activity, dietary intake, and other cardiometabolic risk factors.
Results
Among the 36 enrolled, 27 completed final evaluations. Most attended ≥ 3 sessions (74%), used on-site childcare (88%), and logged onto the website (85%). Steps/day (733 steps, 95% CI 85, 1391) and fruit/vegetable intake (1.5 servings/day, 95% CI 0.3, 2.8) increased. Proportions decreased for convenience meal consumption (−30%, 95% CI −50, −9) and eating out (−22%, 95% CI −44, −0) ≥ 3 times/month. Body mass index and body composition were unchanged. Fasting (−4.9%, 95% CI −9.5, −0.3) and 2-hour postchallenge (−8.0%, 95% CI −15.6, −0.5) glucose declined. Insulin sensitivity increased (ISI 0,120 23.7%, 95% CI 9.1, 38.4; Matsuda index 37.5%, 95% CI 3.5, 72.4). Insulin resistance (HOMA-IR −9.4%, 95% CI −18.6, −0.1) and systolic blood pressure (−3.3%, 95% CI −5.8, −0.8) decreased.
Conclusions
A tailored group intervention appears to lead to improvements in health behaviours and cardiometabolic risk factors despite unchanged body mass index and body composition. This approach merits further study.
Clinical trial registration
ClinicalTrials.gov (NCT01814995).
doi:10.1186/1475-2840-13-104
PMCID: PMC4227099  PMID: 24981579
Gestational diabetes; Type 2 diabetes; Prevention; Insulin resistance; Diet; Exercise; Childcare; Spouse participation
13.  Spousal diabetes as a diabetes risk factor: A systematic review and meta-analysis 
BMC Medicine  2014;12:12.
Background
Diabetes history in biologically-related individuals increases diabetes risk. We assessed diabetes concordance in spouses (that is, biologically unrelated family members) to gauge the importance of socioenvironmental factors.
Methods
We selected cross-sectional, case–control and cohort studies examining spousal association for diabetes and/or prediabetes (impaired fasting glucose or impaired glucose tolerance), indexed in Medline, Embase or Scopus (1 January 1997 to 28 February 2013). Effect estimates (that is, odds ratios, incidence rate ratios, and so on) with body mass index (BMI) adjustment were pooled separately from those without BMI adjustment (random effects models) to distinguish BMI-dependent and independent concordance.
Results
Searches yielded 2,705 articles; six were retained (n = 75,498 couples) for systematic review and five for meta-analysis. Concordance was lowest in a study that relied on women’s reports of diabetes in themselves and their spouses (effect estimate 1.1, 95% CI 1.0 to 1.30) and highest in a study with systematic assessment of glucose tolerance (2.11, 95% CI 1.74 to 5.10). The random-effects pooled estimate adjusted for age and other covariates but not BMI was 1.26 (95% CI 1.08 to 1.45). The estimate with BMI adjustment was lower (1.18, 95% CI 0.97 to 1.40). Two studies assessing between-spouse associations of diabetes/prediabetes determined by glucose testing reported high concordance (OR 1.92, 95% CI 1.55 to 2.37 without BMI adjustment; 2.32, 95% CI 1.87 to 3.98 with BMI adjustment). Two studies did not distinguish type 1 and type 2 diabetes. However given that around 95% of adults is type 2, this is unlikely to have influenced the results.
Conclusions
Our pooled estimate suggests that a spousal history of diabetes is associated with a 26% diabetes risk increase. Recognizing shared risk between spouses may improve diabetes detection and motivate couples to increase collaborative efforts to optimize eating and physical activity habits.
doi:10.1186/1741-7015-12-12
PMCID: PMC3900990  PMID: 24460622
Diabetes mellitus; Prediabetes; Spouses concordance; Risk factor; Systematic review; Meta-analysis
14.  Step Monitoring to improve ARTERial health (SMARTER) through step count prescription in type 2 diabetes and hypertension: trial design and methods 
Background
With increasing numbers of type 2 diabetes (DM2) and hypertension patients, there is a pressing need for effective, time-efficient and sustainable strategies to help physicians support their patients to achieve higher physical activity levels. SMARTER will determine whether physician-delivered step count prescriptions reduce arterial stiffness over a one-year period, compared with usual care, in sedentary overweight/obese adults with DM2/hypertension.
Design
Randomized, allocation-concealed, assessor-blind, multisite clinical trial. The primary outcome is change in arterial stiffness over one year. The secondary outcomes include changes in physical activity, individual vascular risk factors, medication use, and anthropometric parameters. Assessments are at baseline and one year.
Methods
Participants are sedentary/low active adults with 25 ≤ BMI < 40 kg/m2 followed for DM2/hypertension by a collaborating physician. The active arm uses pedometers to track daily step counts and review logs with their physicians at 3 to 4-month intervals. A written step count prescription is provided at each visit, aiming to increase counts by ≥3,000 steps/day over one year, with an individualized rate increase. The control arm visits physicians at the same frequency and receives advice to engage in physical activity 30-60 minutes/day. SMARTER will enroll 364 individuals to detect a 10 ± 5% difference in arterial stiffness change between arms. Arterial stiffness is assessed noninvasively with carotid femoral pulse wave velocity using applanation tonometry.
Discussion
The importance of SMARTER lies not simply in the use of pedometer-based monitoring but also on its integration into a prescription-based intervention delivered by the treating physician. Equally important is the measurement of impact of this approach on a summative indicator of arterial health, arterial stiffness. If effectiveness is demonstrated, this strategy has strong potential for widespread uptake and implementation, given that it is well-aligned with the structure of current clinical practice.
Trial registration
ClinicalTrials.gov (NCT01475201)
doi:10.1186/1475-2840-13-7
PMCID: PMC3893520  PMID: 24393423
15.  Nutritional Education Through Internet-Delivered Menu Plans Among Adults With Type 2 Diabetes Mellitus: Pilot Study 
JMIR Research Protocols  2013;2(2):e41.
Background
A potential barrier to weight loss and vascular risk reduction is difficulty in operationalizing dietary education into a concrete plan. Although a variety of Internet-based software tools are now available to address this issue, there has been little formal evaluation of these tools.
Objective
The aim of this single-arm pilot study is to determine the effect of a 24-week Internet-based menu-planning program, by examining pre- to postintervention changes in the body weight, blood pressure, and glycemia, specifically among overweight adults with type 2 diabetes mellitus (DM2), a clinical population at high risk for vascular diseases.
Methods
A total of 33 adults with DM2 were recruited by collaborating registered dietitians to a 24-week Internet-based menu-planning program. Individualized dietary prescriptions were operationalized into weekly Internet-delivered menu plans through an adapted version of a commercially available service. Adherence was defined as logging into the program at least once per week for a minimum of 18 of the 24 weeks. Multiple imputations were used for missing data. Using baseline and postintervention assessments, we calculated the weight changes (mean, 95% CI) and investigated the corresponding effects (linear regression models) on blood pressure (systolic, diastolic) and hemoglobin A1C (ie, glycemia).
Results
The mean age was 58 (SD 7) years and the mean baseline body mass index was 34.4 (SD 4.6) kg/m2. The results of this study showed that ≥5% weight reduction was achieved by 6/33 participants (18%) and by 5/18 adherent participants (28%). A mean weight change of −2.0% (95% CI −2.6 to −1.4) was observed, with changes occurring in the adherent (−3.6%, 95% CI −4.5 to −2.8) but not in the nonadherent (0%, 95% CI −0.6 to 0.7). It was found that each 1% reduction in body weight was associated with a −2.4 mmHg change in systolic (95% CI −3.5 to −1.2) and a −0.8 mmHg change in diastolic blood pressure (95% CI −1.4 to −0.2). Percent weight change was not found to be related to changes in A1C.
Conclusions
In adults with DM2, an Internet-based menu-planning program has the potential to lead to clinically important weight reductions in more than one quarter of those who adhere, with corresponding improvements in blood pressure.
doi:10.2196/resprot.2525
PMCID: PMC3806354  PMID: 24185033
weight loss; obesity; hemoglobin A1C; blood pressure; Internet; Web; type 2 diabetes mellitus; diet; menu
16.  Systematic Review and Meta-Analysis of Validation Studies on a Diabetes Case Definition from Health Administrative Records 
PLoS ONE  2013;8(10):e75256.
Objectives
Health administrative data are frequently used for diabetes surveillance. We aimed to determine the sensitivity and specificity of a commonly-used diabetes case definition (two physician claims or one hospital discharge abstract record within a two-year period) and their potential effect on prevalence estimation.
Methods
Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we searched Medline (from 1950) and Embase (from 1980) databases for validation studies through August 2012 (keywords: “diabetes mellitus”; “administrative databases”; “validation studies”). Reviewers abstracted data with standardized forms and assessed quality using Quality Assessment of Diagnostic Accuracy Studies (QUADAS) criteria. A generalized linear model approach to random-effects bivariate regression meta-analysis was used to pool sensitivity and specificity estimates. We applied correction factors derived from pooled sensitivity and specificity estimates to prevalence estimates from national surveillance reports and projected prevalence estimates over 10 years (to 2018).
Results
The search strategy identified 1423 abstracts among which 11 studies were deemed relevant and reviewed; 6 of these reported sensitivity and specificity allowing pooling in a meta-analysis. Compared to surveys or medical records, sensitivity was 82.3% (95%CI 75.8, 87.4) and specificity was 97.9% (95%CI 96.5, 98.8). The diabetes case definition underestimated prevalence when it was ≤10.6% and overestimated prevalence otherwise.
Conclusion
The diabetes case definition examined misses up to one fifth of diabetes cases and wrongly identifies diabetes in approximately 2% of the population. This may be sufficiently sensitive and specific for surveillance purposes, in particular monitoring prevalence trends. Applying correction factors to adjust prevalence estimates from this definition may be helpful to increase accuracy of estimates.
doi:10.1371/journal.pone.0075256
PMCID: PMC3793995  PMID: 24130696
17.  Strategies to Optimize Participation in Diabetes Prevention Programs following Gestational Diabetes: A Focus Group Study 
PLoS ONE  2013;8(7):e67878.
Objective
We performed a qualitative study among women within 5 years of Gestational Diabetes (GDM) diagnosis. Our aim was to identify the key elements that would enhance participation in a type 2 diabetes (DM2) prevention program.
Research Design and Methods
Potential participants received up to three invitation letters from their GDM physician. Four focus groups were held. Discussants were invited to comment on potential facilitators/barriers to participation and were probed on attitudes towards meal replacement and Internet/social media tools. Recurring themes were identified through qualitative content analysis of discussion transcripts.
Results
Among the 1,201 contacted and 79 eligible/interested, 29 women attended a focus group discussion. More than half of discussants were overweight/obese, and less than half were physically active. For DM2 prevention, a strong need for social support to achieve changes in dietary and physical activity habits was expressed. In this regard, face-to-face interactions with peers and professionals were preferred, with adjunctive roles for Internet/social media. Further, direct participation of partners/spouses in a DM2 prevention program was viewed as important to enhance support for behavioural change at home. Discussants highlighted work and child-related responsibilities as potential barriers to participation, and emphasized the importance of childcare support to allow attendance. Meal replacements were viewed with little interest, with concerns that their use would provide a poor example of eating behaviour to children.
Conclusions
Among women within 5 years of a GDM diagnosis who participated in a focus group discussion, participation in a DM2 prevention program would be enhanced by face-to-face interactions with professionals and peers, provision of childcare support, and inclusion of spouses/partners.
doi:10.1371/journal.pone.0067878
PMCID: PMC3701629  PMID: 23861824
18.  Effects of meal preparation training on body weight, glycemia, and blood pressure: results of a phase 2 trial in type 2 diabetes 
Background
Modest reductions in weight and small increases in step- related activity (e.g., walking) can improve glycemic and blood pressure control in type 2 diabetes mellitus (DM2). We examined changes in these parameters following training in time- efficient preparation of balanced, low- energy meals combined with pedometer- based step count monitoring.
Methods
Seventy- two adults with DM2 were enrolled in a 24- week program (i.e., 15 three- hour group sessions). They prepared meals under a chef’s supervision, and discussed eating behaviours/nutrition with a registered dietitian. They maintained a record of pedometer- assessed step counts. We evaluated changes from baseline to 24 weeks in terms of weight, step counts, hemoglobin A1c (HbA1c, glycemic control), blood pressure, and eating control ability (Weight Efficacy Lifestyle WEL Questionnaire). 53 participants (73.6%) completed assessments.
Results
There were improvements in eating control (11.2 point WEL score change, 95% CI 4.7 to 17.8), step counts (mean change 869 steps/day, 95% CI 198 to 1,540), weight (mean change −2.2%; 95% CI −3.6 to −0.8), and HbA1c (mean change −0.3% HbA1c, 95% CI −0.6 to −0.1), as well as suggestion of systolic blood pressure reduction (mean change −3.5 mm Hg, 95% CI −7.8 to 0.9). Findings were not attributable to medication changes. In linear regression models (adjusted for age, sex, ethnicity, insulin use, season), a −2.5% weight change was associated with a −0.3% HbA1c change (95% CI −0.4 to −0.2) and a −3.5% systolic blood pressure change (95% CI −5.5 to −1.4).
Conclusions
In this ‘proof of concept’ study, persistence with the program led to improvements in eating and physical activity habits, glycemia reductions, and suggestion of blood pressure lowering effects. The strategy thus merits further study and development to expand the range of options for vascular risk reduction in DM2.
doi:10.1186/1479-5868-9-125
PMCID: PMC3543247  PMID: 23075398
Body weight; Physical activity; Patient education; Risk factors; Type 2 diabetes
19.  Risk of bleeding associated with combined use of selective serotonin reuptake inhibitors and antiplatelet therapy following acute myocardial infarction 
Background:
Patients prescribed antiplatelet treatment to prevent recurrent acute myocardial infarction are often also given a selective serotonin reuptake inhibitor (SSRI) to treat coexisting depression. Use of either treatment may increase the risk of bleeding. We assessed the risk of bleeding among patients taking both medications following acute myocardial infarction.
Methods:
We conducted a retrospective cohort study using hospital discharge abstracts, physician billing information, medication reimbursement claims and demographic data from provincial health services administrative databases. We included patients 50 years of age or older who were discharged from hospital with antiplatelet therapy following acute myocardial infarction between January 1998 and March 2007. Patients were followed until admission to hospital due to a bleeding episode, admission to hospital due to recurrent acute myocardial infarction, death or the end of the study period.
Results:
The 27 058 patients in the cohort received the following medications at discharge: acetylsalicylic acid (ASA) (n = 14 426); clopidogrel (n = 2467), ASA and clopidogrel (n = 9475); ASA and an SSRI (n = 406); ASA, clopidogrel and an SSRI (n = 239); or clopidogrel and an SSRI (n = 45). Compared with ASA use alone, the combined use of an SSRI with antiplatelet therapy was associated with an increased risk of bleeding (ASA and SSRI: hazard ratio [HR] 1.42, 95% confidence interval [CI] 1.08–1.87; ASA, clopidogrel and SSRI: HR 2.35, 95% CI 1.61–3.42). Compared with dual antiplatelet therapy alone (ASA and clopidogrel), combined use of an SSRI and dual antiplatelet therapy was associated with an increased risk of bleeding (HR 1.57, 95% CI 1.07–2.32).
Interpretation:
Patients taking an SSRI together with ASA or dual antiplatelet therapy following acute myocardial infarction were at increased risk of bleeding.
doi:10.1503/cmaj.100912
PMCID: PMC3216455  PMID: 21948719
20.  Daily steps are low year-round and dip lower in fall/winter: findings from a longitudinal diabetes cohort 
Background
Higher walking levels lead to lower mortality in type 2 diabetes, but inclement weather may reduce walking. In this patient population, we conducted a longitudinal cohort study to objectively quantify seasonal variations both in walking and in two vascular risk factors associated with activity levels, hemoglobin A1C and blood pressure.
Methods
Between June 2006 and July 2009, volunteer type 2 diabetes patients in Montreal, Quebec, Canada underwent two weeks of pedometer measurement up to four times over a one year follow-up period (i.e. once/season). Pedometer viewing windows were concealed (snap-on cover and tamper proof seal). A1C, blood pressure, and anthropometric parameters were also assessed. Given similarities in measures for spring/summer and fall/winter, and because not all participants completed four assessments, spring and summer values were collapsed as were fall and winter values. Mean within-individual differences (95% confidence intervals) were computed for daily steps, A1C, and systolic and diastolic blood pressure, by subtracting spring/summer values from fall/winter values.
Results
Among 201 participants, 166 (82.6%) underwent at least one fall/winter and one spring/summer evaluation. Approximately half were women, the mean age was 62.4 years (SD 10.8), and the mean BMI was 30.1 kg/m2 (SD 5.7). Step counts averaged at a sedentary level in fall/winter (mean 4,901 steps/day, SD 2,464) and at a low active level in spring/summer (mean 5,659 steps/day, SD 2,611). There was a -758 (95% CI: -1,037 to -479) mean fall/winter to spring/summer within-individual difference. There were no significant differences in A1C or in anthropometric parameters. Systolic blood pressure was higher in fall/winter (mean 137 mm Hg, SD 16) than spring/summer (133 mm Hg, SD 14) with a mean difference of 4.0 mm Hg (95% CI: 2.3 to 5.7).
Conclusions
Daily step counts in type 2 diabetes patients are low, dipping lower during fall/winter. In this medication-treated cohort, A1C was stable year-round but a fall/winter systolic blood pressure increase was detected. Our findings signal a need to develop strategies to help patients increase step counts year-round and prevent both reductions in step counts and increases in blood pressure during the fall and winter.
doi:10.1186/1475-2840-9-81
PMCID: PMC3004821  PMID: 21118567
21.  Sex Differences in Step Count-Blood Pressure Association: A Preliminary Study in Type 2 Diabetes 
PLoS ONE  2010;5(11):e14086.
Background
Walking and cardiovascular mortality are inversely associated in type 2 diabetes, but few studies have objectively measured associations of walking with individual cardiovascular risk factors. Such information would be useful for “dosing” daily steps in clinical practice. This study aimed to quantify decrements in blood pressure and glycated hemoglobin (A1C) per 1,000 daily step increments.
Methodology/Principal Findings
Two hundred and one subjects with type 2 diabetes underwent assessments of step counts (pedometer-measured), blood pressure, A1C and anthropometric parameters. Due to missing data, the final analysis was conducted on 83 women and 102 men, with a mean age of 60 years. Associations of daily steps with blood pressure and A1C were evaluated using sex-specific multivariate linear regression models (adjusted for age, ethnicity, and BMI). Potential sex differences were confirmed in a combined model (women and men) with interaction terms. Mean values for daily steps, blood pressure, A1C and BMI were 5,357 steps/day; 137/80 mm Hg; 7.7% and 30.4 kg/m2 respectively. A 1,000 daily step increment among women was associated with a −2.6 (95% CI: −4.1 to −1.1) mm Hg change in systolic and a −1.4 (95% CI: −2.2 to −0.6) mm Hg change in diastolic blood pressure. Among men, corresponding changes were −0.7 (95% CI: −2.1 to 0.7) and −0.6 (95% CI: −1.4 to 0.3) mm Hg, respectively. Sex differences were confirmed in combined models. Step counts and A1C did not demonstrate clinically important associations.
Conclusions/Significance
A 1,000 steps/day increment is associated with important blood pressure decrements among women with type 2 diabetes but the data were inconclusive among men. Targeted “dose increments” of 1,000 steps/day in women may lead to measurable blood pressure reductions. This information may be of potential use in the titration or “dosing” of daily steps. No associations were found between step count increments and A1C.
doi:10.1371/journal.pone.0014086
PMCID: PMC2989914  PMID: 21124929
22.  Short-term mortality associated with failure to receive home care after hemiarthroplasty 
Background
Hemiarthroplasty is often the treatment of choice after hip fracture, particularly in frail elderly patients. Such patients may benefit from home care after discharge. We assessed factors associated with the receipt of home care and evaluated the risk of death within three months after discharge.
Methods
We obtained administrative data for patients 65 years or older in the province of Quebec who were discharged alive from hospital after hemiarthroplasty during the period 1997–2004. We evaluated destination after discharge and mortality within three months after discharge.
Results
Of 11 326 study patients, 5.6% were discharged home with home care, 29.9% home without home care, 2.0% to a rehabilitation centre, 24.2% to a nursing home and 38.3% to another hospital. Among patients who were discharged home, those who were older, had osteoarthritis, had an emergent admission and were admitted to a high-volume hospital were less likely to receive home care. Discharge with home care was most likely among patients admitted to teaching hospitals, those in hospital for more than seven days, those with atrial fibrillation and those with acute renal failure. Patients who received home care were at lower risk of death than those discharged home without care (hazard ratio 0.57, 95% confidence interval 0.39–0.85).
Interpretation
Less than 16% of the patients discharged home after hemiarthroplasty received home care. Those who received such care had a lower risk of death within three months after discharge.
doi:10.1503/cmaj.091209
PMCID: PMC2942914  PMID: 20713576
23.  Outcomes in a diabetic population of south Asians and whites following hospitalization for acute myocardial infarction: a retrospective cohort study 
Background
The aim of this study was to determine whether South Asian patients with diabetes have a worse prognosis following hospitalization for acute myocardial infarction (AMI) compared with their White counterparts. We measured the risk of developing a composite cardiovascular outcome of recurrent AMI, congestive heart failure (CHF) requiring hospitalization, or death, in these two groups.
Methods
Using hospital administrative data, we performed a retrospective cohort study of 41,615 patients with an incident AMI in British Columbia and the Calgary Health Region between April 1, 1995, and March 31, 2002. South Asian ethnicity was determined using validated surname analysis. Baseline demographic characteristics and co-morbidities were included in Cox proportional hazard models to compare time to reaching the composite outcome and its individual components.
Results
Among the AMI cohort, 29.7% of South Asian patients and 17.6% of White patients were identified as having diabetes (n = 7416). There was no significant difference in risk of developing the composite cardiovascular outcome (Hazard Ratio = 0.90, 95% CI = 0.80-1.01). However, South Asian patients had significantly lower mortality at long term follow-up (HR = 0.62, 95% CI = 0.51-0.74) compared to their White counterparts.
Conclusions
Following hospitalization for AMI, South Asian patients with diabetes do not have a significantly different long term risk of a composite cardiovascular outcome compared to White patients with diabetes. While previous research has suggested worse cardiovascular outcomes in the South Asian population, we found lower long-term mortality among South Asians with diabetes following AMI.
doi:10.1186/1475-2840-9-4
PMCID: PMC2816974  PMID: 20096107
24.  Pancytopenia and atrial fibrillation associated with chronic hepatitis C infection and presumed hepatocellular carcinoma: a case report 
Introduction
Pancytopenia secondary to hepatitis viral infection is a rare but noted clinical entity. An acute aplastic crisis usually occurs shortly after viral infection, however, viral serologies are usually negative and the pancytopenia is often fatal if left untreated.
Case presentation
A 66-year-old woman presented to the emergency department with shortness of breath and palpitations. She was found to have pulmonary edema secondary to a newly diagnosed atrial fibrillation and was treated with rate control and anticoagulation. She was found to have an anemia that was reported to be longstanding and that was apparently being investigated by a hematologist, although no diagnosis had yet been achieved. Her blood work also revealed a mild leucopenia and pronounced thrombocytopenia. The patient was admitted to ensure appropriate rate control of her atrial fibrillation and for work-up of her pancytopenia. Review of the bone marrow biopsy performed by the hematologist revealed a normal marrow with no infiltrative process. The results of the patient's blood tests ruled out a hemolytic process. There was also no evidence of infection, toxin ingestion, or recent medication that could be associated with pancytopenia. An abdominal ultrasound was ordered to rule out enlargement of the spleen and a possible consumptive coagulopathy. The spleen was mildly enlarged with a diameter of 13 cm. The liver, however, was mildly cirrhotic and a small solitary liver lesion was seen. A magnetic resonance imaging scan of the liver confirmed a single solitary solid mass and the α-fetal protein level in the serum was elevated. The patient's preliminary viral serologies were positive for hepatitis C. The patient was diagnosed with presumed hepatocellular carcinoma and referred to a hepatic surgeon for evaluation of treatment options.
Conclusion
Hepatitis associated aplastic anemia is an acute condition while milder more chronic presentations, such as this case, likely result from increased portal pressure generated from the resulting cirrhosis, which leads to a relative hypersplenism.
doi:10.1186/1752-1947-2-264
PMCID: PMC2518155  PMID: 18694489
25.  Postdischarge thromboprophylaxis and mortality risk after hip-or knee-replacement surgery 
Background
Patients undergoing hip or knee replacement are at high risk of developing a postoperative venous thromboembolism even after discharge from hospital. We sought to identify hospital and patient characteristics associated with receiving thromboprophylaxis after discharge and to compare the risk of short-term mortality among those who did or did not receive thromboprophylaxis.
Methods
We conducted a retrospective cohort study using system-wide hospital discharge summary records, physician billing information, medication reimbursement claims and demographic records. We included patients aged 65 years and older who received a hip or knee replace ment and who were discharged home after surgery.
Results
In total we included 10 744 patients. Of these, 7058 patients who received a hip replacement and 3686 who received a knee replacement. The mean age was 75.4 (standard deviation [SD] 6.8) years and 38% of patients were men. In total, 2059 (19%) patients received thomboprophylaxis at discharge. Patients discharged from university teaching hospitals were less likely than those discharged from community hospitals to received thromboprophylaxis after discharge (odds ratio [OR] 0.89, 95% confidence interval [CI] 0.80–1.00). Patients were less likely to receive thromboprophylaxis after discharge if they had a longer hospital stay (15–30 days v. 1–7 days, OR 0.69, 95% CI 0.59–0.81). Patients were more likely to receive thromboprophylaxis if they had hip (v. knee) replacement, osteoarthritis, heart failure, atrial fibrillation or hypertension, higher (v. lower) income or if they were treated at medium-volume hospitals (69–116 hip and knee replacements per year). In total, 223 patients (2%) died in the 3-month period after discharge. The risk of short-term mortality was lower among those who received thromboprophylaxis after discharge (hazard ratio [HR] 0.34, 95% CI 0.20–0.57).
Interpretation
Fewer than 1 in 5 elderly patients discharged home after a hip-or knee-replacement surgery received postdischarge thromboprophylaxis. Those prescribed these medications had a lower risk of short-term mortality. The benefits of and barriers to thromboprophylaxis therapy after discharge in this population requires further study.
doi:10.1503/cmaj.071388
PMCID: PMC2396368  PMID: 18519902

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