Canadian journal of diabetes最新文献

Objectives: Diabetic ketoacidosis (DKA) is a major acute complication whose prevention depends on patient knowledge and self-management skills. We aimed to identify the patient-level barriers to effective DKA prevention behaviours.

Methods: We conducted a qualitative study using a behavioral science lens and implementation science methods involving three independent, sequential focus groups. Informed by the Action, Actor, Context, Target, Time framework, three targeted behaviors were defined: Testing ketone levels, acting upon ketone results, and seeking emergency medical care. Deductive coding was used to categorize barriers and enablers for each targeted behavior using the Theoretical Domains Framework (TDF). This was followed by thematic analysis and then member checking of key findings.

Results: Twenty-two participants (9 with type 1 diabetes, 1 caregiver, 12 healthcare providers) contributed to one of three focus groups. Key barriers to engaging in the target behaviors were: 1) a lack of understanding of the clinical relevance of ketones; 2) inability to retain necessary steps for ketone testing and a lack of access to supplies; 3) mental health challenges, sense of identity, and resistance to change; and 4) negative experiences with and fear of stigma from the healthcare system. Key enablers included: 1) reminders from clinicians and technologies; 2) community supports and accessible resources.

Conclusions: Acknowledgment of specific barriers are essential to designing future simplified DKA prevention educational tools and to implement continuous ketone monitoring. We aim in a subsequent step to co-create with people living diabetes a simplified DKA prevention infographic that addresses these barriers.

Background: Gestational Diabetes Mellitus (GDM) is a significant metabolic disorder affecting pregnant women, leading to increased risks of adverse maternal and fetal outcomes. Effective management and preventive strategies are crucial to mitigate its short- and long-term complications.

Objective: This study aims to elucidate the causal relationships between multiple modifiable risk factors and GDM using a two-sample Mendelian randomization (MR) approach.

Methods: We analyzed 41 modifiable risk factors, categorized into metabolic and weight factors, dietary habits, smoking and alcohol behaviors, and physical activities. Genetic variants associated with these risk factors were identified from genome-wide association studies (GWAS). GDM data came from the largest GWAS on gestational diabetes, including 12,332 GDM cases and 131,109 Finnish ancestry controls from the FinnGen study. MR analysis was performed using inverse variance weighted (IVW), MR-Egger, weighted median, simple mode, and weighted mode methods.

Results: Preliminary screening identified 12 significant modifiable risk factors, with fasting glucose, fasting insulin, glycated hemoglobin levels, triglycerides, body mass index (BMI), two-hour glucose, and processed meat intake increasing GDM risk, while high-density lipoprotein (HDL) cholesterol, tea consumption, cheese intake, lamb/mutton intake, and dried fruit intake decreased the risk. After correction for multiple comparisons, fasting glucose, fasting insulin, glycated hemoglobin levels, triglycerides, BMI, and HDL cholesterol remained significant and consistent across various methods.

Conclusion: This comprehensive MR study provides strong evidence for the causal effects of various modifiable risk factors on GDM, highlighting the importance of lifestyle interventions targeting metabolic and dietary factors to prevent GDM and improve maternal and fetal outcomes.

Objective: In this study we compared 2 gestational diabetes mellitus (GDM) diagnostic thresholds in relation to large-for-gestational age (LGA) status and secondary adverse pregnancy outcomes.

Methods: This retrospective cohort study examined 840 pregnant women who underwent 2-step GDM screening at 2 hospital centres in Montréal that use distinct GDM diagnostic thresholds. At the second step of GDM screening, one centre used glucose thresholds suggested by the Diabetes Canada preferred approach and the other centre used the lower International Association of Diabetes and Pregnancy Study Groups thresholds. We defined mild hyperglycemia (MH) as having intermediate glucose values that were diagnostic of GDM at one centre but not the other (fasting plasma glucose [PG] 5.1 to 5.2 mmol/L, 1-hour PG 10 to 10.5 mmol/L, or 2-hour PG 8.5 to 8.9 mmol/L). We conducted multivariable linear and logistic regression analyses to evaluate outcomes for women with untreated or treated MH compared to those diagnosed with GDM by higher glucose thresholds within the same centre, and we also explored differences between centres.

Results: The odds of LGA offspring were 3-fold higher (adjusted odds ratio 3.01, 95% confidence interval [CI] 1.47 to 6.19) among women with untreated MH compared with women treated for GDM at the same centre. Also, the odds of macrosomia were over 2-fold higher when comparing treated MH with GDM. In addition, untreated compared with treated MH had lower odds of induction of labour (adjusted OR 0.28, 95% CI 0.11 to 0.70).

Conclusion: Failure to optimally treat MH during pregnancy is associated with fetal overgrowth and may affect obstetrical management.

Objectives: Interest in incretin therapy for type 1 diabetes is increasing, but data are lacking regarding patient-reported outcomes and personal experience among those using this drug.

Methods: This work is an analysis from a double-blind, randomized, crossover trial assessing semaglutide vs placebo, with automated insulin delivery in adults with type 1 diabetes, after 15-week interventions. The following questionnaires were used after each intervention: the Diabetes Distress Scale; the Hypoglycemia Fear Survey; the Diabetes Treatment Satisfaction Questionnaire; Insulin-delivery Systems: Perceptions, Ideas, Reflections and Expectations (INSPIRE); and the Diabetes Bowel Symptom Questionnaire (DBSQ). Semistructured interviews were performed at the end of the trial. Interviews were recorded, transcribed, and coded by research personnel for themes using an inductive-deductive approach.

Results: Twenty-three participants completed their questionnaires, whereas 24 performed interviews. For semaglutide vs placebo, only the DBSQ showed differing scores with increased symptom frequency and severity with semaglutide. Within the interviews, 42% of patients expressed interest in semaglutide use outside the study, with their reasons being lower insulin requirements, weight loss, and improved glycemic control. Many of these qualities, including complication risk reduction, were qualities of the ideal adjunctive therapy as per participants. Nausea and fear of vomiting were barriers to accurate preprandial determination of upcoming carbohydrate intake and thus preprandial bolus. Synergy was noted between the drug and automated insulin delivery by the participants.

Conclusions: Semaglutide is of interest to those with type 1 diabetes. Safe and accurate bolus practice by patients in the context of nausea should be reviewed during dose titration. Questionnaires did not capture differences between semaglutide and placebo outside of increased gastrointestinal side effects. (Clinicaltrials.gov NCT05205928).

Objectives: Our aim in this study was to assess the effect of a 6-week continuous glucose monitor (CGM) intervention with telemonitoring-enabled virtual diabetes educator visits on patient-reported outcomes (PROs) in adults with type 2 diabetes (T2D) not using insulin.

Methods: Individuals with glycated hemoglobin (A1C) >7.0% (n=105) were computer randomized in an open-label parallel-group design (clinicaltrials.gov NCT05319496) to receive either 6 weeks of upfront CGM (weeks 0 to 6) (n=45) or enhanced usual care (n=41), both with virtual diabetes educator visits. The following outcomes were measured at baseline (week 0), 6 weeks, and 12 weeks using the Problem Areas in Diabetes (PAID), the Diabetes Empowerment Scale---Short Form, the EuroQol-5D Visual Analogue Scale, the International Physical Activity Questionnaire, and the UK Diabetes and Diet Questionnaire. Between-group differences in change scores for each outcome at 6 and 12 weeks were assessed using t tests.

Results: Of the 105 participants (mean age 57 years, 51% male, A1C 8.1%) studied, 86 completed the trial. CGM participants exhibited a greater reduction in total PAID scores at 12 weeks vs baseline when compared with those not using CGM (p=0.03), with similar between-group differences observed for PAID subscales of emotional distress (p=0.02) and food-related problems (p=0.004). CGM participants also had larger improvements in diabetes empowerment at 6 weeks (p=0.009). We did not detect any differences in the number of antihyperglycemic medication classes, physical activity, and diet.

Conclusions: In adults with T2D not on insulin, CGM with virtual educator visits produced improvements in emotional and food-related distress and in diabetes-related empowerment at 12 weeks.

Objectives: Subcutaneous (SC) insulin has been studied as an alternative to intravenous (IV) insulin to reduce resource consumption in the management of diabetic ketoacidosis (DKA). However, feasibility and safety of an SC protocol have not been demonstrated in a Canadian context.

Methods: In this retrospective cohort study we examined the association between IV and SC insulin treatment for DKA and time to anion gap (AG) closure and length of stay (LOS) in hospital at a large Canadian tertiary care centre, in nonpregnant adults with mild to moderate DKA. Rates of hypoglycemia, hypokalemia, and AG reopening requiring intervention were compared between treatment groups.

Results: Compared with the SC-treated group, the IV group had a shorter time to AG closure (median time to AG closure 15.6 hours in the IV group vs 24.0 hours in the SC group, adjusted hazard ratio 0.65, 95% confidence interval [CI] 0.45 to 0.92, p=0.02). IV-treated patients had much higher rates of hypoglycemia (1.6% in SC treated vs 19.6% in IV treated). SC-treated patients had a much lower rate of hypokalemia compared with IV-treated patients (adjusted odds ratio 0.35, 95% CI 0.15 to 0.80, p=0.01). However, the groups had similar LOSs in hospital and rates of anion gap reopening requiring intervention.

Conclusions: These results suggest SC insulin is safe. Although it may take 8.4 hours longer to close the AG with SC insulin, there is less hypoglycemia and hypokalemia and no difference in LOS in hospital.

Objective: Our aim in this work was to examine postpartum diabetes screening and rates in women diagnosed with gestational diabetes mellitus (GDM) using standard vs modified criteria during the COVID-19 pandemic.

Methods: Women with GDM pregnancies between January 1, 2020, and December 31, 2021, in Alberta, Canada, were stratified by the GDM diagnosis criteria and followed for 18 months postpartum diabetes screening. Proportions of prediabetes and diabetes were compared between the standard vs modified GDM criteria groups at 6 and 18 months. Multivariable logistic regression analysis was used to examine differences in prediabetes and diabetes rates between the 2 GDM criteria groups after adjusting for baseline differences.

Results: Among 10,238 individuals with GDM, 780 were diagnosed using the modified criteria and 9,458 were diagnosed using the standard criteria. There was no difference in the proportion of individuals who underwent postpartum screening by 6 months (27.1% vs 28.9%, p=0.29) or by 18 months (43.1% vs 45.3%, p=0.24) among the modified and standard groups, respectively. Diabetes proportions were higher in women diagnosed with GDM using the modified criteria compared with those diagnosed using the standard criteria (27.0% vs 4.2%, p<0.0001; adjusted odds ratio 8.18, 95% confidence interval 5.76 to 11.6). Proportions of prediabetes and diabetes at 18 months were 15.2% and 20.8% (p=0.014) and 29.8% and 6.1% (p<0.0001) for modified and standard groups, respectively.

Conclusions: Regardless of the GDM diagnostic method, postpartum diabetes screening among women with GDM was suboptimal during the COVID-19 pandemic. The modified criteria for GDM identified a group of women who were at higher risk for conversion to diabetes.