Publications by authors named "Paul Poirier"

333 Publications

Glycemic Index, Glycemic Load, and Cardiovascular Disease and Mortality.

N Engl J Med 2021 Feb 24. Epub 2021 Feb 24.

From the Departments of Nutritional Sciences and Medicine, Temerty Faculty of Medicine, University of Toronto (D.J.A.J.), and Li Ka Shing Knowledge Institute, St. Michael's Hospital Toronto (D.J.A.J., K.S.), Toronto, the Population Health Research Institute (M.D., S.I.B., K.T., S.Y.) and Department of Health Research Methods, Evidence, and Impact (A.M., S.I.B.), McMaster University, and McMaster University and Hamilton Health Sciences (S.R.), Hamilton, ON, Faculté de Pharmacie, Université Laval, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec, QC (P.P.), the Division of Cardiac Prevention and Rehabilitation, University of Ottawa Heart Institute, Ottawa (A.P.), and the Department of Medicine, Queen's University, Kingston, ON (K. Yeates) - all in Canada; the Madras Diabetes Research Foundation, Chennai (V.M.), and St. John's Research Institute, St. John's National Academy of Health Sciences, Bangalore (S.S.) - both in India; the International Research Center, Hospital Alemão Oswaldo Cruz, São Paulo (A.A.); Estudios Clínicos Latino América, Rosario, Santa Fe, Argentina (R.D.); the Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, and Sahlgrenska University Hospital, Gothenburg, Sweden (A.R.); Universidad de la Frontera, Temuco, Chile (F.L.); the Masira Research Institute, Medical School, Universidad de Santander, Bucaramanga, Colombia (P.L.-J.); the Medical Research and Biometrics Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, and Peking Union Medical College, Beijing (W.L., X.L.); the Department of Internal Medicine, Faculty of Medicine, Istanbul Medeniyet University, Istanbul, Turkey (A.O.); the Institute for Community and Public Health, Birzeit University, Birzeit, Palestine (R.K.); Advocate Research Institute, Advocate Health Care, Downers Grove, IL (R.K.); Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran (N.M.); the Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia (K.F.A.); the Department of Physiology, University of Zimbabwe College of Health Sciences, Harare (J.C.); Hatta Hospital, Dubai Medical College, Dubai Health Authority, Dubai, United Arab Emirates (A.H.Y.); the Department of Community Health Sciences and Medicine, Aga Khan University, Pakistan (R.I.); Universiti Teknologi MARA, Sungai Buloh, and UCSI University, Selangor (K. Yusoff), and the Department of Community Health, University Kebangsaan Malaysia Medical Center, Kuala Lumpur (N.I.) - both in Malaysia; the Department of Social Medicine, Wroclaw Medical University, Wroclaw, Poland (K.Z.); and the School of Life Sciences, Independent University, Dhaka, Bangladesh (R.Y.).

Background: Most data regarding the association between the glycemic index and cardiovascular disease come from high-income Western populations, with little information from non-Western countries with low or middle incomes. To fill this gap, data are needed from a large, geographically diverse population.

Methods: This analysis includes 137,851 participants between the ages of 35 and 70 years living on five continents, with a median follow-up of 9.5 years. We used country-specific food-frequency questionnaires to determine dietary intake and estimated the glycemic index and glycemic load on the basis of the consumption of seven categories of carbohydrate foods. We calculated hazard ratios using multivariable Cox frailty models. The primary outcome was a composite of a major cardiovascular event (cardiovascular death, nonfatal myocardial infarction, stroke, and heart failure) or death from any cause.

Results: In the study population, 8780 deaths and 8252 major cardiovascular events occurred during the follow-up period. After performing extensive adjustments comparing the lowest and highest glycemic-index quintiles, we found that a diet with a high glycemic index was associated with an increased risk of a major cardiovascular event or death, both among participants with preexisting cardiovascular disease (hazard ratio, 1.51; 95% confidence interval [CI], 1.25 to 1.82) and among those without such disease (hazard ratio, 1.21; 95% CI, 1.11 to 1.34). Among the components of the primary outcome, a high glycemic index was also associated with an increased risk of death from cardiovascular causes. The results with respect to glycemic load were similar to the findings regarding the glycemic index among the participants with cardiovascular disease at baseline, but the association was not significant among those without preexisting cardiovascular disease.

Conclusions: In this study, a diet with a high glycemic index was associated with an increased risk of cardiovascular disease and death. (Funded by the Population Health Research Institute and others.).
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http://dx.doi.org/10.1056/NEJMoa2007123DOI Listing
February 2021

Validity of the Modified Dyspnea Index for the French-Canadian Population.

J Nurs Meas 2021 Feb 16. Epub 2021 Feb 16.

Laval University, Québec, QC, Canada.

Background And Purpose: Multidimensional tools could evaluate the dyspnea of patients with chronic lung disease. The aim was to validate the use of the French-Canadian version of the modified dyspnea index (MDI) among patients with pulmonary arterial hypertension (PAH) and interstitial lung disease (ILD).

Methods: The Spearman test analyzed the convergent validation of the MDI with pulmonary function tests (PFTs), New York Heart Association (NYHA) functional classification, the Modified Borg Scale, the Veterans Specific Activity Questionnaire (VSAQ), physical capacity, physical activity (Godin- Shephard Leisure-Time Physical Activity Questionnaire [GSLTPAQ]), and quality of life (SF-12).

Results: The MDI had a low correlation with PFT and physical activity; a moderate with physical capacity; a high with the physical dimension (SF-12).

Conclusion: The results support the convergent validation of the MDI French-Canadian version with PAH or ILD.
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http://dx.doi.org/10.1891/JNM-D-19-00042DOI Listing
February 2021

Epidemiology and prognostic implications of panic disorder and generalized anxiety disorder in patients with coronary artery disease: rationale and design for a longitudinal cohort study.

BMC Cardiovasc Disord 2021 Jan 12;21(1):26. Epub 2021 Jan 12.

School of Psychology, Université Laval, 2325 rue des Bibliothèques, bureau 1018, Québec, QC, G1V 0A6, Canada.

Background: Anxiety is associated with poorer prognosis in patients with coronary artery disease (CAD). Due to their severity and chronic course, anxiety disorders, particularly generalized anxiety disorder (GAD) and panic disorder (PD), are of considerable interest and clinical importance in this population. This study has two main objectives: (1) to estimate the prevalence and incidence of GAD and PD in patients with CAD over a 2-year period and (2) to prospectively assess the association between PD or GAD and adverse cardiac events, treatment adherence, CAD-related health behaviors, quality of life and psychological distress.

Design/method: This is a longitudinal cohort study in which 3610 participants will be recruited following a CAD-related revascularization procedure. They will complete an interview and questionnaires at 5 time points over a 2-year period (baseline and follow-ups after 3, 6, 12 and 24 months). The presence of PD or GAD, adherence to recommended treatments, health behaviors, quality of life and psychological distress will be assessed at each time point. Data regarding mortality and adverse cardiac events will be collected with a combination of interviews and review of medical files.

Discussion: This study will provide essential information on the prevalence and incidence of anxiety disorders in patients with CAD and on the consequences of these comorbidities. Such data is necessary in order to develop clear clinical recommendations for the management of PD and GAD in patients with CAD. This will help improve the prognosis of patients suffering from both conditions.
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http://dx.doi.org/10.1186/s12872-021-01848-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7801787PMC
January 2021

Acute glycaemic management before, during and after exercise for cardiac rehabilitation participants with diabetes mellitus: a joint statement of the British and Canadian Associations of Cardiovascular Prevention and Rehabilitation, the International Council for Cardiovascular Prevention and Rehabilitation and the British Association of Sport and Exercise Sciences.

Br J Sports Med 2020 Dec 23. Epub 2020 Dec 23.

Cardiology, Institut universitaire de cardiologie et de pneumologie de Québec, Quebec City, Quebec, Canada.

Type 1 (T1) and type 2 (T2) diabetes mellitus (DM) are significant precursors and comorbidities to cardiovascular disease and prevalence of both types is still rising globally. Currently,~25% of participants (and rising) attending cardiac rehabilitation in Europe, North America and Australia have been reported to have DM (>90% have T2DM). While there is some debate over whether improving glycaemic control in those with heart disease can independently improve future cardiovascular health-related outcomes, for the individual patient whose blood glucose is well controlled, it can aid the exercise programme in being more efficacious. Good glycaemic management not only helps to mitigate the risk of acute glycaemic events during exercising, it also aids in achieving the requisite physiological and psycho-social aims of the exercise component of cardiac rehabilitation (CR). These benefits are strongly associated with effective behaviour change, including increased enjoyment, adherence and self-efficacy. It is known that CR participants with DM have lower uptake and adherence rates compared with those without DM. This expert statement provides CR practitioners with nine recommendations aimed to aid in the participant's improved blood glucose control before, during and after exercise so as to prevent the risk of glycaemic events that could mitigate their beneficial participation.
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http://dx.doi.org/10.1136/bjsports-2020-102446DOI Listing
December 2020

L’obésité chez l’adulte : ligne directrice de pratique clinique.

CMAJ 2020 Dec;192(49):E1757-E1775

Départements de médecine (Wharton), endocrinologie et métabolisme (Poddar, Sherifali), médecine familiale (Naji, Tytus), et Health Research Methods, Evidence and Impact (HEI) Canada (Naji), Université McMaster; Clinique Wharton (Wharton, Poddar), Hamilton, Ont.; Départements: de médecine (Lau, Nerenberg) et médecine familiale (Boyling, Henderson, McInnes, Walji, Wicklum), École de médecine Cumming, Université de Calgary; Centre de recherche sur le diabète Julia McFarlane et Institut de cardiologie Libin de l'Alberta (Lau), Calgary, Alta.; Département de médecine familiale (Vallis, Piccinini-Vallis), Université Dalhousie, Halifax, N.-É; Départements de médecine (Sharma, Toth), médecine familiale (Campbell-Scherer, Kemp), agriculture, alimentation et science de la nutrition (Bell, Pereira), éducation physique et loisirs (Boulé), et ergothérapie (Forhan), Université de l'Alberta; Adult Bariatric Specialty Clinic (Sharma), Hôpital Royal Alexandra; Obésité Canada (Sharma, Patton, Ramos Salas), Edmonton, Alta.; Département de chirurgie (Biertho), Université Laval, Québec, Que.; École des sciences de l'activité physique (Adamo, Prud'homme), Université d'Ottawa, Ottawa, Ont.; Département de santé, kinésiologie et physiologie appliquée (Alberga), Université Concordia, Montréal, Que.; Centre d'Excellence en soins bariatriques(Brown), Hôpital d'Ottawa, Ottawa, Ont.; Départements de médecine familiale (Calam) et endocrinologie (Manjoo), Université de la Colombie-Britannique; Programme de résidence en pratique familiale de la UBC (Calam) et chaire de recherche en prévention des maladies cardiovasculaires Pfizer/Fondation des maladies du cœur et de l'AVC (Lear), Hôpital St. Paul, Vancouver, C.-B.; consultant en nutrition (Clarke), Hamilton, Ont.; Indigenous Health Dialogue (Crowshoe), Health Sciences Centre, Université de Calgary, Calgary, Alta.; Main East Medical Associates (Divalentino), Hamilton, Ont.; Bariatric Medical Institute (Freedhoff), Ottawa, Ont.; Département de médecine familiale (Freedhoff) et Division d'endocrinologie et métabolisme (Shiau), Département de médecine, Université d'Ottawa, Ottawa, Ont.; Herbert Wertheim School of medicine (Gagner), Florida International University, Miami, FL; Hôpital du Sacré-Cœur de Montréal (Gagner), Montréal, Que.; Humber River Hospital (Glazer), Toronto, Ont.; Division d'endocrinologie et métabolisme (Glazer), Université Queen's, Kingston, Ont.; Départements de médecine interne (Glazer), psychiatrie (Hawa, Sockalingam), médecine familiale et communautaire (Macklin), et des sciences de la nutrition (Sievenpiper), Université de Toronto, Toronto, Ont.; Services de santé de l'Alberta (Grand, Hung, Johnson-Stoklossa), Edmonton, Alta.; Départements de médecine familiale, et d'études sur les sciences et les politiques de santé publique (Green), Université Queen's; Centre des sciences de la santé de Kingston (Green); Providence Care Hospital (Green), Kingston, Ont.; Centre for Addiction and Mental Health (Hahn, Sockalingam); Réseau universitaire de santé (Hawa, Sockalingam), Toronto, Ont.; Division de chirurgie générale (Hong), Université McMaster, Hamilton, Ont.; Département de médecine familiale et de santé biocomportementale (Jacklin), Faculté de médecine de l'Université du Minnesota, campus Duluth, Duluth, Minn.; Faculté de kinésiologie et d'études sur la santé (Janssen), Université Queen's, Kingston, Ont.; École de santé et performance humaine (Kirk), Université Dalhousie, Halifax, N.-É; École de kinésiologie et de sciences de la santé (Wharton, Kuk), Université York, Toronto, Ont.; Division d'endocrinologie (Langlois), Université de Sherbrooke; Centre intégré universitaire de santé et de services sociaux de l'Estrie - Centre hospitalier universitaire de Sherbrooke (Langlois), Sherbrooke, Qc; École de kinésiologie (Lear), Université Simon Fraser, Vancouver, C.-B.; Medcan Clinic ( Macklin), Toronto, Ont.; Cardiometabolic Collaborative Clinic (Manjoo), Régie régionale de la santé de Vancouver, Victoria, C.-B.; Institut universitaire de cardiologie et de pneumologie de Québec (Morin, Poirier), Université Laval, Québec, Qc; Centre médical Foothills (Nerenberg); C-ENDO Diabetes & Endocrinology Clinic (Pedersen), Calgary, Alta.; LMC Diabetes and Endocrinology (Poddar), Toronto, Ont.; Département de médecine (Rueda-Clausen), Université de la Saskatchewan; Hôpital général de Regina (Rueda-Clausen), Regina, Sask.; Psychologie de l'éducation (Russell-Mayhew), Faculté d'éducation Werklund, Université de Calgary, Calgary, Alta.; LEAF Weight Management Clinic (Shiau), Ottawa, Ont.; Chaire de recherche en santé interprofessionnelle de l'Institut de recherche sur la santé des populations Heather M Arthur/Hamilton Health Sciences, Faculté des sciences infirmières (Sherifali), Université McMaster, Hamilton, Ont.; Division d'endocrinologie et métabolisme (Sievenpiper), Hôpital St. Michael, Toronto, Ont.; Département de psychiatrie (Taylor), Université de Calgary, Calgary, Alta.; École de pharmacie (Twells), Université Memorial, St. John's, T.-N.-L.; Steelcity Medical Clinic (Tytus), Hamilton, Ont.; Calgary Weight Management Centre (Walji), Calgary, Alta.; École de santé des populations et de santé publique (Walker), Université de la Colombie-Britannique; Centre for Excellence in Indigenous Health (Walker), Université de la Colombie-Britannique, Vancouver, C.-B.; Institut de santé publique O'Brien (Wicklum), Université de Calgary, Calgary, Alta.

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http://dx.doi.org/10.1503/cmaj.191707-fDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7721377PMC
December 2020

COVID-19-Myocarditis and Return to Play: Reflections and Recommendations From a Canadian Working Group.

Can J Cardiol 2020 Nov 26. Epub 2020 Nov 26.

University of Toronto, Toronto Ontario, Canada.

The COVID-19-related pandemic has resulted in profound health, financial, and societal impacts. Organized sporting events, from recreational to the Olympic level, have been cancelled to both mitigate the spread of COVID-19 and protect athletes and highly active individuals from potential acute and long-term infection-associated harms. COVID-19 infection has been associated with increased cardiac morbidity and mortality. Myocarditis and late gadolinium enhancement as a result of COVID-19 infection have been confirmed. Correspondingly, myocarditis has been implicated in sudden cardiac death of athletes. A pragmatic approach is required to guide those who care for athletes and highly active persons with COVID-19 infection. Members of the Community and Athletic Cardiovascular Health Network (CATCHNet) and the writing group for the Canadian Cardiovascular Society/Canadian Heart Rhythm Society Joint Position Statement on the Cardiovascular Screening of Competitive Athletes recommend that highly active persons with suspected or confirmed COVID-19 infection refrain from exercise for 7 days after resolution of viral symptoms before gradual return to exercise. We do not recommend routine troponin testing, resting 12-lead electrocardiography, echocardiography, or cardiac magnetic resonance imaging before return to play. However, medical assessment including history and physical examination with consideration of resting electrocardiography and troponin can be considered in the athlete manifesting new active cardiac symptoms or a marked reduction in fitness. If concerning abnormalities are encountered at the initial medical assessment, then referral to a cardiologist who cares for athletes is recommended.
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http://dx.doi.org/10.1016/j.cjca.2020.11.007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7688421PMC
November 2020

Effects of bariatric surgery on lipid-lipoprotein profile.

Metabolism 2021 02 25;115:154441. Epub 2020 Nov 25.

Institut universitaire de cardiologie et de pneumologie de Québec-Université Laval, Quebec, Canada; Faculty of Pharmacy, Laval University, Quebec, Canada. Electronic address:

Most patients with severe obesity will present some lipid-lipoprotein abnormalities. The atherogenic dyslipidemia associated with severe obesity is characterized by elevated fasting and postprandial triglyceride levels, low high-density lipoprotein cholesterol concentrations, and increased proportion of small and dense low-density lipoproteins. Bariatric surgery has been proven safe and successful in terms of long-term weight loss and improvement in obesity co-existing metabolic conditions including lipid-lipoprotein abnormalities. Nevertheless, bariatric surgery procedures are not all equivalent. We conducted a comprehensive critical analysis of the literature related to severe obesity, bariatric surgery and lipid-lipoprotein metabolism/profile. In this review, we described the metabolic impacts of different bariatric surgery procedures on the lipid-lipoprotein profile, and the mechanisms linking bariatric surgery and dyslipidemia remission based on recent epidemiological, clinical and preclinical studies. Further mechanistic studies are essential to assess the potential of bariatric/metabolic surgery in the management of lipid-lipoprotein abnormalities associated with severe obesity. Understanding the beneficial effects of various bariatric surgery procedures on the lipid-lipoprotein metabolism and profile may result in a wider acceptance of this strategy as a long-term metabolic treatment of lipid-lipoprotein abnormalities in severe obesity and help clinician to develop an individualized and optimal approach in the management of dyslipidemia associated with severe obesity. BRIEF SUMMARY: Abnormal lipid-lipoprotein profile is frequent in patients with severe obesity. Significant improvements in lipid-lipoprotein profile following bariatric surgery occur early in the postoperative period, prior to weight loss, and persists throughout the follow-up. The mechanisms that facilitate the remission of dyslipidemia after bariatric surgery, may involve positive effects on adipose tissue distribution/function, insulin sensitivity, liver fat content/function and lipid-lipoprotein metabolism.
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http://dx.doi.org/10.1016/j.metabol.2020.154441DOI Listing
February 2021

Secondary prevention after CABG: do new agents change the paradigm?

Curr Opin Cardiol 2020 11;35(6):664-672

Institut Universitaire de Cardiologie et de Pneumologie de Québec-Université Laval.

Purpose Of Review: Coronary artery bypass graft (CABG) surgery remains the gold-standard treatment for multivessel and left main coronary artery disease. Despite significant improvement in cardiovascular outcomes, patients undergoing CABG remain at risk for recurrent adverse ischemic events and other cardiovascular outcomes (coronary revascularisation, stroke, cardiac death, etc.). The purpose of this review is to summarize the most recent evidence in pharmacological preventive therapies addressing the residual cardiovascular risk in patients who have undergone CABG.

Recent Findings: Novel cardiovascular pharmacological preventive strategies targeting inflammatory, metabolic and prothrombotic (antiplatelet and anticoagulation) pathways have been recently assessed, with promising results for secondary prevention after CABG.

Summary: Secondary prevention is an essential part of postoperative care after CABG. Novel lipid-lowering and glucose-controlling agents suggest a strong and consistent benefit on native coronary artery disease and overall cardiovascular outcomes. The role and the choice of enhanced antiplatelet/anticoagulation/lipid/glucose-modulating therapies following CABG should be better defined and deserves further investigation. Additional studies are required to identify new therapeutic target addressing the specific multifactorial nature of the graft CV disease and identifying the best preventive strategies for long-term graft patency.
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http://dx.doi.org/10.1097/HCO.0000000000000783DOI Listing
November 2020

Physiological factors characterizing heat-vulnerable older adults: A narrative review.

Environ Int 2020 11 9;144:105909. Epub 2020 Sep 9.

Human and Environmental Physiology Research Unit, School of Human Kinetics, University of Ottawa, Ottawa, Ontario, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada. Electronic address:

More frequent and intense periods of extreme heat (heatwaves) represent the most direct challenge to human health posed by climate change. Older adults are particularly vulnerable, especially those with common age-associated chronic health conditions (e.g., cardiovascular disease, hypertension, obesity, type 2 diabetes, chronic kidney disease). In parallel, the global population is aging and age-associated disease rates are on the rise. Impairments in the physiological responses tasked with maintaining homeostasis during heat exposure have long been thought to contribute to increased risk of health disorders in older adults during heatwaves. As such, a comprehensive overview of the provisional links between age-related physiological dysfunction and elevated risk of heat-related injury in older adults would be of great value to healthcare officials and policy makers concerned with protecting heat-vulnerable sectors of the population from the adverse health impacts of heatwaves. In this narrative review, we therefore summarize our current understanding of the physiological mechanisms by which aging impairs the regulation of body temperature, hemodynamic stability and hydration status. We then examine how these impairments may contribute to acute pathophysiological events common during heatwaves (e.g., heatstroke, major adverse cardiovascular events, acute kidney injury) and discuss how age-associated chronic health conditions may exacerbate those impairments. Finally, we briefly consider the importance of physiological research in the development of climate-health programs aimed at protecting heat-vulnerable individuals.
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http://dx.doi.org/10.1016/j.envint.2020.105909DOI Listing
November 2020

White Rice Intake and Incident Diabetes: A Study of 132,373 Participants in 21 Countries.

Diabetes Care 2020 Nov 1;43(11):2643-2650. Epub 2020 Sep 1.

Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Canada.

Objective: Previous prospective studies on the association of white rice intake with incident diabetes have shown contradictory results but were conducted in single countries and predominantly in Asia. We report on the association of white rice with risk of diabetes in the multinational Prospective Urban Rural Epidemiology (PURE) study.

Research Design And Methods: Data on 132,373 individuals aged 35-70 years from 21 countries were analyzed. White rice consumption (cooked) was categorized as <150, ≥150 to <300, ≥300 to <450, and ≥450 g/day, based on one cup of cooked rice = 150 g. The primary outcome was incident diabetes. Hazard ratios (HRs) were calculated using a multivariable Cox frailty model.

Results: During a mean follow-up period of 9.5 years, 6,129 individuals without baseline diabetes developed incident diabetes. In the overall cohort, higher intake of white rice (≥450 g/day compared with <150 g/day) was associated with increased risk of diabetes (HR 1.20; 95% CI 1.02-1.40; for trend = 0.003). However, the highest risk was seen in South Asia (HR 1.61; 95% CI 1.13-2.30; for trend = 0.02), followed by other regions of the world (which included South East Asia, Middle East, South America, North America, Europe, and Africa) (HR 1.41; 95% CI 1.08-1.86; for trend = 0.01), while in China there was no significant association (HR 1.04; 95% CI 0.77-1.40; for trend = 0.38).

Conclusions: Higher consumption of white rice is associated with an increased risk of incident diabetes with the strongest association being observed in South Asia, while in other regions, a modest, nonsignificant association was seen.
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http://dx.doi.org/10.2337/dc19-2335DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7576435PMC
November 2020

Clinical Impact of Weight-Loss Pharmacotherapy in Patients with Atherosclerotic Cardiovascular Disease.

Am J Cardiovasc Drugs 2020 Aug 19. Epub 2020 Aug 19.

Quebec Heart and Lung Institute, 2725, Chemin Ste Foy, Quebec, QC, G1V 4G5, Canada.

Obesity is associated with the development and progression of multiple cardiovascular risk factors, such as hypertension, dyslipidemia, and type 2 diabetes mellitus, and is an important contributor to the global burden of atherosclerotic cardiovascular disease (CVD). Guidelines suggest that clinicians provide lifestyle counseling and promote lifestyle modifications before considering weight-loss surgery. However, despite lifestyle modifications and increased physical activity, most patients with obesity will not lose significant weight or will experience weight regain. Weight-loss pharmacotherapy added to lifestyle modification has long been perceived as a bridge between lifestyle modifications alone and weight-loss surgery. However, since its inception, weight-loss pharmacotherapy has been plagued by variable efficacy and concern about cardiovascular safety. Following requirements from regulatory authorities, efficacy and cardiovascular safety trials have been conducted for the currently available weight-loss pharmacotherapeutic agents. Overall, these trials have shown that weight-loss pharmacotherapy is only modestly efficient for the inducement of weight loss. Recent trials have also demonstrated the cardiovascular safety of some of these agents. We review these trials with a focus on the clinical impact of these weight-loss pharmacotherapeutic agents in patients with atherosclerotic CVD.
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http://dx.doi.org/10.1007/s40256-020-00428-8DOI Listing
August 2020

Obesity in adults: a clinical practice guideline.

CMAJ 2020 Aug;192(31):E875-E891

Departments of Medicine (Wharton), Endocrinology and Metabolism (Poddar, Sherifali), Family Medicine (Naji, Tytus) and Health Research Methods, Evidence and Impact Canada (Naji), McMaster University, Hamilton, Ont; The Wharton Medical Clinic (Wharton, Poddar), Hamilton, Ont.; Departments of Medicine (Lau, Nerenberg) and Family Medicine (Boyling, Henderson, McInnes, Walji, Wicklum), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Julia McFarlane Diabetes Research Centre and Libin Cardiovascular Institute of Alberta (Lau), Calgary, Alta.; Department of Family Medicine (Vallis, Piccinini-Vallis), Dalhousie University, Halifax, NS; Departments of Medicine (Sharma, Toth), Family Medicine (Campbell-Scherer, Kemp), Agricultural, Food and Nutritional Science (Bell, Pereira), Physical Education and Recreation (Boulé), and Occupational Therapy (Forhan), University of Alberta, Edmonton, Alta.; Adult Bariatric Specialty Clinic (Sharma), Royal Alexandra Hospital, Edmonton, Alta.; Obesity Canada (Sharma, Patton, Ramos Salas), Edmonton, Alta.; Department of Surgery (Biertho), Laval University, Quebec, Que.; School of Human Kinetics (Adamo, Prud'homme), University of Ottawa, Ottawa, Ont.; Department of Health, Kinesiology & Applied Physiology (Alberga), Concordia University, Montréal, Que.; Bariatric Centre of Excellence (Brown), The Ottawa Hospital, Ottawa, Ont.; Departments of Family Practice (Calam) and Endocrinology (Manjoo), University of British Columbia, Vancouver, BC; UBC Family Practice Residency Program (Calam) and Pfizer/Heart and Stroke Foundation Chair in Cardiovascular Prevention Research (Lear), St. Paul's Hospital, Vancouver, BC; nutrition consultant (Clarke), Hamilton, Ont.; Indigenous Health Dialogue (Crowshoe), Health Sciences Centre, University of Calgary, Calgary, Alta.; Main East Medical Associates (Divalentino), Hamilton, Ont.; Bariatric Medical Institute (Freedhoff), Ottawa, Ont.; Department of Family Medicine (Freedhoff) and Division of Endocrinology and Metabolism (Shiau), Department of Medicine, University of Ottawa, Ottawa, Ont.; Herbert Wertheim School of Medicine (Gagner), Florida International University, Miami, Fla.; Hôpital du Sacre Coeur de Montréal (Gagner), Montréal, Que.; Humber River Hospital (Glazer), Toronto, Ont.; Division of Endocrinology and Metabolism (Glazer), Queen's University, Kingston, Ont.; Departments of Internal Medicine (Glazer), Psychiatry (Hawa, Sockalingam), Family and Community Medicine (Macklin) and Nutritional Sciences (Sievenpiper), University of Toronto, Toronto, Ont.; Alberta Health Services (Grand, Hung, Johnson-Stoklossa), Edmonton, Alta.; Departments of Family Medicine and Public Health Sciences and Policy Studies (Green), Queen's University, Kingston, Ont.; Kingston Health Sciences Centre (Green), Kingston, Ont.; Providence Care Hospital (Green), Kingston, Ont.; Centre for Addiction and Mental Health (Hahn, Sockalingam), Toronto, Ont.; University Health Network (Hawa, Sockalingam), Toronto, Ont.; Division of General Surgery (Hong), McMaster University, Hamilton, Ont.; Department of Family Medicine and Biobehavioral Health (Jacklin), University of Minnesota Medical School Duluth Campus, Duluth, Minn.; School of Kinesiology and Health Studies (Janssen), Queen's University, Kingston, Ont.; School of Health and Human Performance (Kirk), Dalhousie University, Halifax, NS; School of Kinesiology and Health Science (Wharton, Kuk), York University, Toronto, Ont.; Division of Endocrinology (Langlois), Université de Sherbrooke, Sherbrooke, Que.; Centre intégré universitaire de santé et de services sociaux de l'Estrie - Centre hospitalier universitaire de Sherbrooke (Langlois), Sherbrooke, Que.; School of Kinesiology (Lear), Simon Fraser University, Vancouver, BC; Medcan Clinic (Macklin), Toronto, Ont.; Cardiometabolic Collaborative Clinic (Manjoo), Vancouver Island Health Authority, Victoria, BC; Institut universitaire de cardiologie et de pneumologie de Québec (Morin, Poirier), Laval University, Québec, Que.; Foothills Medical Centre (Nerenberg), Calgary, Alta.; C-ENDO Diabetes & Endocrinology Clinic (Pedersen), Calgary, Alta.; LMC Diabetes and Endocrinology ( Poddar), Toronto, Ont.; Department of Medicine (Rueda-Clausen), University of Saskatchewan, Regina, Sask.; Regina General Hospital (Rueda-Clausen), Regina, Sask.; Education Psychology (Russell-Mayhew), Werklund School of Education, University of Calgary, Calgary, Alta.; LEAF Weight Management Clinic (Shiau), Ottawa, Ont.; Heather M. Arthur Population Health Research Institute/Hamilton Health Sciences Chair in Interprofessional Health Research, School of Nursing (Sherifali), McMaster University, Hamilton, Ont.; Division of Endocrinology & Metabolism (Sievenpiper), St. Michael's Hospital, Toronto, Ont.; Department of Psychiatry (Taylor), University of Calgary, Calgary, Alta.; School of Pharmacy (Twells), Memorial University, St. John's, NL; Steelcity Medical Clinic (Tytus), Hamilton, Ont.; Calgary Weight Management Centre (Walji), Calgary, Alta.; School of Population and Public Health (Walker), University of British Columbia, Vancouver, BC; Centre for Excellence in Indigenous Health (Walker), University of British Columbia, Vancouver, BC.; O'Brien Institute of Public Health (Wicklum), University of Calgary, Calgary, Alta.

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http://dx.doi.org/10.1503/cmaj.191707DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7828878PMC
August 2020

Determinants of Cardiorespiratory Fitness After Bariatric Surgery: Insights From a Randomised Controlled Trial of a Supervised Training Program.

Can J Cardiol 2021 Feb 30;37(2):251-259. Epub 2020 Mar 30.

Québec Heart and Lung Institute, Laval University, Québec, Québec, Canada; Faculty of Pharmacy, Laval University, Québec, Québec, Canada. Electronic address:

Background: Severely obese patients have decreased cardiorespiratory fitness (CRF) and poor functional capacity. Bariatric surgery-induced weight loss improves CRF, but the determinants of this improvement are not well known. We aimed to assess the determinants of CRF before and after bariatric surgery and the impact of an exercise training program on CRF after bariatric surgery.

Methods: Fifty-eight severely obese patients (46.1 ± 6.1 kg/m, 78% women) were randomly assigned to either an exercise group (n = 39) or usual care (n = 19). Exercise training was conducted from the 3rd to the 6th months after surgery. Anthropometric measurements, abdominal and mid-thigh computed tomographic scans, resting echocardiography, and maximal cardiopulmonary exercise testing was performed before bariatric surgery and 3 and 6 months after surgery.

Results: Weight, fat mass, and fat-free mass were reduced significantly at 3 and 6 months, without any additive impact of exercise training in the exercise group. From 3 to 6 months, peak aerobic power (V̇O) increased significantly (P < 0.0001) in both groups but more importantly in the exercise group (exercise group: from 18.6 ± 4.2 to 23.2 ± 5.7 mL/kg/min; control group: from 17.4 ± 2.3 to 19.7 ± 2.4 mL/kg/min; P value, group × time = 0.01). In the exercise group, determinants of absolute V̇O (L/min) were peak exercise ventilation, oxygen pulse, and heart rate reserve (r = 0.92; P < 0.0001), whereas determinants of V̇O indexed to body mass (mL/kg/min) were peak exercise ventilation and early-to-late filling velocity ratio (r = 0.70; P < 0.0001).

Conclusions: A 12-week supervised training program has an additive benefit on cardiorespiratory fitness for patients who undergo bariatric surgery.
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http://dx.doi.org/10.1016/j.cjca.2020.03.032DOI Listing
February 2021

Long-Term Outcomes and Weight Loss After Bariatric Embolization of the Left Gastric Artery.

J Invasive Cardiol 2020 Aug;32(8):310-314

Quebec Heart-Lung Institute, 2725, Chemin Ste Foy, Quebec (Quebec) G1V 4G5, Canada.

Objectives: Bariatric embolization of the left gastric artery is a promising technique to induce weight loss in obese patients. We aimed to assess long-term effects.

Methods: Patients with severe obesity were recruited to undergo left gastric artery embolization via transradial access. We report clinical outcomes and weight loss up to 2 years.

Results: We completed 7 procedures successfully in 7 men with severe obesity after diagnostic coronary angiography. Median weight was 160 kg (interquartile range, 140.0-180.0 kg) and body mass index was 49.4 kg/m² (interquartile range, 43.2-61.7 kg/m²). Acutely, no adverse events were reported other than mild epigastric pain, which subsided within 24 hours with proton pump inhibitors. No delayed gastrointestinal complications were reported up to 2 years after index procedure. One patient died of pulmonary embolism 18 months after the procedure. One patient underwent a second embolization procedure after it was shown that the left gastric artery was patent 18 months after the initial procedure. Compared with baseline in the 6 surviving patients, overall weight loss was 7.7% (range, 3.2%-14.1%).

Conclusions: Bariatric embolization of the left gastric artery may induce weight loss, which appears sustained up to 2 years. Spontaneous recanalization of the left gastric artery may pave the way for repeat procedures and other interventions. Further research is necessary to define the benefits, safety, and indications for this technique.
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August 2020

Visceral adiposity and liver fat as mediators of the association between cardiorespiratory fitness and plasma glucose-insulin homeostasis.

Am J Physiol Endocrinol Metab 2020 09 27;319(3):E548-E556. Epub 2020 Jul 27.

Centre de recherche de l'Institut universitaire de cardiologie et de pneumologie de Québec - Université Laval, Québec City, Québec, Canada.

Cardiorespiratory fitness (CRF) is positively associated with insulin sensitivity, whereas excessive levels of visceral adipose tissue (AT) and liver fat (LF) are both associated with insulin resistance and impaired plasma glucose-insulin homeostasis. To what extent levels of visceral AT and LF content contribute to the relationship between CRF and indices of plasma glucose-insulin homeostasis is uncertain. Our objective was to explore the interactions among CRF, visceral AT, and LF with glucose tolerance/insulin levels in asymptomatic and apparently healthy individuals. CRF was measured in 135 women and 177 men with a maximal treadmill graded exercise test. Indices of plasma glucose-insulin homeostasis were derived from a 3-h oral glucose tolerance test (OGTT) performed in the morning after a 12-h fast. Visceral AT levels and LF content were measured using magnetic resonance imaging and spectroscopy. For any given CRF level, women presented significantly lower visceral AT and LF than men as well as lower homeostasis model assessment of insulin resistance (HOMA-IR) and plasma glucose-insulin levels during the OGTT compared with men. In both sexes, there were significant negative correlations between CRF and HOMA-IR as well as glucose and insulin levels measured during the OGTT. Both glucose and insulin levels during the OGTT correlated positively with visceral AT and LF. In women and men, being in the top CRF tertile was associated with low levels of visceral AT and LF. Multivariable linear regression analyses suggested that visceral AT and LF were plausible mediators of the association between CRF and indices of plasma glucose-insulin homeostasis.
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http://dx.doi.org/10.1152/ajpendo.00251.2020DOI Listing
September 2020

Acute and Chronic Impact of Biliopancreatic Diversion with Duodenal Switch Surgery on Plasma Lipoprotein(a) Levels in Patients with Severe Obesity.

Obes Surg 2020 Oct 14;30(10):3714-3720. Epub 2020 Jul 14.

Centre de Recherche de l'Institut Universitaire de Cardiologie et de Pneumologie de Québec, Y-3601, Pavillon Marguerite D'Youville, 2725 chemin Ste-Foy, Québec, QC, G1V 4G5, Canada.

Background: Elevated lipoprotein(a) (Lp(a)) level is an independent risk factor for cardiovascular diseases. Lifestyle intervention studies targeting weight loss revealed little to no significant changes in Lp(a) levels. The impact of interventions that induce substantial weight loss, such as bariatric surgery, on Lp(a) levels is currently unclear.

Objective: To determine the acute and long-term impact of bariatric surgery on Lp(a) levels in patients with severe obesity.

Methods: Sixty-nine patients with severe obesity underwent biliopancreatic diversion with duodenal switch (BPD-DS) surgery. The lipid profile was evaluated and Lp(a) levels were measured before surgery and at 6 and 12 months after BPD-DS surgery.

Results: Median Lp(a) levels at baseline were 11.1 (4.1-41.6) nmol/L. Six months and 12 months after the BDP-DS surgery, we observed an improvement of lipid profile. At 6 months, we observed a 13% decrease in Lp(a) levels (9.7 (2.9-25.6) nmol/L, p < 0.0001) but this decrease was not sustained at 12 months (11.1 (3.9-32.8) nmol/L, p = 0.8). When the patients were separated into tertiles according to Lp(a) levels at baseline, we observed that the Lp(a) reduction at 12 months after BPD-DS surgery remained significant but modest in patients of the top Lp(a) tertile.

Conclusion: Our results suggest that BPD-DS surgery modestly reduces Lp(a) levels in the short term (6 months) in patients with severe obesity but this improvement is sustained over time only in patients with higher Lp(a) levels.
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http://dx.doi.org/10.1007/s11695-020-04450-2DOI Listing
October 2020

Associations of outdoor fine particulate air pollution and cardiovascular disease in 157 436 individuals from 21 high-income, middle-income, and low-income countries (PURE): a prospective cohort study.

Lancet Planet Health 2020 06;4(6):e235-e245

School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada.

Background: Most studies of long-term exposure to outdoor fine particulate matter (PM) and cardiovascular disease are from high-income countries with relatively low PM concentrations. It is unclear whether risks are similar in low-income and middle-income countries (LMICs) and how outdoor PM contributes to the global burden of cardiovascular disease. In our analysis of the Prospective Urban and Rural Epidemiology (PURE) study, we aimed to investigate the association between long-term exposure to PM concentrations and cardiovascular disease in a large cohort of adults from 21 high-income, middle-income, and low-income countries.

Methods: In this multinational, prospective cohort study, we studied 157 436 adults aged 35-70 years who were enrolled in the PURE study in countries with ambient PM estimates, for whom follow-up data were available. Cox proportional hazard frailty models were used to estimate the associations between long-term mean community outdoor PM concentrations and cardiovascular disease events (fatal and non-fatal), cardiovascular disease mortality, and other non-accidental mortality.

Findings: Between Jan 1, 2003, and July 14, 2018, 157 436 adults from 747 communities in 21 high-income, middle-income, and low-income countries were enrolled and followed up, of whom 140 020 participants resided in LMICs. During a median follow-up period of 9·3 years (IQR 7·8-10·8; corresponding to 1·4 million person-years), we documented 9996 non-accidental deaths, of which 3219 were attributed to cardiovascular disease. 9152 (5·8%) of 157 436 participants had cardiovascular disease events (fatal and non-fatal incident cardiovascular disease), including 4083 myocardial infarctions and 4139 strokes. Mean 3-year PM at cohort baseline was 47·5 μg/m (range 6-140). In models adjusted for individual, household, and geographical factors, a 10 μg/m increase in PM was associated with increased risk for cardiovascular disease events (hazard ratio 1·05 [95% CI 1·03-1·07]), myocardial infarction (1·03 [1·00-1·05]), stroke (1·07 [1·04-1·10]), and cardiovascular disease mortality (1·03 [1·00-1·05]). Results were similar for LMICs and communities with high PM concentrations (>35 μg/m). The population attributable fraction for PM in the PURE cohort was 13·9% (95% CI 8·8-18·6) for cardiovascular disease events, 8·4% (0·0-15·4) for myocardial infarction, 19·6% (13·0-25·8) for stroke, and 8·3% (0·0-15·2) for cardiovascular disease mortality. We identified no consistent associations between PM and risk for non-cardiovascular disease deaths.

Interpretation: Long-term outdoor PM concentrations were associated with increased risks of cardiovascular disease in adults aged 35-70 years. Air pollution is an important global risk factor for cardiovascular disease and a need exists to reduce air pollution concentrations, especially in LMICs, where air pollution levels are highest.

Funding: Full funding sources are listed at the end of the paper (see Acknowledgments).
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http://dx.doi.org/10.1016/S2542-5196(20)30103-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7457447PMC
June 2020

Variations between women and men in risk factors, treatments, cardiovascular disease incidence, and death in 27 high-income, middle-income, and low-income countries (PURE): a prospective cohort study.

Lancet 2020 07 20;396(10244):97-109. Epub 2020 May 20.

Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada.

Background: Some studies, mainly from high-income countries (HICs), report that women receive less care (investigations and treatments) for cardiovascular disease than do men and might have a higher risk of death. However, very few studies systematically report risk factors, use of primary or secondary prevention medications, incidence of cardiovascular disease, or death in populations drawn from the community. Given that most cardiovascular disease occurs in low-income and middle-income countries (LMICs), there is a need for comprehensive information comparing treatments and outcomes between women and men in HICs, middle-income countries, and low-income countries from community-based population studies.

Methods: In the Prospective Urban Rural Epidemiological study (PURE), individuals aged 35-70 years from urban and rural communities in 27 countries were considered for inclusion. We recorded information on participants' sociodemographic characteristics, risk factors, medication use, cardiac investigations, and interventions. 168 490 participants who enrolled in the first two of the three phases of PURE were followed up prospectively for incident cardiovascular disease and death.

Findings: From Jan 6, 2005 to May 6, 2019, 202 072 individuals were recruited to the study. The mean age of women included in the study was 50·8 (SD 9·9) years compared with 51·7 (10) years for men. Participants were followed up for a median of 9·5 (IQR 8·5-10·9) years. Women had a lower cardiovascular disease risk factor burden using two different risk scores (INTERHEART and Framingham). Primary prevention strategies, such as adoption of several healthy lifestyle behaviours and use of proven medicines, were more frequent in women than men. Incidence of cardiovascular disease (4·1 [95% CI 4·0-4·2] for women vs 6·4 [6·2-6·6] for men per 1000 person-years; adjusted hazard ratio [aHR] 0·75 [95% CI 0·72-0·79]) and all-cause death (4·5 [95% CI 4·4-4·7] for women vs 7·4 [7·2-7·7] for men per 1000 person-years; aHR 0·62 [95% CI 0·60-0·65]) were also lower in women. By contrast, secondary prevention treatments, cardiac investigations, and coronary revascularisation were less frequent in women than men with coronary artery disease in all groups of countries. Despite this, women had lower risk of recurrent cardiovascular disease events (20·0 [95% CI 18·2-21·7] versus 27·7 [95% CI 25·6-29·8] per 1000 person-years in men, adjusted hazard ratio 0·73 [95% CI 0·64-0·83]) and women had lower 30-day mortality after a new cardiovascular disease event compared with men (22% in women versus 28% in men; p<0·0001). Differences between women and men in treatments and outcomes were more marked in LMICs with little differences in HICs in those with or without previous cardiovascular disease.

Interpretation: Treatments for cardiovascular disease are more common in women than men in primary prevention, but the reverse is seen in secondary prevention. However, consistently better outcomes are observed in women than in men, both in those with and without previous cardiovascular disease. Improving cardiovascular disease prevention and treatment, especially in LMICs, should be vigorously pursued in both women and men.

Funding: Full funding sources are listed at the end of the paper (see Acknowledgments).
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http://dx.doi.org/10.1016/S0140-6736(20)30543-2DOI Listing
July 2020

Association of nut intake with risk factors, cardiovascular disease, and mortality in 16 countries from 5 continents: analysis from the Prospective Urban and Rural Epidemiology (PURE) study.

Am J Clin Nutr 2020 07;112(1):208-219

Population Health Research Institute, Hamilton, ON, Canada.

Background: The association of nuts with cardiovascular disease and deaths has been investigated mostly in Europe, the USA, and East Asia, with few data available from other regions of the world or from low- and middle-income countries.

Objective: To assess the association of nuts with mortality and cardiovascular disease (CVD).

Methods: The Prospective Urban Rural Epidemiology study is a large multinational prospective cohort study of adults aged 35-70 y from 16 low-, middle-, and high-income countries on 5 continents. Nut intake (tree nuts and ground nuts) was measured at the baseline visit, using country-specific validated FFQs. The primary outcome was a composite of mortality or major cardiovascular event [nonfatal myocardial infarction (MI), stroke, or heart failure].

Results: We followed 124,329 participants (age = 50.7 y, SD = 10.2; 41.5% male) for a median of 9.5 y. We recorded 10,928 composite events [deaths (n = 8,662) or major cardiovascular events (n = 5,979)]. Higher nut intake (>120 g per wk compared with <30 g per mo) was associated with a lower risk of the primary composite outcome of mortality or major cardiovascular event [multivariate HR (mvHR): 0.88; 95% CI: 0.80, 0.96; P-trend = 0.0048]. Significant reductions in total (mvHR: 0.77; 95% CI: 0.69, 0.87; P-trend <0.0001), cardiovascular (mvHR: 0.72; 95% CI: 0.56, 0.92; P-trend = 0.048), and noncardiovascular mortality (mvHR: 0.82; 95% CI: 0.70, 0.96; P-trend = 0.0046) with a trend to reduced cancer mortality (mvHR: 0.81; 95% CI: 0.65, 1.00; P-trend = 0.081) were observed. No significant associations of nuts were seen with major CVD (mvHR: 0.91; 95% CI: 0.81, 1.02; P-trend = 0.14), stroke (mvHR: 0.98; 95% CI: 0.84, 1.14; P-trend = 0.76), or MI (mvHR: 0.86; 95% CI: 0.72, 1.04; P-trend = 0.29).

Conclusions: Higher nut intake was associated with lower mortality risk from both cardiovascular and noncardiovascular causes in low-, middle-, and high-income countries.
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http://dx.doi.org/10.1093/ajcn/nqaa108DOI Listing
July 2020

Association of dairy consumption with metabolic syndrome, hypertension and diabetes in 147 812 individuals from 21 countries.

BMJ Open Diabetes Res Care 2020 04;8(1)

Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada.

Objective: Our aims were to assess the association of dairy intake with prevalence of metabolic syndrome (MetS) (cross-sectionally) and with incident hypertension and incident diabetes (prospectively) in a large multinational cohort study.

Methods: The Prospective Urban Rural Epidemiology (PURE) study is a prospective epidemiological study of individuals aged 35 and 70 years from 21 countries on five continents, with a median follow-up of 9.1 years. In the , we assessed the association of dairy intake with prevalent MetS and its components among individuals with information on the five MetS components (n=112 922). For , we examined the association of dairy with incident hypertension (in 57 547 individuals free of hypertension) and diabetes (in 131 481 individuals free of diabetes).

Results: In cross-sectional analysis, higher intake of total dairy (at least two servings/day compared with zero intake; OR 0.76, 95% CI 0.71 to 0.80, p-trend<0.0001) was associated with a lower prevalence of MetS after multivariable adjustment. Higher intakes of whole fat dairy consumed alone (OR 0.72, 95% CI 0.66 to 0.78, p-trend<0.0001), or consumed jointly with low fat dairy (OR 0.89, 95% CI 0.80 to 0.98, p-trend=0.0005), were associated with a lower MetS prevalence. Low fat dairy consumed alone was not associated with MetS (OR 1.03, 95% CI 0.77 to 1.38, p-trend=0.13). In prospective analysis, 13 640 people with incident hypertension and 5351 people with incident diabetes were recorded. Higher intake of total dairy (at least two servings/day vs zero serving/day) was associated with a lower incidence of hypertension (HR 0.89, 95% CI 0.82 to 0.97, p-trend=0.02) and diabetes (HR 0.88, 95% CI 0.76 to 1.02, p-trend=0.01). Directionally similar associations were found for whole fat dairy versus each outcome.

Conclusions: Higher intake of whole fat (but not low fat) dairy was associated with a of MetS and most of its component factors, and with a of hypertension and diabetes. Our findings should be evaluated in large randomized trials of the effects of whole fat dairy on the risks of MetS, hypertension, and diabetes.
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http://dx.doi.org/10.1136/bmjdrc-2019-000826DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7326257PMC
April 2020

Corporate Lobbyists: Open Season on Academic Health Science?

Can J Cardiol 2021 Feb 4;37(2):182-183. Epub 2020 May 4.

Centre de Recherche de l'Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec City, Québec, Canada; Faculté de Pharmacie, Université Laval, Québec City, Québec, Canada.

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http://dx.doi.org/10.1016/j.cjca.2020.04.033DOI Listing
February 2021

Impact of a 12-Week Randomized Exercise Training Program on Lipid Profile in Severely Obese Patients Following Bariatric Surgery.

Obes Surg 2020 Aug;30(8):3030-3036

Institut Universitaire de Cardiologie et de Pneumologie de Québec-Université Laval, Québec, Québec, Canada.

Purpose: The benefit of exercise training on lipid profile in bariatric surgery patients is scarce. We assess the effect of a supervised exercise-training program on lipid profile following bariatric surgery.

Materials And Methods: A total of 60 patients were prospectively recruited, of those 49 completed the study (age 41 ± 11 years; body mass index 45.9 ± 6.1 kg/m, 75% women). The bariatric surgery procedures performed were sleeve gastrectomy (SG) (n = 24) and biliopancreatic diversion with duodenal switch (BPD-DS) (n = 25). Of the 49 patients who completed the study, 34 had been randomized to a 12-week supervised exercise training program (exercise group) between the 3rd and the 6th month following bariatric surgery (SG = 17 and BPD-DS = 17). Fasting blood samples and anthropometric measurements were performed preoperatively and at 3, 6, and 12 months after bariatric surgery.

Results: At 6 months and 12 months, percentage of weight loss was similar between groups (6 months: - 29.6 ± 5.5 vs. - 27.8 ± 7.7%; P = 0.371; 12 months: - 38.4 ± 10.4 vs. - 37.9 ± 9.5%; P = 0.876 exercise vs. control). Both groups had an increase in HDL values between the 3nd and the 6th month following bariatric surgery. There was a significantly greater increment in HDL values in the exercise group (0.18 ± 0.14 vs. 0.07 ± 0.12 mmol/L, P = 0.014; exercise vs. control).

Conclusion: Our results showed a beneficial effect of a 12-week supervised exercise-training program in bariatric surgery patients showing similar weight loss on HDL-cholesterol levels without additional effect on LDL-cholesterol levels.
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http://dx.doi.org/10.1007/s11695-020-04647-5DOI Listing
August 2020

Public Health Outcomes May Differ After Switching from Brand-Name to Generic Angiotensin II Receptor Blockers.

Drugs R D 2020 Jun;20(2):135-145

Faculté de Pharmacie, Université Laval, Quebec City, QC, Canada.

Background: It is unclear whether generics are as safe as brand-name drugs in cardiology. For public health surveillance purposes, we evaluated if switching from the brand-name losartan, valsartan, or candesartan impacted the occurrence of the following outcomes: emergency room (ER) consultations, hospitalizations, or death.

Study Design: This was a retrospective cohort study.

Methods: This study was conducted in the Quebec Integrated Chronic Disease Surveillance System, including healthcare administrative data of the population of Quebec, Canada. We included brand-name users of losartan, valsartan, or candesartan aged ≥ 66 years who had undergone ≥ 30 days of stable treatment on the brand-name drug prior to cohort entry (substitution time-distribution matching was used to prevent immortal time bias). Outcomes up to 1 year were compared between groups using multivariable Cox proportional hazards regression models (validity assumptions were verified).

Results: In our cohorts (losartan, n =15,783; valsartan, n =16,907; candesartan, n =26,178), mean age was 76-78 years, 59-66% were female, 90-92% had hypertension, and 13-15% had heart failure. Validity assumptions were violated for losartan only. For patients switched to generic valsartan, the hazard ratio (95% confidence interval) was 1.07 (0.99-1.14) for ER consultation, 1.26 (1.14-1.39) for hospitalization, and 1.01 (0.61-1.67) for death. The corresponding rates for candesartan were 1.00 (0.95-1.05), 0.96 (0.89-1.03), and 0.57 (0.37-0.88), respectively.

Conclusions: We observed an increased risk of hospitalizations for patients switched to generic valsartan, and a decreased risk of death for patients switched to generic candesartan, compared with those who continued taking the brand-name drug. The differences between generic and brand-name drugs may lead to some differences in public health outcomes, but this safety signal must be further studied using other cohorts and settings.
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http://dx.doi.org/10.1007/s40268-020-00307-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7221012PMC
June 2020

Changes in fat-free mass and muscle mass at 6 and 12 months after biliopancreatic diversion with duodenal switch surgery.

Surg Obes Relat Dis 2020 Jul 20;16(7):878-885. Epub 2020 Mar 20.

Institut Universitaire de Cardiologie et de Pneumologie de Québec-Université Laval, Québec, Canada; Faculty of Pharmacy, Laval University, Québec, Canada. Electronic address:

Background: Bariatric surgery is associated with concomitant loss in both fat and muscle masses. Literature on muscle composition/quality after bariatric surgery is limited.

Objectives: To measure and compare the changes in fat-free mass with the changes in muscle composition after biliopancreatic diversion with duodenal switch surgery (BPD/DS).

Setting: Bariatric surgery is associated with concomitant loss in both fat and muscle masses. Literature on muscle composition/quality after bariatric surgery is limited.

Methods: Forty patients underwent BPD/DS and 22 patients are considered as controls. Bioelectrical impedance analysis (body composition) and computed tomography scan at the midthigh and abdominal levels (muscle composition) were performed at baseline, 6, and 12 months.

Results: At 6 and 12 months, the BPD/DS group displayed significant reduction in weight (12 months: -46.6 ± 13.5 kg) and fat-free mass (12 months: -8.2 ± 4.4 kg; both P < .001). A significant reduction in abdominal (-15 ± 8%, P < .001) and midthigh muscle areas (-18 ± 7%, P < .001) was observed during the first postoperative 6 months, followed by a plateau after 6 months (abdominal: -1 ± 5%, midthigh: -1 ± 4%, both P > .05). At 6 months, both midthigh fat-infiltrated muscle (-22 ± 10%, P < .001) and normal-density muscle (-16 ± 9%, P < .001) areas decreased. Further reduction at 12 months was only observed in the fat-infiltrated muscle (-11 ± 8%, P < .001) in comparison with an increase in the normal-density muscle area (5 ± 8%, P = .001). There was no significant change for the control group.

Conclusions: Reduction in muscle, assessed with computed tomography scans, occurs mostly during the first 6 months postoperatively after BPD/DS. Focus on muscle quantity as well as quality, using precise imaging methods, instead of quantifying total body lean mass, is likely to provide better assessment in body content modulation after BPD/DS.
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http://dx.doi.org/10.1016/j.soard.2020.03.012DOI Listing
July 2020

Long-term exposure to outdoor and household air pollution and blood pressure in the Prospective Urban and Rural Epidemiological (PURE) study.

Environ Pollut 2020 Jul 24;262:114197. Epub 2020 Feb 24.

School of Biological and Population Health Sciences, College of Public Health and Human Sciences, Oregon State University, Corvallis, OR, USA.

Exposure to air pollution has been linked to elevated blood pressure (BP) and hypertension, but most research has focused on short-term (hours, days, or months) exposures at relatively low concentrations. We examined the associations between long-term (3-year average) concentrations of outdoor PM and household air pollution (HAP) from cooking with solid fuels with BP and hypertension in the Prospective Urban and Rural Epidemiology (PURE) study. Outdoor PM exposures were estimated at year of enrollment for 137,809 adults aged 35-70 years from 640 urban and rural communities in 21 countries using satellite and ground-based methods. Primary use of solid fuel for cooking was used as an indicator of HAP exposure, with analyses restricted to rural participants (n = 43,313) in 27 study centers in 10 countries. BP was measured following a standardized procedure and associations with air pollution examined with mixed-effect regression models, after adjustment for a comprehensive set of potential confounding factors. Baseline outdoor PM exposure ranged from 3 to 97 μg/m across study communities and was associated with an increased odds ratio (OR) of 1.04 (95% CI: 1.01, 1.07) for hypertension, per 10 μg/m increase in concentration. This association demonstrated non-linearity and was strongest for the fourth (PM > 62 μg/m) compared to the first (PM < 14 μg/m) quartiles (OR = 1.36, 95% CI: 1.10, 1.69). Similar non-linear patterns were observed for systolic BP (β = 2.15 mmHg, 95% CI: -0.59, 4.89) and diastolic BP (β = 1.35, 95% CI: -0.20, 2.89), while there was no overall increase in ORs across the full exposure distribution. Individuals who used solid fuels for cooking had lower BP measures compared to clean fuel users (e.g. 34% of solid fuels users compared to 42% of clean fuel users had hypertension), and even in fully adjusted models had slightly decreased odds of hypertension (OR = 0.93; 95% CI: 0.88, 0.99) and reductions in systolic (-0.51 mmHg; 95% CI: -0.99, -0.03) and diastolic (-0.46 mmHg; 95% CI: -0.75, -0.18) BP. In this large international multi-center study, chronic exposures to outdoor PM was associated with increased BP and hypertension while there were small inverse associations with HAP.
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http://dx.doi.org/10.1016/j.envpol.2020.114197DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7767575PMC
July 2020

Reduced Cognitive Assessment Scores Among Individuals With Magnetic Resonance Imaging-Detected Vascular Brain Injury.

Stroke 2020 04 4;51(4):1158-1165. Epub 2020 Mar 4.

Hotchkiss Brain Institute, Department of Clinical Neurosciences, University of Calgary, Alberta, Canada (E.E.S.).

Background and Purpose- Little is known about the association between covert vascular brain injury and cognitive impairment in middle-aged populations. We investigated if scores on a cognitive screen were lower in individuals with higher cardiovascular risk, and those with covert vascular brain injury. Methods- Seven thousand five hundred forty-seven adults, aged 35 to 69 years, free of cardiovascular disease underwent a cognitive assessment using the Digital Symbol Substitution test and Montreal Cognitive Assessment, and magnetic resonance imaging (MRI) to detect covert vascular brain injury (high white matter hyperintensities, lacunar, and nonlacunar brain infarctions). Cardiovascular risk factors were quantified using the INTERHEART (A Global Study of Risk Factors for Acute Myocardial Infarction) risk score. Multivariable mixed models tested for independent determinants of reduced cognitive scores. The population attributable risk of risk factors and MRI vascular brain injury on low cognitive scores was calculated. Results- The mean age of participants was 58 (SD, 9) years; 55% were women. Montreal Cognitive Assessment and Digital Symbol Substitution test scores decreased significantly with increasing age (<0.0001), INTERHEART risk score (<0.0001), and among individuals with high white matter hyperintensities, nonlacunar brain infarction, and individuals with 3+ silent brain infarctions. Adjusted for age, sex, education, ethnicity covariates, Digital Symbol Substitution test was significantly lowered by 1.0 (95% CI, -1.3 to -0.7) point per 5-point cardiovascular risk score increase, 1.9 (95% CI, -3.2 to -0.6) per high white matter hyperintensities, 3.5 (95% CI, -6.4 to -0.7) per nonlacunar stroke, and 6.8 (95% CI, -11.5 to -2.2) when 3+ silent brain infarctions were present. No postsecondary education accounted for 15% (95% CI, 12-17), moderate and high levels of cardiovascular risk factors accounted for 19% (95% CI, 8-30), and MRI vascular brain injury accounted for 10% (95% CI, -3 to 22) of low test scores. Conclusions- Among a middle-aged community-dwelling population, scores on a cognitive screen were lower in individuals with higher cardiovascular risk factors or MRI vascular brain injury. Much of the population attributable risk of low cognitive scores can be attributed to lower educational attainment, higher cardiovascular risk factors, and MRI vascular brain injury.
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http://dx.doi.org/10.1161/STROKEAHA.119.028179DOI Listing
April 2020

Outcomes in Patients with Obesity and Coronary Artery Disease with and Without Bariatric Surgery.

Obes Surg 2020 Jun;30(6):2085-2092

Quebec Heart-Lung Institute, 2725, Chemin Ste Foy, Quebec, Quebec, G1V 4G5, Canada.

Objectives: The clinical benefit of bariatric surgery in patients with severe obesity and established coronary artery disease (CAD) is unclear. We aimed to compare the cardiovascular outcomes of severely obese CAD patients with and without bariatric surgery.

Methods: Patients with a history of myocardial revascularization documented prior to bariatric surgery were identified from a dedicated database with prospectively collected outcomes. These patients were matched 1 to 1 with CAD patients who had prior revascularization but who did not undergo bariatric surgery. The primary outcomes were death (cardiac and non-cardiac) and major adverse cardio-cerebral events (MACCE), including death, myocardial infarction (MI), stroke, and repeat myocardial revascularization throughout follow-up.

Results: After propensity score matching, 116 bariatric patients were matched with 116 control patients. Ninety-eight had a history of coronary artery bypass surgery and 134 had a previous percutaneous coronary intervention. After a median follow-up of 8.9 (6.3-14.2) years, MACCE was significantly lower in the bariatric group (HR 0.65; 95% CI 0.42-1.00; P = 0.049) driven by a significant reduction in non-cardiac mortality (HR 0.49; 95% CI 0.23-1.00; P = 0.049). There was no significant difference in the rates of all-cause death (HR 0.58; 95% CI 0.33-1.01; P = 0.056), cardiovascular death (HR 0.77; 95% CI 0.31-1.85; P = 0.55), MI (HR 1.09; 95% CI 0.47-2.58; P = 0.85), stroke (HR 1.47; 95% CI 0.24-11.2; P = 0.67), and repeat myocardial revascularization (HR 0.56; 95% CI 0.27-1.13; P = 0.11).

Conclusion: Although bariatric surgery in obese CAD patients may reduce the composite MACCE endpoint during long-term follow-up, this effect seems unrelated to cardiovascular outcomes.
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http://dx.doi.org/10.1007/s11695-020-04467-7DOI Listing
June 2020

Acceptability of a computer-tailored and pedometer-based socio-cognitive intervention in a secondary coronary heart disease prevention program: A qualitative study.

Digit Health 2020 Jan-Dec;6:2055207619899840. Epub 2020 Jan 10.

Faculty of Nursing, Université de Montréal, Canada.

When developing an innovative intervention, its acceptability to patients, health care professionals and managers must be considered to ensure the implementation into practice. This study aims to identify factors influencing the acceptability of a computer-tailored and pedometer-based socio-cognitive intervention for patients with heart disease. Focus group interviews were conducted in two outlying regions of the province of Quebec (Canada). The Theory of Planned Behavior formed the theoretical basis of the interview guide. Two researchers performed verbatim analysis independently until consensus was achieved. The sample included 44 participants divided into six groups (patients  = 7 + 8, health care professionals  = 8 + 8, managers  = 6 + 7). Health care professionals and managers mentioned benefits concerning partners' opportunity to improve assessment and monitoring. Patients believed the intervention could be useful to improve adherence to physical activity. Additional benefits indicated were self-monitoring behavior and improved health-related outcomes. However, patients expressed concern about the online security, fearing possible data breach. Some clinicians felt the pedometer may not be able to evaluate physical activities other than walking. With regard to behavioral control, a web application and pedometer must be easy to use and compatible with services already in place. Further barriers include level of literacy, cost and the various difficulties associated with wearing a pedometer. Findings suggest that, to improve the acceptability of a computer-tailored and pedometer-based socio-cognitive intervention, users must be assured of a secure website, validated, affordable and easy-to-use pedometers, and an intervention adapted to their level of literacy.
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http://dx.doi.org/10.1177/2055207619899840DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6956605PMC
January 2020

Explaining the variability in cardiovascular risk factors among First Nations communities in Canada: a population-based study.

Lancet Planet Health 2019 12;3(12):e511-e520

Department of Medicine, University of Alberta, Edmonton, AB, Canada.

Background: Historical, colonial, and racist policies continue to influence the health of Indigenous people, and they continue to have higher rates of chronic diseases and reduced life expectancy compared with non-Indigenous people. We determined factors accounting for variations in cardiovascular risk factors among First Nations communities in Canada.

Methods: Men and women (n=1302) aged 18 years or older from eight First Nations communities participated in a population-based study. Questionnaires, physical measures, blood samples, MRI of preclinical vascular disease, and community audits were collected. In this cross-sectional analysis, the main outcome was the INTERHEART risk score, a measure of cardiovascular risk factor burden. A multivariable model was developed to explain the variations in INTERHEART risk score among communities. The secondary outcome was MRI-detected carotid wall volume, a measure of subclinical atherosclerosis.

Findings: The mean INTERHEART risk score of all communities was 17·2 (SE 0·2), and more than 85% of individuals had a risk score in the moderate to high risk range. Subclinical atherosclerosis increased significantly across risk score categories (p<0·0001). Socioeconomic advantage (-1·4 score, 95% CI -2·5 to -0·3; p=0·01), trust between neighbours (-0·7, -1·2 to -0·3; p=0·003), higher education level (-1·9, -2·9 to -0·8, p<0·001), and higher social support (-1·1, -2·0 to -0·2; p=0·02) were independently associated with a lower INTERHEART risk score; difficulty accessing routine health care (2·2, 0·3 to 4·1, p=0·02), taking prescription medication (3·5, 2·8 to 4·3; p<0·001), and inability to afford prescription medications (1·5, 0·5 to 2·6; p=0·003) were associated with a higher INTERHEART risk score. Collectively, these factors explained 28% variation in the cardiac risk score among communities. Communities with higher socioeconomic advantage and greater trust, and individuals with higher education and social support, had a lower INTERHEART risk score. Communities with difficulty accessing health care, and individuals taking or unable to afford prescription medications, had a higher INTERHEART risk score.

Interpretation: Cardiac risk factors are lower in communities with high socioeconomic advantage, greater trust, social support and educational opportunities, and higher where it is difficult to access health care or afford prescription medications. Strategies to optimise the protective factors and reduce barriers to health care in First Nations communities might contribute to improved health and wellbeing.

Funding: Heart and Stroke Foundation of Canada, Canadian Partnership Against Cancer, Canadian Institutes for Health Research.
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http://dx.doi.org/10.1016/S2542-5196(19)30237-2DOI Listing
December 2019

The Local Food Environment and Obesity: Evidence from Three Cities.

Obesity (Silver Spring) 2020 01 26;28(1):40-45. Epub 2019 Nov 26.

Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada.

Objective: This study aimed to identify the association between the food environment and obesity.

Methods: BMI and waist circumference (WC) were measured in 8,076 participants from three cities. The number of fast-food restaurants, full-service restaurants, bars/pubs, markets, and liquor stores within 500 m of each participant was documented. The association between the food environment (ratio of fast-food to full-service restaurants, ratio of bars/pubs to liquor stores, and presence of markets) with obesity (BMI ≥ 30 kg/m ) and abdominal obesity (WC ≥ 102 cm for males or WC ≥ 88 cm for females) was investigated, adjusted for age, sex, education level, neighborhood deprivation, neighborhood type, and total hours per week of walking and taking into account city-level clustering.

Results: The ratios of fast-food to full-service restaurants and of bars/pubs to liquor stores were positively associated with obesity (OR = 1.05 [CI: 1.02-1.09] and OR = 1.08 [CI: 1.04-1.13], respectively). The ratio of bars/pubs to liquor stores was positively associated with abdominal obesity (OR = 1.10 [CI: 1.05-1.14]). There was no association between markets and either obesity or abdominal obesity.

Conclusions: Features of the food environment have varying associations with obesity. These features have an additive effect, and future studies should not focus on only one feature in isolation.
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http://dx.doi.org/10.1002/oby.22614DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6972660PMC
January 2020