Publications by authors named "Zubin Punthakee"

62 Publications

Seropositivity and risk factors for SARS-CoV-2 infection in a South Asian community in Ontario: a cross-sectional analysis of a prospective cohort study.

CMAJ Open 2022 Jul-Sep;10(3):E599-E609. Epub 2022 Jul 5.

Department of Medicine (Anand, Bowdish, Punthakee, Schulze, Williams), McMaster University; Population Health Research Institute (Anand, Bangdiwala, de Souza, Desai, F. Khan, Z. Khan, Limbachia, Punthakee), Hamilton, Ont.; Department of Biochemistry, Microbiology and Immunology (Arnold, Langlois, Nakka, Pelchat), University of Ottawa, Ottawa, Ont.; Department of Health Research Methods, Evidence and Impact (Bangdiwala, de Souza, Kandasamy, Loeb, Manoharan), McMaster University, Hamilton, Ont.; Public Health Ontario (Bolotin); Dalla Lana School of Public Health (Bolotin, Loh), University of Toronto, Toronto, Ont.; Department of Pediatrics (Chanchlani, Wahi), McMaster University, Hamilton, Ont.; Faculty of Health Sciences (Lear), Simon Fraser University, Vancouver, BC; Department of Pathology and Molecular Medicine (Loeb), McMaster University, Hamilton, Ont.

Background: Early in the COVID-19 pandemic, the South Asian community in the Greater Toronto Area (GTA) was identified as having risk factors for exposure and specific barriers to accessing testing and reliable health information, rendering them particularly vulnerable to SARS-CoV-2 infection. We sought to investigate the burden of SARS-CoV-2 infection among South Asian people in the GTA, and to characterize the demographic characteristics, risk perceptions and trusted sources of health information in this group.

Methods: We conducted a cross-sectional analysis from the baseline assessment of participants in a prospective cohort study. Participants from the GTA were enrolled from Apr. 14 to July 28, 2021. Seropositivity for antispike and antinucleocapsid antibodies was determined from dried blood spots, and estimates of seropositivity were age and sex standardized to the South Asian population in Ontario. Demographic characteristics, risk perceptions and sources of COVID-19 information were collected via questionnaire and reported descriptively.

Results: Among the 916 South Asian participants enrolled (mean age 41 yr), the age- and sex-standardized seropositivity was 23.6% (95% confidence interval 20.8%-26.4%). Of the 693 respondents to the questionnaire, 228 (32.9%) identified as essential workers, and 125 (19.1%) reported living in a multigenerational household. A total of 288 (49.4%) perceived that they were at high COVID-19 risk owing to their geographic location, and 149 (34.3%) owing to their type of employment. The top 3 most trusted sources of information related to COVID-19 included health care providers and public health, traditional media sources and social media.

Interpretation: By the third wave of the COVID-19 pandemic, about one-quarter of a sample of South Asian individuals in Ontario had serologic evidence of prior SARS-CoV-2 infection. Insight into factors that put certain populations at risk can help future pandemic planning and disease control efforts.
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July 2022

Development and Validation of the Transition Readiness Assessment Instrument in Type 1 Diabetes "On TRAck".

Can J Diabetes 2022 Feb 11. Epub 2022 Feb 11.

Division of Endocrinology and Metabolism, Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada. Electronic address:

Objectives: Transition to adult care is challenging for youth with type 1 diabetes (T1D) and their caregivers. We have developed the diabetes-specific "On TRAck" transition readiness scale, and in this study we assess its reliability and validity compared with TRANSITION-Q, a generic transition readiness questionnaire.

Methods: We systematically created 3 versions of On TRAck: adolescent, parent and health-care provider (HCP) versions (for case managers and physicians). Among adolescents 13 to 18 years of age with T1D at a single academic centre, we conducted an exploratory factor analysis and assessed interrater agreement, internal consistency and relationship with age; recent glycated hemoglobin (A1C); and recent diabetic ketoacidosis (DKA) with On TRAck and TRANSITION-Q.

Results: One hundred fifteen adolescents (age 15.8±1.6 years and diabetes duration 6.7±4.1 years), their caregivers and diabetes HCPs participated. The final 24-item adolescent and parent scales (with 3 subscales: "Self-efficacy," "Autonomy" and "Support & maturity") and the 3-item HCP version had a Cronbach's alpha of 0.86 to 0.93. Adolescent scores correlated with parents (r=0.64), case managers (r=0.39) and physicians (r=0.28). Mean adolescent score was 190.3±27.1 points out of 240. Adolescent scores were 3.4 points higher per year of age (p=0.03) and 4.4 points higher for every 1% lower A1C (p=0.01), but were not associated with DKA. TRANSITION-Q was associated with age. On TRAck HCP scores were associated with adolescent's age, A1C and DKA.

Conclusions: On TRAck represents a new psychometrically comprehensive diabetes-specific scale that can be used in adolescent diabetes clinics for measuring transition readiness. It is a multidimensional instrument with ease of use, and high reliability scores.
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February 2022

Indications for ordering thyroid-stimulating hormone in noncritically ill adult inpatients-A Delphi consensus recommendation.

J Hosp Med 2022 Jun 13. Epub 2022 Jun 13.

Department of Medicine, McMaster University, Hamilton, Ontario, Canada.

Background: Thyroid-stimulating hormone (TSH) is ordered commonly among inpatients, but the possibility of nonthyroidal illness syndrome challenges interpretation.

Objective: Our objective was to obtain Canadian consensus on appropriate indications for ordering TSH in the first 48 h following presentation of a noncritically ill internal medicine patient.

Design, Setting And Participants: Canadian endocrinologists with inpatient expertise were invited via snowball sampling to an online 3-round Delphi study. Main Outcome and Measures using a 6-point Likert scale, they rated 58 indications on appropriateness for measuring TSH in medical inpatients. These indications included clinical presentations, signs, and symptoms. Items that reached consensus and agreement (≥80% of participants selecting a rating of 5 or 6 on the Likert scale) were tabulated and dropped after each round. Qualitative analysis of comments identified additional contextual considerations as themes.

Results: There were 45 participants (academic setting: 84%) representing 8 provinces (Ontario: 64%). Rounds 2 and 3 were completed by 42 and 33 participants, respectively. Nine indications reached consensus and agreement: presumed myxedema coma, presumed thyroid storm, atrial fibrillation/flutter, euvolemic hyponatremia, proptosis, adrenal insufficiency, hypothermia, thyroid medication noncompliance, and goiter. There was also agreement that two contextual considerations identified in thematic analysis, including a recent abnormal outpatient TSH, and the presence of other findings of thyroid dysfunction, would significantly change some mid-range responses.

Conclusions: Canadian experts agreed upon nine specific indications for ordering an inpatient TSH, with others requiring consideration of previous TSH measurement and clinical context.
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June 2022

Impact of SARS-CoV-2 pandemic on the mental and physical health of children enrolled in a paediatric weight management clinic.

Paediatr Child Health 2022 Jun 5;27(Suppl 1):S72-S77. Epub 2022 May 5.

Children's Exercise and Nutrition Centre, McMaster Children's Hospital, Hamilton, Ontario, Canada.

Background: Obesity is a global public health concern. Given the widespread disruption caused by the SARS-CoV-2 pandemic, it is important to evaluate its impact on children with chronic health conditions. This study examines the health of paediatric patients with obesity enrolled in a tertiary hospital weight management program, before and 1 year into the COVID-19 pandemic.

Methods: This is a retrospective chart review of patients aged 2 to 17 years enrolled in a paediatric weight management clinic. Mental health outcomes (i.e., new referrals to psychologist, social work, eating disorder program, incidence of dysregulated eating, suicidal ideation, and/or self-harm) and physical health (anthropometric measures) were compared before and 1 year into the pandemic.

Results: Among the 334 children seen in either period, there was an increase in referrals to psychologist (12.4% versus 26.5%; P=0.002) and the composite mental health outcome (17.2% versus 30.2%; P=0.005) during the pandemic compared with pre-pandemic. In a subset of children (n=30) with anthropometric measures in both periods, there was a lower rate of decline in BMIz score (-1.5 [2.00] versus -0.3 [0.73]/year; P=0.002) and an increase in adiposity (-0.8 [4.64] versus 2.7 [5.54]%/year; P=0.043) during the pandemic.

Discussion: The pandemic has impacted the mental and physical health of children with obesity engaged in a weight management clinic. While our study provides evidence of a negative impact on mental health outcomes and less improvement in anthropometric measures, future research when patients return to in-person care will enable further examination of our findings with additional objective measures.
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June 2022

Impaired Cold-Stimulated Supraclavicular Brown Adipose Tissue Activity in Young Boys With Obesity.

Diabetes 2022 06;71(6):1193-1204

Centre for Metabolism, Obesity and Diabetes Research, McMaster University, Hamilton, Ontario, Canada.

Childhood obesity is a growing worldwide problem. In adults, lower cold-induced brown adipose tissue (BAT) activity is linked to obesity and metabolic dysfunction; this relationship remains uncertain in children. In this cross-sectional study, we compared cold-induced supraclavicular (SCV) BAT activity (percent change in proton density fat fraction [PDFF]) within the SCV region after 1 h of whole-body cold exposure (18°C), using MRI in 26 boys aged 8-10 years: 13 with normal BMI and 13 with overweight/obesity. Anthropometry, body composition, hepatic fat, visceral adipose tissue (VAT), and pre- and postcold PDFF of the subcutaneous adipose tissue (SAT) in the posterior neck region and the abdomen were measured. Boys with overweight/obesity had lower cold-induced percent decline in SCV PDFF compared with those with normal BMI (1.6 ± 0.8 vs. 4.7 ± 1.2%, P = 0.044). SCV PDFF declined significantly in boys with normal BMI (2.7 ± 0.7%, P = 0.003) but not in boys with overweight/obesity (1.1 ± 0.5%, P = 0.053). No cold-induced changes in the PDFF of either neck SAT (-0.89 ± 0.7%, P = 0.250, vs. 0.37 ± 0.3%, P = 0.230) or abdominal SAT (-0.39 ± 0.5%, P = 0.409, and 0.25 ± 0.2%, P = 0.139, for normal BMI and overweight/obesity groups, respectively) were seen. The cold-induced percent decline in SCV PDFF was inversely related to BMI (r = -0.39, P = 0.047), waist circumference (r = -0.48, P = 0.014), and VAT (r = -0.47, P = 0.014). Thus, in young boys, as in adults, BAT activity is lower in those with overweight/obesity, suggesting that restoring activity may be important for improving metabolic health.
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June 2022

Relationship of parental feeding practices and diet with children's diet among South Asians in Canada.

Appetite 2022 06 7;173:105991. Epub 2022 Mar 7.

Population Health Research Institute, Hamilton, ON, Canada; Department of Medicine, McMaster University, Hamilton, ON, Canada. Electronic address:

Background: South Asian children's diets are considered unhealthy, yet the relationship with food parenting among South Asians is understudied.

Methods: In a cross-sectional study, questionnaires were administered to dyads of Canadian South Asian elementary and high school children and a parent. Relationships between parental factors (perceived responsibility, restriction, pressure to eat, monitoring, home food environment, nutrition knowledge and intake of fruits and vegetables (FV), sugary beverages (SB) and sweets and fast foods (SWFF) and children's intake of FV, SB and SWFF were assessed by linear regression adjusted for sociodemographics. Subgroup differences by children's age and acculturation were explored by interaction analysis.

Results: 291 children (age 9.8 ± 3.2 years) had mean daily intake frequencies of 3.1 ± 2.0 FV, 1.0 ± 0.9 SB and 2.1 ± 1.5 SWFF. Positive associations were found between parent and child intake of FV (standardized beta (ß) = 0.230, [95%CI 0.115, 0.345], p < 0.001), SB (β = 0.136 [0.019, 0.252], p = 0.02), and SWFF (β = 0.167 [0.052, 0.282], p = 0.005). Parental monitoring was associated with lower children's SWFF intake (ß = -0.131 [-0.248, -0.015], p = 0.03). Among those expressing less Western culture, parental SWFF intake was associated with child's SB intake (β = 0.255 [0.085, 0.425], p = 0.004). Among those expressing less traditional culture, positive home food environment was associated with lower child SWFF intake (β = -0.208 [-0.374, -0.042], p = 0.015).

Conclusion: South Asian children's diets have stronger relationships with their parents' diets than with food parenting practices or nutrition knowledge, though parental monitoring was associated with lower unhealthy food intake. However, with greater acculturation, the home food environment was more important for unhealthy food intake.
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June 2022

Gastrointestinal Symptoms in Type 1 Diabetes: Relationship With Autoimmune and Microvascular Complications.

J Clin Endocrinol Metab 2022 05;107(6):e2431-e2437

Division of Endocrinology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Canada.

Purpose: To assess reported rates of gastrointestinal (GI) symptoms and their association with autoimmune diseases and microvascular complications in adults and children with type 1 diabetes.

Methods: The Gastrointestinal Symptom Scale was used to assess GI symptom type and severity in 2370 patients with type 1 diabetes aged 8 to 45 years evaluated as part of a clinical trial screening for celiac disease (CD). The presence and severity of GI symptoms and relationships with demographic, clinical, and other diabetes-related factors were evaluated.

Results: Overall, 1368 adults (57.7%) aged 19 to 45 years and 1002 (42.3%) pediatric patients aged 8 to 18 years were studied. At least 1 GI symptom was reported in 34.1% of adults as compared with 21.7% of children (P < 0.0001). Common symptoms in children included upper and lower abdominal pain while adults more frequently reported lower GI symptoms. Participants with GI symptoms had higher hemoglobin A1c (HbA1c) levels (68 ± 14mmol/mol; 8.35 ± 1.37%) than those without symptoms (66 ± 15mmol/mol; 8.22 ± 1.40%; P = 0.041). Patients with microvascular complications (nephropathy, retinopathy, and/or neuropathy) were 1.8 times more likely to report GI symptoms (95% CI: 1.26-2.60; P < 0.01) after adjusting for age and sex. No association was observed between GI symptoms and the presence of autoimmune conditions, including thyroid and biopsy-confirmed CD (odds ratio = 1.1; 95% CI: 0.86-1.42; P = 0.45).

Main Conclusions: These results highlight that GI symptoms are an important clinical morbidity and are associated with increasing age, duration of type 1 diabetes, HbA1c, and microvascular complications but not with autoimmune comorbidities including CD.
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May 2022

Deriving Normative Data on 24-Hour Ambulatory Blood Pressure Monitoring for South Asian Children (ASHA): A Clinical Research Protocol.

Can J Kidney Health Dis 2022 31;9:20543581211072329. Epub 2022 Jan 31.

Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada.

Background: The global prevalence of hypertension in children and adolescents has increased over the past 2 decades and is the strongest predictor of adult hypertension. South Asians have an increased prevalence of metabolic syndrome associated risk factors including abdominal obesity, diabetes, and hypertension. All these factors contribute to their increased cardiovascular disease burden. Accurate and early identification of hypertension in South Asian children is a necessary aspect of cardiovascular disease prevention. Ambulatory blood pressure monitoring (ABPM) is considered the gold-standard for pediatric blood pressure (BP) measurement. However, its utilization is limited due to the lack of validated normative reference data in diverse, multiethnic pediatric populations.

Objective: The primary objective is to establish normative height-sex and age-sex-specific reference values for 24-h ABPM measurements among South Asian children and adolescents (aged 5-17 years) in Ontario and British Columbia, Canada. Secondary objectives are to evaluate differences in ABPM measurements by body mass index classification, to compare our normative data against pre-existing data from German and Hong Kong cohorts, and to evaluate relationships between habitual movement behaviors, diet quality, and ABPM measurements.

Design: Cross-sectional study, quasi-representative sample.

Setting: Participants will be recruited from schools, community centers, and places of worship in Southern Ontario (Greater Toronto and Hamilton area, including the Peel Region) and Greater Vancouver, British Columbia.

Participants: We aim to recruit 2113 nonoverweight children (aged 5-17 years) for the primary objective. We aim to recruit an additional 633 overweight or obese children to address the secondary objectives.

Measurements: Ambulatory BP monitoring measurements will be obtained using Spacelabs 90217 ABPM devices, which are validated for pediatric use. The ActiGraph GT3X-BT accelerometer, which has also been validated for pediatric use, will be used to obtain movement behavior data.

Methods: Following recruitment, eligible children will be fitted with 24-h ABPM and physical activity monitors. Body anthropometrics and questionnaire data regarding medical and family history, medications, diet, physical activity, and substance use will be collected. Ambulatory BP monitoring data will be used to develop height-sex- and age-sex-specific normative reference values for South Asian children. Secondary objectives include evaluating differences in ABPM measures between normal weight, overweight and obese children; and comparing our South Asian ABPM data to existing German and Hong Kong data. We will also use compositional data analysis to evaluate associations between a child's habitual movement behaviors and ABPM measures.

Limitations: Bloodwork will not be performed to facilitate recruitment. A non-South Asian comparator cohort will not be included due to feasibility concerns. Using a convenience sampling approach introduces the potential for selection bias.

Conclusions: Ambulatory BP monitoring is a valuable tool for the identification and follow-up of pediatric hypertension and overcomes many of the limitations of office-based BP measurement. The development of normative ABPM data specific to South Asian children will increase the accuracy of BP measurement and hypertension identification in this at-risk population, providing an additional strategy for primary prevention of cardiovascular disease.
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January 2022

Economic Analysis of a Diabetes Health Coaching Intervention for Adults Living With Type 2 Diabetes: A Single-Centre Evaluation From a Community-Based Randomized Controlled Trial.

Can J Diabetes 2022 Mar 14;46(2):165-170. Epub 2021 Aug 14.

Diabetes Care and Research Program, Hamilton Health Sciences, Hamilton, Ontario, Canada; School of Nursing, Faculty of Health Sciences. McMaster University, Hamilton, Ontario, Canada. Electronic address:

Background: A recent randomized controlled trial demonstrated that a community-based, telephone-delivered diabetes health coaching intervention was effective for improving diabetes management. Our aim in this study was to determine whether this intervention is also cost-effective.

Methods: An economic evaluation, in the form of a cost-utility analysis (CUA), was used to assess the cost-effectiveness of the coaching intervention from a public payer's perspective. All direct medical costs, as well as intervention implementation, were included. The outcome measure for the CUA was quality-adjusted life-year (QALY). Uncertainty of cost-effectiveness results was estimated using nonparametric bootstraps of patient-level costs and QALYs in the coaching and control arms. A cost-effectiveness acceptability curve was used to express this uncertainty as the probability that diabetes health coaching is cost-effective across a range of values of willingness-to-pay thresholds for a QALY.

Results: The results show that subjects in the coaching arm incurred higher overall costs (in Canadian dollars) than subjects in the control arm ($1,581 vs $1,086, respectively) and incurred 0.02 more QALYs. The incremental cost-effectiveness ratio of the diabetes health coaching intervention compared with usual care was found to be $35,129 per QALY, with probabilities of 67% and 82% that diabetes health coaching would be cost-effective at a willingness-to-pay threshold of $50,000 per QALY and $100,000 per QALY, respectively.

Conclusion: A community-based, telephone-delivered diabetes health coaching intervention is cost-effective.
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March 2022

Lower brown adipose tissue activity is associated with non-alcoholic fatty liver disease but not changes in the gut microbiota.

Cell Rep Med 2021 09 14;2(9):100397. Epub 2021 Sep 14.

Centre for Metabolism, Obesity and Diabetes Research, McMaster University, Hamilton, ON L8S 4L8, Canada.

In rodents, lower brown adipose tissue (BAT) activity is associated with greater liver steatosis and changes in the gut microbiome. However, little is known about these relationships in humans. In adults (n = 60), we assessed hepatic fat and cold-stimulated BAT activity using magnetic resonance imaging and the gut microbiota with 16S sequencing. We transplanted gnotobiotic mice with feces from humans to assess the transferability of BAT activity through the microbiota. Individuals with NAFLD (n = 29) have lower BAT activity than those without, and BAT activity is inversely related to hepatic fat content. BAT activity is not related to the characteristics of the fecal microbiota and is not transmissible through fecal transplantation to mice. Thus, low BAT activity is associated with higher hepatic fat accumulation in human adults, but this does not appear to have been mediated through the gut microbiota.
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September 2021

Accuracy of Screening Tests for Celiac Disease in Asymptomatic Patients With Type 1 Diabetes.

Am J Gastroenterol 2021 07;116(7):1545-1549

Division of Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.

Introduction: To evaluate the diagnostic performance of celiac serologic tests in asymptomatic patients with type 1 diabetes (T1D).

Methods: Patients with T1D asymptomatic for celiac disease were prospectively screened with immunoglobulin A anti-tissue transglutaminase. Test characteristics were calculated and optimal cutoffs for a positive screen determined.

Results: Two thousand three hundred fifty-three patients were screened and 101 proceeded to biopsy. The positive predictive value of immunoglobulin A anti-tissue transglutaminase at the assay referenced upper limit of normal (30CU) was 85.9%, and the sensitivity and specificity were 100% and 38%, respectively.

Discussion: Thresholds extrapolated from the general population for the diagnostic evaluation of celiac disease are not suitable for use in asymptomatic T1D patients. Population-specific screening cutoffs are required.
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July 2021

Canadian national hypoparathyroidism registry: an overview of hypoparathyroidism in Canada.

Endocrine 2021 05 2;72(2):553-561. Epub 2021 Mar 2.

McMaster University, Hamilton, ON, Canada.

Purpose: To evaluate the epidemiology, presentation and management of hypoparathyroidism in Canada. Hypoparathyroidism is associated with significant morbidity and poor quality of life. We present baseline results from the Canadian National Hypoparathyroidism Registry, a prospective observational study evaluating hypoparathyroidism in Canada.

Methods: Our study enrolled 130 patients with hypoparathyroidism. Patients were followed every 6 months with clinical and lab assessments. We present baseline data in this manuscript.

Results: Seventy percent (91/130) of patients had postsurgical hypoparathyroidism, 30% (39/130) of patients had nonsurgical hypoparathyroidism due to autoimmune, genetic or idiopathic causes, and a molecular diagnosis was confirmed in 11 of these 39 patients. Pseudohypoparathyroidism was confirmed in 4/39 patients, DiGeorge syndrome in 2/39 patients, Barakat syndrome with a mutation in the GATA3 gene in 1/39, and activating mutations of the CASR gene in 3/39 patients with nonsurgical hypoparathyroidism. Renal complications with nephrocalcinosis or nephrolithiasis were present in 27% (14/52) of patients with postsurgical disease and 17% (4/24) of patients with nonsurgical hypoparathyroidism. Basal ganglia calcification was noted on imaging in 15% (n = 5/34) of patients with postsurgical hypoparathyroidism and 37% (n = 7/19) of patients with nonsurgical hypoparathyroidism.

Conclusions: Hypercalciuria was more commonly seen in those with renal complications of nephrocalcinosis, nephrolithiasis or CKD, and hyperphosphatemia was more commonly seen in those with basal ganglia calcification. Hospitalization occurred in 28% of those with postsurgical hypoparathyroidism and 46% of those with nonsurgical hypoparathyroidism. Hypoparathyroidism is associated with significant morbidity. Effective strategies to reduce the short-and long-term complications of hypoparathyroidism need to be developed and evaluated.
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May 2021

Effect of Diabetes Health Coaching on Glycemic Control and Quality of Life in Adults Living With Type 2 Diabetes: A Community-Based, Randomized, Controlled Trial.

Can J Diabetes 2021 Oct 5;45(7):594-600. Epub 2020 Dec 5.

Diabetes Care and Research Program, Hamilton Health Sciences, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Population Health Research Institute, Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada.

Objectives: Health coaching for type 2 diabetes (T2DM) represents a promising addition toward efforts to improve clinical health outcomes and quality of life. The purpose of this study was to evaluate the effect of a 12-month telephone diabetes health coaching (DHC) intervention on glycemic control in persons living with T2DM.

Methods: In this community-based, randomized, controlled trial, adults with T2DM, glycated hemoglobin (A1C) ≥7.5% and telephone access were assigned to either usual diabetes education (DE) or DHC and access to DE. The primary outcome was change in A1C after 1 year, and secondary outcomes included score on the 19-item Audit of Diabetes-Dependent Quality of Life (ADDQoL-19) instrument and self-care behaviours. Safety was assessed in all participants (NCT02128815 at

Results: Three hundred sixty-five participants (50% females; mean age, 57 years; mean A1C, 8.98%) were randomized to control (DE, n=177) or intervention (DHC, n=188) groups. The A1C level decreased by an absolute amount of 1.8% and 1.3% in the intervention and control groups, respectively. DHC plus DE reduced A1C by 0.49% more than DE alone (95% confidence interval, -0.80 to -0.18; p<0.01) and improved ADDQoL-19 scores, with between-group differences for the average weighted score of 0.28 (95% confidence interval, 0.04 to 0.52; p=0.02). There were no differences between groups for proportion of participants having an emergency department visit or hospitalization.

Conclusions: Providing frequent telephone-based DHC and access to DE to adults living with T2DM for 1 year supports improvements in glycemic control and quality of life.
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October 2021

Impact of a Gluten-Free Diet on Quality of Life and Health Perception in Patients With Type 1 Diabetes and Asymptomatic Celiac Disease.

J Clin Endocrinol Metab 2021 04;106(5):e1984-e1992

Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada.

Context: Celiac disease (CD) is a common comorbidity seen in patients with type 1 diabetes (T1D) and is frequently asymptomatic. As chronic conditions requiring significant lifestyle changes, there are limited reports assessing changes in health-related quality of life (HRQoL) during transition to a gluten-free diet (GFD) in patients with T1D who are asymptomatic for CD.

Objective: This work aims to prospectively assess HRQoL and health perception in children and adults with T1D and asymptomatic CD after random assignment to GFD vs usual diet.

Methods: Patients with T1D aged 8 to 45 years without CD symptoms were serologically screened for CD, with positive results confirmed with intestinal biopsy. Participants were randomly assigned in an open-label fashion to a GFD or gluten-containing diet (GCD) for 12 months. Generic and diabetes-specific HRQoL and self-perceived wellness (SPW) were assessed longitudinally.

Results: A total of 2387 T1D patients were serologically screened. CD was biopsy-confirmed in 82 patients and 51 participants were randomly assigned to a GFD (N = 27) or GCD (N = 24). Excellent adherence to the assigned diets was observed. Overall, no changes in generic (P = .73) or diabetes-specific HRQoL (P = .30), or SPW (P = .41) were observed between groups over 12 months. Hemoglobin A1c (HbA1c) and gastrointestinal symptoms were consistent predictors of HRQoL and SPW.

Conclusion: HRQoL and SPW were not significantly affected by the adoption of a GFD over 12 months, but worsened with symptom onset and increased HbA1c. Our findings indicate that transition to a GFD can be made successfully in this population without adversely affecting quality of life.
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April 2021

Diabetes knowledge, risk perception, and quality of life among South Asian caregivers in young adulthood.

BMJ Open Diabetes Res Care 2020 11;8(2)

School of Nursing, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada

Introduction: Persons of South Asian descent have a higher prevalence of type 2 diabetes mellitus (T2DM). The management of T2DM in the South Asian community has required the support of adult children, potentially impacting the quality of life, diabetes-related knowledge, and risk perception among these caregivers.

Research Design And Methods: To investigate diabetes-related knowledge, quality of life, risk perception, and actual risk of developing diabetes among South Asian young adults whose parents are living with T2DM. A cross-sectional study was conducted (n=150). An online survey was administered. Data were analyzed with descriptive and inferential statistics.

Results: There was a statistically significant difference in diabetes-related knowledge between males and females (p<0.001). Males (in comparison to females) had a lower risk perception of developing diabetes (p=0.06). Further, risk perception and diabetes-related knowledge were positively associated with caregiver's physical health (p0.002).

Conclusion: Findings highlight the importance of providing gender-specific and culturally tailored diabetes educational interventions.
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November 2020

Conversations and Reactions Around Severe Hypoglycemia Study: Results of Hypoglycemia Experiences in Canadian Adults With Insulin-Treated Diabetes and Their Caregivers.

Can J Diabetes 2021 Apr 2;45(3):236-242. Epub 2020 Sep 2.

Department of Sociology, Loyola University Maryland, Baltimore, Maryland, United States.

Objectives: The Conversations and Reactions Around Severe Hypoglycemia cross-sectional study was conducted to better understand the severe hypoglycemia experiences in persons with diabetes (PWD) and their caregivers (CGs).

Methods: Adults with type 1 or type 2 diabetes and CGs were recruited in 8 countries; Canadian cohort data are reported in this study. Insulin-treated PWD who reported a severe hypoglycemic event within the past 3 years and CGs who care for PWD ≥4 years old and who met the criteria were eligible for the study. Participants completed an online survey about their experience with severe hypoglycemia, its treatment and actions during and after severe hypoglycemia.

Results: Of the 324 respondents, 139 (43%) reported discussions about severe hypoglycemia with a health-care provider (HCP) at every visit. During the most recent severe hypoglycemic event, the most common actions taken included ingestion of oral carbohydrates and calling emergency medical services; glucagon was rarely used. Despite many respondents (67%) feeling scared because of the most recent severe hypoglycemic event, only 55% (51% with type 1 and 61% with type 2) discussed this event with an HCP. The event affected the mood/emotional status, physical activities and sleep of PWD and CGs.

Conclusions: Severe hypoglycemia impacts the emotional and physical status of PWD and CGs. Despite this, many respondents did not report discussions about the most recent severe hypoglycemic event with HCPs. Furthermore, <50% of the respondents reported discussions about severe hypoglycemia with HCPs at every visit. Purposeful communication about severe hypoglycemia can help fulfil Diabetes Canada guideline recommendations to review experiences with hypoglycemia among PWD at every visit.
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April 2021

Exploring Knowledge and Perspectives of South Asian Children and Their Parents Regarding Healthy Cardiovascular Behaviors: A Qualitative Analysis.

Glob Pediatr Health 2020 1;7:2333794X20924505. Epub 2020 Jul 1.

Simon Fraser University, Burnaby, British Columbia, Canada.

South Asian children and parents have been shown to have a higher risk for cardiovascular disease (CVD) relative to white individuals. To design interventions aimed at addressing the comparatively higher burden in South Asians, a better understanding of attitudes and perspectives regarding CVD-associated behaviors is needed. As a result, we sought to understand knowledge about CVD risk in both children and parents, and attitudes toward physical activity and diet in both the children and parents, including potential cultural influences. In-depth interviews were conducted with 13 South Asian child-and-parent dyads representing a range of child body mass index (BMI) levels, ages, and with both sexes. South Asian children and parents demonstrated good knowledge about CVD prevention; however, knowledge did not always translate into behavior. The influence of social and cultural dynamics on behavior was also highlighted. To ensure that interventions aimed at this population are effective, an understanding of the unique social dynamics that influence diet and physical activity-related behaviors is needed.
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July 2020

Screening and Treatment Outcomes in Adults and Children With Type 1 Diabetes and Asymptomatic Celiac Disease: The CD-DIET Study.

Diabetes Care 2020 07 28;43(7):1553-1556. Epub 2020 Apr 28.

Division of Endocrinology, Markham-Stouffville Hospital, Markham, Ontario, Canada.

Objective: To describe celiac disease (CD) screening rates and glycemic outcomes of a gluten-free diet (GFD) in patients with type 1 diabetes who are asymptomatic for CD.

Research Design And Methods: Asymptomatic patients (8-45 years) were screened for CD. Biopsy-confirmed CD participants were randomized to GFD or gluten-containing diet (GCD) to assess changes in HbA and continuous glucose monitoring over 12 months.

Results: Adults had higher CD-seropositivity rates than children (6.8% [95% CI 4.9-8.2%, = 1,298] vs. 4.7% [95% CI 3.4-5.9%, = 1,089], = 0.035) with lower rates of prior CD screening (6.9% vs. 44.2%, < 0.0001). Fifty-one participants were randomized to a GFD ( = 27) or GCD ( = 24). No HbA differences were seen between the groups (+0.14%, 1.5 mmol/mol; 95% CI -0.79 to 1.08; = 0.76), although greater postprandial glucose increases (4-h +1.5 mmol/L; 95% CI 0.4-2.7; = 0.014) emerged with a GFD.

Conclusions: CD is frequently observed in asymptomatic patients with type 1 diabetes, and clinical vigilance is warranted with initiation of a GFD.
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July 2020

Testing an audit and feedback-based intervention to improve glycemic control after transfer to adult diabetes care: protocol for a quasi-experimental pre-post design with a control group.

BMC Health Serv Res 2019 Nov 25;19(1):885. Epub 2019 Nov 25.

ICES, Toronto, Canada.

Background: When young adults transfer from pediatric to adult diabetes care they are at risk for deterioration of glycemic control, putting them at an increased risk of developing both acute and chronic complications. Despite increased awareness of these risks, there are gaps in care delivery during this vulnerable time and variability in the implementation of recommended transition practice. Audit and feedback (AF) interventions have a positive but variable effect on implementation of best practices. An expert group identified specific suggestions for optimizing the effectiveness of AF interventions. We aim to test an AF-based intervention incorporating these specific suggestions to improve transition practices and glycemic control in the first year after transfer from pediatric to adult diabetes care.

Methods: This is a pragmatic quasi-experimental study; a series of three cohort studies (pre-implementation, early-implementation, and post-implementation) to compare the baseline adjusted hemoglobin A1c (HbA1c) in the 12 months after the final pediatric visit in five pediatric diabetes centres within the Ontario Pediatric Diabetes Network in Ontario, Canada. The intervention includes three components: 1) centre-level feedback reports compiling data from chart abstraction, linked provincial administrative datasets, and patient-reported experience measures; 2) webinars for facilitated conversations/coaching about the feedback; and 3) online repository of curated transition resources for providers. The primary outcome will be analyzed using a multivariable linear regression model. We will conduct a qualitative process evaluation to understand intervention fidelity and to provide insight into the mechanisms of action of our results.

Discussion: There is a need to develop an innovative system-level approach to improve outcomes and the quality of care for young adults with type 1 diabetes during the vulnerable time when they transfer to adult care. Our research team, a collaboration of health services, implementation science, and quality improvement researchers, are designing, implementing, and evaluating an AF-based intervention using recommendations about how to optimize effectiveness. This knowledge will be generalizable to other care networks that aim to deliver uniformly high-quality care in diverse care settings.

Trial Registration: NCT03781973. Registered 13 December 2018. Date of enrolment of the first participant to the trial: June 1, 2019.
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November 2019

Relationship between diet and acculturation among South Asian children living in Canada.

Appetite 2020 04 20;147:104524. Epub 2019 Nov 20.

McMaster University, Hamilton, ON, Canada; Population Health Research Institute, Hamilton, ON, Canada. Electronic address:

Introduction: Diet and South Asian ethnicity are both associated with early onset of cardiovascular risk factors. Among youth of South Asian origin, little is known about the role of culture in determining healthy dietary patterns. We aimed to assess dietary patterns and their relationships with acculturation to Western and traditional lifestyles among South Asian youth in Canada.

Methods: The Research in Cardiovascular Health - Lifestyles, Environments and Genetic Attributes in Children and Youth (RICH LEGACY) study targeted South Asian children and adolescents aged 7-8 and 14-15 years in two Canadian cities. In this cross-sectional study, acculturation questionnaires and food frequency questionnaires were administered to assess the correlations between Western and traditional culture scores, immigration status (generation and length of residency) in Canada and intake frequency of various foods.

Results: Among 759 youth, those who ate fruits and vegetables more often consumed dairy and whole grains more often (all r = 0.17-0.22, all p < 0.001), while those who ate fast food more often consumed meat, sweets and sugared drinks more often (all r 0.24-0.38, all p < 0.001). Traditional culture scores were weakly positively correlated with whole grain intake frequency (r = 0.12, p = 0.001), and negatively with meat intake frequency (r = -0.14, p < 0.001). Western culture scores positively correlated with high intake frequency of meat (r = 0.23, p < 0.001), fast food (r = 0.14, p < 0.001) and sweets (r = 0.14, p < 0.001).

Discussion: Children who are more acculturated with Western lifestyle consumed foods associated with increased metabolic risk. However, whether this eating pattern translates into increased risk of obesity and cardiovascular diseases needs to be further explored.
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April 2020

MRI Reveals Human Brown Adipose Tissue Is Rapidly Activated in Response to Cold.

J Endocr Soc 2019 Dec 14;3(12):2374-2384. Epub 2019 Oct 14.

Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada.

Context: In rodents, cold exposure induces the activation of brown adipose tissue (BAT) and the induction of intracellular triacylglycerol (TAG) lipolysis. However, in humans, the kinetics of supraclavicular (SCV) BAT activation and the potential importance of TAG stores remain poorly defined.

Objective: To determine the time course of BAT activation and changes in intracellular TAG using MRI assessment of the SCV ( BAT depot) and fat in the posterior neck region ( non-BAT).

Design: Cross-sectional.

Setting: Clinical research center.

Patients Or Other Participants: Twelve healthy male volunteers aged 18 to 29 years [body mass index = 24.7 ± 2.8 kg/m and body fat percentage = 25.0% ± 7.4% (both, mean ± SD)].

Interventions: Standardized whole-body cold exposure (180 minutes at 18°C) and immediate rewarming (30 minutes at 32°C).

Main Outcome Measures: Proton density fat fraction (PDFF) and T2* of the SCV and posterior neck fat pads. Acquisitions occurred at 5- to 15-minute intervals during cooling and subsequent warming.

Results: SCV PDFF declined significantly after only 10 minutes of cold exposure [-1.6% (SE: 0.44%; = 0.007)] and continued to decline until 35 minutes, after which time it remained stable until 180 minutes. A similar time course was also observed for SCV T2*. In the posterior neck fat (non-BAT), there were no cold-induced changes in PDFF or T2*. Rewarming did not result in a change in SCV PDFF or T2*.

Conclusions: The rapid cold-induced decline in SCV PDFF suggests that in humans BAT is activated quickly in response to cold and that TAG is a primary substrate.
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December 2019

Multifactorial correlates of blood pressure in South Asian children in Canada: a cross-sectional study.

BMJ Open 2019 04 8;9(4):e027844. Epub 2019 Apr 8.

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

Objective: We sought to explore various correlates of blood pressure (BP) and hypertension, and to identify the most important aggregate combination of correlates for BP in South Asian children.

Design: Cross-sectional study SETTING: Community-based recruitment in two Canadian cities PARTICIPANTS: South Asian children (n=762) provided a range of physiological, lifestyle and social variables. BP was assessed using an automated device. Body mass index (BMI), waist circumference (WC), waist-to-height ratio (WHtR) and BP were transformed to z-scores using published standards.

Outcome Measures: Linear and logistic regression analyses were used to explore associations between the range of variables with BP z-scores and hypertension while stepwise regression was used to identify aggregate factors that provided explanatory capacity for systolic BP (SBP) and diastolic BP (DBP) z-scores.

Results: A range of variables were associated with BP z-score and hypertension in unadjusted analysis. On adjustment for confounders, the association between age (β=-0.054, 95% CI=-0.078 to 0.029), female sex (β=-0.208, 95% CI=-0.350 to -0.067), height (β=0.022, 95% CI=0.011 to 0.033), weight (β=0.047, 95% CI=0.040 to 0.055), BMI z-score (β=0.292, 95% CI=0.249 to 0.336), WC z-score (β=0.273, 95% CI=0.219 to 0.326), WHtR z-score (β=0.289, 95% CI=0.236 to 0.342), heart rate (β=0.016, 95% CI=0.010 to 0.022), child's perception of body image (β=0.183, 95% CI=0.128 to 0.239) and grip strength (β=0.025, 95% CI=0.007 to 0.043) with SBP z-score remained. In stepwise regression, age, sex, BMI z-score, heart rate and weight accounted for 30% of the variance of SBP z-score, while age, BMI z-score, heart rate and daily fast food intake accounted for 23% of the DBP z-score variance.

Conclusion: Our findings suggest that variables, such as age, sex, height, adiposity and heart rate, provide stronger explanatory capacity to BP variance and hypertension risk than other variables in South Asian children.
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April 2019

Adiposity measures and their validity in estimating risk of hypertension in South Asian children: a cross-sectional study.

BMJ Open 2019 02 20;9(2):e024087. Epub 2019 Feb 20.

Department of Biomedical Physiology and Kinesiology, Simon Fraser University, Burnaby, British Columbia, Canada.

Objective: Given the South Asian phenotype of higher body fat at similar body mass index (BMI) relative to Caucasians, we sought to explore the association between prominent adiposity indicators with blood pressure (BP) and hypertension, to compare the accuracy of these indicators in estimating hypertension, and to provide cut-off values associated with adverse hypertension risk in South Asian children.

Design: Cross-sectional study.

Setting: Community-based recruitment in two Canadian cities (Hamilton and Surrey).

Participants: South Asian children (n=762) were recruited from two Canadian cities. Waist circumference, waist to height ratio and BMI were determined. Body fat percentage was assessed by bioelectrical impedance analysis and BP was assessed using an automated device. All variables (except body fat percentage) were transformed to z-scores using published standards.

Outcome Measures: Linear and Poisson regression was used to explore associations between the adiposity indicators with BP z-score and hypertension. Receiver operating curve (ROC) analysis was used to explore the strength of the adiposity indicators in estimating hypertension risk and sex-stratified optimal adiposity cut-off values associated with hypertension risk.

Results: Significant associations were detected in adjusted and unadjusted models between the adiposity indicators with BP z-score and hypertension (p<0.01 for all). The area under the curve (AUC) values for the adiposity indicators for boys and girls ranged from 0.74 to 0.80, suggesting that the adiposity indicators are fair measures of estimating hypertension risk. Sex-stratified cut-off associated with adverse risk of hypertension for girls and boys, respectively, were at the 92nd and 82nd percentile for BMI z-scores, 65th and 80th percentile for WC z-score, 63rd and 67th percentile for WHtR z-score and at 29.8% and 23.5% for body fat.

Conclusion: Our results show associations between adiposity indicators with BP and hypertension and suggests that South Asian children might be at adverse risk of hypertension at levels of adiposity considered normal.
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February 2019

The Diabetes Health Coaching Randomized Controlled Trial: Rationale, Design and Baseline Characteristics of Adults Living With Type 2 Diabetes.

Can J Diabetes 2019 Oct 17;43(7):477-482. Epub 2018 Oct 17.

Department of Health Research Methods, Evidence and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada; McMaster Evidence Review and Synthesis Team, McMaster University, Hamilton, Ontario, Canada.

Objectives: The Diabetes Health Coaching Trial was a single-blind, randomized controlled trial designed to evaluate the effect of a 1-year telephone-based diabetes health-coaching intervention for community-dwelling adults living with type 2 diabetes mellitus. It concerned glycated hemoglobin levels, self-care behaviours and cost-effectiveness. The purpose of this article is to describe the rationale, design and participants' characteristics.

Methods: The eligibility criteria were: 1) adults ≥18 years of age; 2) a diagnosis of type 2 diabetes; 3) glycated hemoglobin levels of ≥7.5% 6 months before randomization; 4) the ability to read, write and understand English; and 5) having telephone access. Participants were randomized to either usual diabetes education or diabetes education plus diabetes health coaching.

Results: From May 2016 to December 2017, 365 participants were randomized into the trial. At baseline, the mean age was 57.9 (11.78) years, the mean duration of diabetes was 8.69 (8.54) years, the mean glycated hemoglobin level was 8.98 (1.58) %, and the mean body mass index was 35.03 (8.07) kg/m.

Conclusions: The baseline characteristics of the participants were equally distributed across the intervention and control groups. The Diabetes Health Coaching Trial is in a position to evaluate a potential treatment alternative and approach for type 2 diabetes and examined the effect of the intervention on clinical outcomes, self-care behaviours and cost-effectiveness.
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October 2019

Hypoglycemia and Incident Cognitive Dysfunction: A Post Hoc Analysis From the ORIGIN Trial.

Diabetes Care 2019 01 13;42(1):142-147. Epub 2018 Nov 13.

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

Objective: Epidemiological studies have reported a relationship between severe hypoglycemia, cognitive dysfunction, and dementia in middle-aged and older people with type 2 diabetes. However, whether severe or nonsevere hypoglycemia precedes cognitive dysfunction is unclear. Thus, the aim of this study was to analyze the relationship between hypoglycemia and incident cognitive dysfunction in a group of carefully followed patients using prospectively collected data in the Outcome Reduction with Initial Glargine Intervention (ORIGIN) trial.

Research Design And Methods: This prospective cohort analysis of data from a randomized controlled trial included individuals with dysglycemia who had additional cardiovascular risk factors and a Mini-Mental State Examination (MMSE) score ≥24 ( = 11,495). Severe and nonsevere hypoglycemic events were collected prospectively during a median follow-up time of 6.2 years. Incident cognitive dysfunction was defined as either reported dementia or an MMSE score of <24. The hazard of at least one episode of severe or nonsevere hypoglycemia for incident cognitive dysfunction (i.e., the dependent variable) from the time of randomization was estimated using a Cox proportional hazards model after adjusting for baseline cardiovascular disease, diabetes status, treatment allocation, and a propensity score for either form of hypoglycemia.

Results: This analysis did not demonstrate an association between severe hypoglycemia and incident cognitive impairment either before (hazard ratio [HR] 1.16; 95% CI 0.89, 1.52) or after (HR 1.00; 95% CI 0.76, 1.31) adjusting for the severe hypoglycemia propensities. Conversely, nonsevere hypoglycemia was inversely related to incident cognitive impairment both before (HR 0.59; 95% CI 0.52, 0.68) and after (HR 0.58; 95% CI 0.51, 0.67) adjustment.

Conclusions: Hypoglycemia did not increase the risk of incident cognitive dysfunction in 11,495 middle-aged individuals with dysglycemia.
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January 2019

Association of preoperative glucose concentration with myocardial injury and death after non-cardiac surgery (GlucoVISION): a prospective cohort study.

Lancet Diabetes Endocrinol 2018 10 26;6(10):790-797. Epub 2018 Jul 26.

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

Background: Myocardial injury after non-cardiac surgery (MINS) is the most common perioperative cardiovascular complication and is independently associated with 30-day mortality. We aimed to assess the association between preoperative glucose concentration and postoperative MINS and mortality.

Methods: The VISION study is a prospective cohort study done at 12 centres in eight countries. Patients aged 45 years or older who required at least one overnight hospital admission for non-cardiac surgery were enrolled from Aug 6, 2007, to Jan 11, 2011. In the GlucoVISION analysis, we assessed the relations between preoperative casual or fasting glucose concentration and MINS within 3 days after surgery using logistic regression, and 30-day mortality using Cox proportional regression, in people with and without diabetes.

Findings: 11 954 patients were included in this analysis, of whom 2809 (23%) had diabetes. Within the first three postoperative days, MINS occurred in 813 (7%) patients. 249 (2%) patients died by day 30. More patients with diabetes had MINS (odds ratio [OR] 1·98 [95% CI 1·70-2·30]; p<0·0001), and died (OR 1·41 [1·08-1·86]; p=0·016) than did patients without diabetes. Casual glucose concentrations were associated with MINS in all patients (adjusted OR 1·06 [1·04-1·09] per 1 mmol/L increment in glucose; p=0·0003), and with death in patients without diabetes (adjusted hazard ratio [HR] 1·13 [95% CI 1·05-1·23] per mmol/L; p=0·002). We noted a progressive relation between unadjusted fasting glucose concentration and both MINS (OR 1·14 [1·08-1·20] per mmol/L; p<0·0001), driven by the effect in the subgroup without previous diabetes (p=0·025), and 30-day mortality (HR 1·10 [1·02-1·19] per mmol/L; p=0·013). For patients without diabetes, casual glucose of more than 6·86 mmol/L and fasting glucose of more than 6·41 mmol/L predicted MINS (OR 1·71 [1·36-2·15]; p<0·0001, and OR 2·71 [1·85-3·98]; p<0·0001, respectively). For patients with diabetes, only casual glucose concentration more than 7·92 mmol/L predicted MINS (OR 1·47 [1·10-1·96]; p=0·0096).

Interpretation: Preoperative glucose concentration, particularly casual glucose concentration, predicts risk for postoperative cardiovascular outcomes, especially in patients without diabetes.

Funding: Full funding sources listed at the end of the paper (see Acknowledgments).
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October 2018