Gestational diabetes: One size does not fit all-an observational study of maternal and neonatal outcomes by maternal glucose profile.

OBJECTIVES: To examine obstetrical and neonatal outcomes across maternal glucose profiles at the population level and to explore insulin sensitivity and beta-cell function across profiles in an independent, well-phenotyped cohort for potential pathophysiologic explanation. RESEARCH DESIGN AND METHODS: Observational cohort study of all pregnancies with gestational diabetes screening between October 2008 and December 2018 resulting in live singleton birth in Alberta, Canada (n = 436,773) were categorized into seven maternal glucose profiles: (1) normal 50 g-glucose challenge test (nGCT), (2) normal 75-g OGTT (nOGTT), (3) isolated elevated 1 h post-load glucose (ePLPG1), (4) isolated elevated 2 h post-load glucose (ePLPG2), (5) elevated 1 and 2 h post-load glucose (ePLPG12), (6) isolated elevated FPG (eFPG), and (7) elevated FPG + elevated 1-h and/or 2-h PLG (Combined). Primary outcomes were large for gestational age (LGA) and neonatal intensive care unit (NICU) admission rates. An independent observational cohort of 1451 women was examined for measures of beta-cell function (ISSI-2, insulinogenic index/HOMA-IR) and insulin sensitivity/resistance (Matsuda index, HOMA-IR) by similar maternal glucose profiles. RESULTS: Pregnancies with elevated FPG, either isolated or combined, had higher adverse events and lower insulin sensitivity. The combination of elevated FPG + elevated 1-h and/or 2-h PLG had the highest rates of LGA(20.9%), NICU admissions (14.7%), and lowest insulin sensitivity as measured by Matsuda index and HOMA-IR, and beta-cell function as measured by ISSI-2 and Insulinogenic index/HOMA-IR. CONCLUSIONS: Elevated fasting plasma glucose, either alone or combined with post-load glucose elevation is associated with worse outcomes than isolated post-load glucose elevation, possibly due to higher degrees of insulin resistance. Future work is needed to better understand these differences, and explore whether tailored treatment of GDM can improve neonatal outcomes.

Impact of a modified screening approach during the COVID-19 pandemic on the diagnosis and outcomes of gestational diabetes mellitus: A population-level analysis of 90,518 pregnant women.

AIMS: To provide real-world evidence on the uptake of and outcomes associated with the modified gestational diabetes mellitus (GDM) screening approach offered during the COVID-19 pandemic compared with the standard screening approach. METHODS: All pregnancies between 01 January 2020 and 31 December 2021, in Alberta, Canada, were included in the study. We examined GDM screening and diagnosis rates, and large-for-gestational-age (LGA) outcomes. RESULTS: Annual GDM screening rates were > 95% during the study time period. Overall, 84.7%, and 11.6% of the 92,505 pregnancies underwent standard and modified screening for GDM, respectively. The use of modified screening was the highest among deliveries in August 2020 (49.8%) which corresponded to the early first wave of the pandemic. GDM diagnosis rate was lower in the modified screening (7.4%) than in the standard screening (12.3%, p < 0.001) group. The LGA rates in the modified screening with GDM and the standard screening with GDM groups were 24.8% and 12.6%, respectively (p < 0.001). Women in the modified screening with GDM group were at a higher risk of having an LGA infant (adjusted odds ratio: 3.46; 95% confidence interval: 2.93, 4.08) compared to the standard screening with no GDM group. CONCLUSIONS: The COVID-19 epidemic had no impact on screening for GDM. Women who underwent modified screening, based on HbA1c/random plasma glucose, had lower rates of GDM cases.

Achievement of treatment targets among patients with type 2 diabetes in 2015 and 2020 in Canadian primary care.

BACKGROUND: An update on the degree to which patients with type 2 diabetes in Canada achieve treatment targets is needed to document progress and identify subgroups that need attention. We sought to estimate the frequency with which patients managed in primary care met treatment targets (i.e., HbA1c ≤ 7.0%, blood pressure < 130/80 mm Hg and low-density lipoprotein cholesterol [LDL-C] < 2.00 mmol/L), guideline-based use of statins and of angiotensin-convertingenzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs), and the effects of patient age and sex. METHODS: We conducted a cross-sectional study of 32 503 and 44 930 adults with diabetes in Canada on June 30, 2015, and 2020, respectively, using electronic medical record data from primary care practices across 5 provinces. We grouped achievement of diabetes targets by age and sex, and compared between groups using logistic regression with adjustment for cardiovascular comorbidities. RESULTS: In 2020, target HbA1c levels were achieved for 63.8% of women and 58.9% of men. Blood pressure and LDL-C targets were achieved for 45.6% and 45.8% of women, and for 43.1% and 59.4% of men, respectively. All 3 treatment targets were achieved for 13.3% of women and 16.5% of men. Overall, 45.3% and 54.0% of women and men, respectively, used statins; 46.5% of women used ACE inhibitors or ARBs, compared with 51.9% of men. With the exception of blood pressure and HbA1c levels among women, target achievement was lower among younger patients. Achievement of the LDL-C target, statin use and ACE inhibitor or ARB use were lower among women at any age. From 2015 to 2020, target achievement increased for HbA1c, remained consistent for LDL-C and declined for blood pressure; use of statins and of ACE inhibitors or ARBs also declined. INTERPRETATION: Target achievement for blood pressure and use of statins and of ACE inhibitors and ARBs declined between 2015 and 2020, and was suboptimal in all patient groups. Widespread quality improvement is needed to increase evidence-based therapy for people with diabetes.

Real word challenges in integrating electronic medical record and administrative health data for regional quality improvement in diabetes: a retrospective cross-sectional analysis.

BACKGROUND: Linked electronic medical records and administrative data have the potential to support a learning health system and data-driven quality improvement. However, data completeness and accuracy must first be assessed before their application. We evaluated the processes, feasibility, and limitations of linking electronic medical records and administrative data for the purpose of quality improvement within five specialist diabetes clinics in Edmonton, Alberta, a province known for its robust health data infrastructure. METHODS: We conducted a retrospective cross-sectional analysis using electronic medical record and administrative data for individuals ≥ 18 years attending the clinics between March 2017 and December 2018. Descriptive statistics were produced for demographics, service use, diabetes type, and standard diabetes benchmarks. The systematic and iterative process of obtaining results is described. RESULTS: The process of integrating electronic medical record with administrative data for quality improvement was found to be non-linear and iterative and involved four phases: project planning, information generating, limitations analysis, and action. After limitations analysis, questions were grouped into those that were answerable with confidence, answerable with limitations, and not answerable with available data. Factors contributing to data limitations included inaccurate data entry, coding, collation, migration and synthesis, changes in laboratory reporting, and information not captured in existing databases. CONCLUSION: Electronic medical records and administrative databases can be powerful tools to establish clinical practice patterns, inform data-driven quality improvement at a regional level, and support a learning health system. However, there are substantial data limitations that must be addressed before these sources can be reliably leveraged.

Association between maternal glucose and large for gestational outcomes: Real-world evidence to support Hyperglycaemia and Adverse Pregnancy Outcomes (HAPO) study findings.

AIMS: To compare large for gestational age (LGA) rates by maternal glucose levels in a real-world setting with those in the Hyperglycaemia and Adverse Pregnancy Outcomes (HAPO) study. To examine the association between fasting plasma glucose (FPG), 1- and 2-h on a 75-g oral glucose tolerance tests (OGTT) and LGA. METHODS: Pregnancies were categorized according to HAPO thresholds. Category-specific LGA rates were compared to those in HAPO. Categories with glucose thresholds below or above the diagnostic criteria for gestational diabetes mellitus (GDM) were labelled as lower and higher/GDM, respectively. GDM pregnancies were further stratified according to FPG or post-load elevations and logistic regression was used to examine their independent association with LGA. FINDINGS: In our cohort of 97,032 pregnancies, rates of LGA increased with increasing maternal glucose in lower categories of FPG, 1- and 2-h glucose (trend p < 0.01). However, LGA rates in higher/GDM categories were significantly lower in our study than those in HAPO for 1- and 2-h glucose, but not for FPG. Elevated FPG alone was associated with an almost twofold increase in risk of LGA, while elevated post-load glucose alone was associated with a 20% reduction in risk of LGA, compared to negative OGTT. CONCLUSIONS: Real-world data confirm the HAPO study findings at lower levels of maternal glycaemia. At higher levels, GDM diagnosis and treatment appear to be effective in reducing rates of LGA in pregnancies with post-load glucose elevations, but not elevated FPG. Elevated FPG is a stronger predictor of LGA than post-load glucose elevations.

Understanding the bigger picture: syndemic interactions of the immigrant and refugee context with the lived experience of diabetes and obesity.

BACKGROUND: Providing contextually appropriate care and interventions for people with diabetes and/or obesity in vulnerable situations within ethnocultural newcomer communities presents significant challenges. Because of the added complexities of the refugee and immigrant context, a deep understanding of their realities is needed. Syndemic theory sheds light on the synergistic nature of stressors, chronic diseases and environmental impact on immigrant and refugee populations living in vulnerable conditions. We used a syndemic perspective to examine how the migrant ethnocultural context impacts the experience of living with obesity and/or diabetes, to identify challenges in their experience with healthcare. METHODS: This qualitative participatory research collaborated with community health workers from the Multicultural Health Brokers Cooperative of Edmonton, Alberta. Study participants were people living with diabetes and/or obesity from diverse ethnocultural communities in Edmonton and the brokers who work with these communities. We conducted 3 focus groups (two groups of 8 and one of 13 participants) and 22 individual interviews (13 community members and 9 brokers). The majority of participants had type 2 diabetes and 4 had obesity. We conducted a thematic analysis to explore the interactions of people's living conditions with experiences of: 1) diabetes and obesity; and 2) healthcare and resources for well-being. RESULTS: The synergistic effects of pre- and post-immigration stressors, including lack of social network cultural distance, and poverty present an added burden to migrants' lived experience of diabetes/obesity. People need to first navigate the challenges of immigration and settling into a new environment in order to have capacity to manage their chronic diseases. Diabetes and obesity care is enhanced by the supportive role of the brokers, and healthcare providers who have an awareness of and consideration for the contextual influences on patients' health. CONCLUSIONS: The syndemic effects of the socio-cultural context of migrants creates an additional burden for managing the complexities of diabetes and obesity that can result in inadequate healthcare and worsened health outcomes. Consequently, care for people with diabetes and/or obesity from vulnerable immigrant and refugee situations should include a holistic approach where there is an awareness of and consideration for their context.

Association between maternal diabetes, being large for gestational age and breast-feeding on being overweight or obese in childhood.

AIMS/HYPOTHESIS: This study aimed to examine the association of maternal diabetes, being large for gestational age (LGA) and breast-feeding with being overweight or obese in pre-school-aged children. METHODS: Data on height and weight at the time of their pre-school (age 4-6 years) immunisation visit between January 2009 and August 2017, as well as breast-feeding status in the first 5 months of life, for 81,226 children born between January 2005 and August 2013 were linked with maternal hospitalisation and outpatient records and birth registry data. Children were grouped into six categories based on maternal diabetes status during pregnancy (no diabetes, gestational diabetes or pre-existing diabetes) and birthweight (appropriate for gestational age [AGA] or LGA). WHO criteria were used to identify children who were overweight or obese. RESULTS: There were 69,506 children in the no diabetes/AGA group (control), 5926 in the no diabetes/LGA group, 4563 in the gestational diabetes/AGA group, 573 in the gestational diabetes/LGA group, 480 in the pre-existing diabetes/AGA group and 178 in the pre-existing diabetes/LGA group. The rate of being overweight/obese at pre-school age ranged from 20.5% in the control group to 42.9% in the gestational diabetes/LGA group. The adjusted attributable risk per cent for LGA alone (39.4%) was significantly higher than that for maternal gestational diabetes (16.0%) or pre-existing diabetes alone (15.1%); the risk for the combinations of gestational diabetes/LGA and pre-existing diabetes/LGA were 50.1% and 39.1%, respectively. Further stratification of the pre-existing diabetes groups found the prevalence of being overweight/obese was 21.2% in the type 1/AGA group, 31.4% in the type 1/LGA group (similar to those in the no diabetes groups), 26.7% in the type 2/AGA group and 42.5% in the type 2/LGA group. Breast-feeding was associated with a lower likelihood of being overweight/obese in childhood in all groups except gestational diabetes/LGA and pre-existing diabetes/LGA (both type 1 and type 2). CONCLUSION/INTERPRETATION: LGA is a stronger marker for risk of being overweight/obese in early childhood, compared with maternal diabetes during pregnancy. Rates of being overweight/obese in childhood were highest in LGA children born to mothers with gestational diabetes or pre-existing type 2 diabetes. Breast-feeding was associated with a lower risk of being overweight/obese in childhood in the majority of children; however, this association was not maintained in LGA children of mothers with diabetes.

Not quite type 1 or type 2, what now? Review of monogenic, mitochondrial, and syndromic diabetes.

Diabetes mellitus is a heterogeneous group of conditions defined by resultant chronic hyperglycemia. Given the increasing prevalence of diabetes mellitus and the increasing understanding of genetic etiologies, we present a broad review of rare genetic forms of diabetes that have differing diagnostic and/or treatment implications from type 1 and type 2 diabetes. Advances in understanding the genotype-phenotype associations in these rare forms of diabetes offer clinically available examples of evolving precision medicine where defining the correct genetic etiology can radically alter treatment approaches. In this review, we focus on forms of monogenic diabetes, mitochondrial diabetes, and syndromic diabetes.

Atteinte des cibles thérapeutiques pour le diabète de type 2 en 2015 et 2020 en médecine de soins primaires au Canada.

CONTEXTE: Une vérification du degré d'atteinte des cibles thérapeutiques pour le diabète de type 2 au Canada s'impose afin d'en documenter l'évolution et d'identifier les sousgroupes auprès desquels il est plus urgent d'intervenir. Nous avons voulu estimer la fréquence à laquelle les cas suivis en soins primaires atteignaient leurs cibles thérapeutiques (c.-a-d., HbA1c ≤ 7,0 %, tension artérielle (TA) < 130/80 mm Hg et cholestérol à lipoprotéines de basse densité [LDL-C] < 2,00 mmol/L), le recours aux statines et aux inhibiteurs de l'enzyme de conversion de l'angiotensine (IECA) ou aux bloqueurs des récepteurs de l'angiotensine (BRA) conformément aux lignes directrices, et les effets de l'âge et du sexe. MÉTHODES: Nous avons réalisé une étude transversale auprès de 32 503 et 44 930 adultes atteints de diabète au Canada le 30 juin 2015 et le 30 juin 2020, respectivement, à l'aide des données tirées des dossiers médicaux électroniques (DME) des milieux de soins primaires de 5 provinces. Nous avons regroupé l'atteinte des cibles thérapeutiques pour le diabète selon l'âge et le sexe et comparé les groupes à l'aide d'analyses de régression logistique en tenant compte des comorbidités cardiovasculaires. RÉSULTATS: En 2020, les taux cibles d'HbA1c ont été atteints par 63,8 % des femmes et 58,9 % des hommes. Les cibles de TA et de LDL-C ont été atteintes par 45,6 % et 45,8 % des femmes et par 43,1 % et 59,4 % des hommes, respectivement. Les 3 cibles thérapeutiques ont été atteintes par 13,3 % des femmes et 16,5 % des hommes. Globalement, 45,3 % et 54,0 % des femmes et des hommes, respectivement, ont utilisé des statines; 46,5 % des femmes ont utilisé des inhibiteurs de l'ECA ou des BRA, contre 51,9 % des hommes. À l'exception de la TA et des taux d'HbA1c chez les femmes, l'atteinte des cibles a été moindre chez les patientes plus jeunes. L'atteinte de la cible de LDL-C et l'utilisation de statines et d'IECA ou de BRA ont été moindres chez les femmes de toutes les catégories d'âge. Entre 2015 et 2020, l'atteinte des cibles a augmenté pour l'HbA1c, est demeurée constante pour le LDL-C et a diminué pour la TA; l'utilisation des statines et des IECA ou des BRA a aussi diminué. INTERPRÉTATION: L'atteinte des cibles de TA et l'utilisation des statines, des IECA et des BRA ont diminué entre 2015 et 2020 et étaient sous-optimales dans tous les groupes. Une amélioration à grande échelle de la qualité des soins s'impose pour promouvoir un traitement du diabète fondé sur des données probantes.

Measuring depression with CES-D in Chinese patients with type 2 diabetes: the validity and its comparison to PHQ-9.

BACKGROUND: The validity of the 20-item Center for Epidemiological Studies Depression (CES-D) scale for depression screening in Hong Kong Chinese patients with type 2 diabetes remains unknown. We aimed to validate CES-D, compare its psychometric properties with the 9-item Patient Health Questionnaire (PHQ-9), and explore whether one of the two is more suitable for depression screening in Chinese patients with type 2 diabetes. METHODS: Between June 2010 and July 2011, 545 consecutive Chinese patients with type 2 diabetes who underwent structured comprehensive assessments completed the CES-D and PHQ-9. Forty patients were retested within 2-4 weeks by telephone interview and 97 patients were randomly selected to undergo the Mini International Neuropsychiatric Interview (MINI) by psychiatrists for clinical diagnosis of depression. RESULTS: The internal consistency (Cronbach's α) of CES-D was 0.85, with a test-retest correlation coefficient of 0.64. The area under the curve for CES-D compared to the clinical diagnosis of major depression was 0.85. A cut-off score of ≥21 for CES-D provided the optimal balance between sensitivity (78.3 %) and specificity (74.3 %) and identified 17.8 % (n = 97) of patients with depression. CES-D and PHQ-9 showed moderate agreement in depression screening (Cohen's Kappa: 0.45). Compared to non-depressed patients, those who screened positive by PHQ-9 had a higher HbA1c whereas the glycemic differences were not significant when using CES-D. CONCLUSION: The CES-D is a valid screening tool for depression in Chinese type 2 diabetic patients although the PHQ-9 was more discriminative in identifying those with suboptimal glycemic control.

Association Between Hemoglobin A1c and Development of Cardiovascular Disease in Canadian Men and Women Without Diabetes at Baseline: A Population-Based Study of 608 474 Adults.

BACKGROUND: We examined the association between hemoglobin A1c (HbA1c) and the development of cardiovascular disease (CVD) in men and women, without diabetes or CVD at baseline. METHODS AND RESULTS: This retrospective cohort study included adults aged 40 to <80 years in Alberta, Canada. Men and women were divided into categories based on a random HbA1c during a 3-year enrollment period. The primary outcome of CVD hospitalization and secondary outcome of combined CVD hospitalization/mortality were examined during a 5-year follow-up period until March 31, 2021. A total of 608 474 individuals (55.2% women) were included. Compared with HbA1c 5.0% to 5.4%, men with HbA1c of 5.5% to 5.9% had an increased risk of CVD hospitalization (adjusted hazard ratio [aHR], 1.12 [95% CI, 1.07-1.19]) whereas women did not (aHR, 1.01 [95% CI, 0.95-1.08]). Men and women with HbA1c of 6.0% to 6.4% had a 38% and 17% higher risk and men and women with HbA1c ≥6.5% had a 79% and 51% higher risk of CVD hospitalization, respectively. In addition, HbA1c of 6.0% to 6.4% and HbA1c ≥6.5% were associated with a higher risk (14% and 41%, respectively) of CVD hospitalization/death in men, but HbA1c ≥6.5% was associated with a 24% higher risk only among women. CONCLUSIONS: In both men and women, HbA1c ≥6.0% was associated with an increased risk of CVD and mortality outcomes. The association between CVD and HbA1c levels of 5.5% to 5.9%, considered to be in the "normal" range, highlights the importance of optimizing cardiovascular risk profiles at all levels of glycemia, especially in men.

Real-world Use and Outcomes of Sodium-glucose Cotransporter-2 Inhibitors in Adults With Diabetes and Heart Failure: A Population-level Cohort Study in Alberta, Canada.

OBJECTIVES: Since 2016, clinical guidelines have recommended sodium-glucose cotransporter-2 inhibitors (SGLT2is) for people with type 2 diabetes with heart failure. We examined SGLT2i dispensation, factors associated with dispensation, and heart failure hospitalization and all-cause mortality in people with diabetes and heart failure. METHODS: This retrospective, population-based cohort study, identified people with diabetes and heart failure between Jan 1, 2014 to Dec 31, 2017 in Alberta, Canada and followed them for a minimum of three years for SGLT2i dispensation and outcomes. Multivariate logistic regression assessed the factors associated with SGTL2i dispensation. Propensity scores were used with regression adjustment to estimate the effect of SGLT2i treatment on heart failure hospitalization. RESULTS: Among 22,025 individuals with diabetes and heart failure (43.4% women, mean age 74.7±11.8 years), only 10.2% were dispensed an SGLT2i. Male sex, age <65 years, a higher baseline A1C, no chronic kidney disease, presence of atherosclerotic cardiovascular disease, and urban residence were associated with SGLT2i dispensation. Lower heart failure hospitalization rates were observed in those with SGLT2i dispensation (548.1 per 100 person years) vs those without (813.5 per 1,000 person years; p<0.001) and lower all-cause mortality in those with an SGLT2i than those without (48.5 per 1,000 person years vs 206.1 per 1,000 person years; p<0.001). Regression adjustment found SGLT2i therapy was associated with a 23% reduction in hospitalization. CONCLUSIONS: SGLT2is were dispensed to only 10% of people with diabetes and established heart failure, underscoring a significant care gap. SGLT2i use was associated with a real-world reduction in heart failure hospitalization and all-cause death. This study highlights an important opportunity to optimize SGLT2i use.

Validity of Alternative Claims-based Algorithms for Type 1, Type 2, and Gestational Diabetes in Pregnancy.

OBJECTIVE: Our aim in this study was to evaluate the accuracy of alternative algorithms for identifying pre-existing type 1 or 2 diabetes (T1DM or T2DM) and gestational diabetes mellitus (GDM) in pregnant women. METHODS: Data from a clinical registry of pregnant women presenting to an Edmonton diabetes clinic between 2002 and 2009 were linked and administrative health records. Three algorithms for identifying women with T1DM, T2DM, and GDM based on International Classification of Diseases---tenth revision (ICD-10) codes were assessed: delivery hospitalization records (Algorithm #1), outpatient clinics during pregnancy (Algorithm #2), and delivery hospitalization plus outpatient clinics during pregnancy (Algorithm #3). In a subset of women with clinic visits between 2005 and 2009, we examined the performance of an additional Algorithm #4 based on Algorithm #3 plus outpatient clinics in the 2 years before pregnancy. Using the diabetes clinical registry as the "gold standard," we calculated true positive rates and agreement levels for the algorithms. RESULTS: The clinical registry included data on 928 pregnancies, of which 90 were T1DM, 89 were T2DM, and 749 were GDM. Algorithm #3 had the highest true positive rate for the detection of T1DM, T2DM, and GDM of 94%, 72%, and 99.9%, respectively, resulting in an overall agreement of 97% in diagnosis between the administrative databases and the clinical registry. Algorithm #4 did not provide much improvement over Algorithm #3 in overall agreement. CONCLUSIONS: An algorithm based on ICD-10 codes in the delivery hospitalization and outpatient clinic records during pregnancy can be used to accurately identify women with T1DM, T2DM, and GDM.

Use of sodium-glucose cotransporter 2 inhibitors in Alberta adults with chronic kidney disease: a cross-sectional study identifying care gaps to inform knowledge translation.

BACKGROUND: Sodium-glucose cotransporter 2 (SGLT2) inhibitors have important kidney and cardiovascular benefits in adults with chronic kidney disease. Among adults with diabetes, we characterized the prevalence of chronic kidney disease eligible for SGLT2 inhibitor treatment, based on definitions of eligibility from trials and diabetes guidelines, and assessed the predictors of SGLT2 inhibitor use. METHODS: We conducted a cross-sectional study using linked administrative data from Alberta Health in adults with diabetes (2002-2019). Chronic kidney disease was defined as an estimated glomerular filtration rate (eGFR) less than 90 mL/min/1.73 m2 with severe or greater proteinuria (trial-based definition); or eGFR less than 60 mL/min/1.73 m2 or moderate or greater proteinuria regardless of eGFR (diabetes guideline-based definition). Predictors (sociodemographic characteristics, comorbidities and health care utilization) of SGLT2 inhibitor use were identified using logistic regression. RESULTS: Of 446 315 adults with diabetes, 76 630 (17.2%, guideline-based definition; 12 867 [2.9%], trial-based definition) had chronic kidney disease eligible for SGLT2 inhibitor treatment. A total of 7.1% used SGLT2 inhibitors. Older age, lower hemoglobin A1c (HbA1c) levels, female sex, lower neighbourhood income, rural residence and hospital admission were among variables associated with nonuse of SGLT2 inhibitors (adjusted odds ratios [ORs] from 0.13 [age ≥ 85 yr] to 0.92 [rural residence], p < 0.05). Family physician visits were associated with higher SGLT2 inhibitor use (adjusted OR 4.01, p < 0.001 for > 4 visits/yr). Considering all adults, both with and without diabetes, 162 012 individuals with chronic kidney disease (5% of all Alberta adults) may benefit from treatment with SGLT2 inhibitors. INTERPRETATION: Many adults with chronic kidney disease would derive heart and kidney benefits from treatment with SGLT2 inhibitors but had low SGLT2 inhibitor use as of 2019. Efforts will be needed to address lower use of SGLT2 inhibitors among female, older and lower-income adults, and to enhance primary care and promote awareness of the benefits of SGLT2 inhibitors independent of glycemic control.

Temporal Trends in Type 1, Type 2, and Gestational Diabetes in Pregnancy: Impact of Rural Residence, Ethnicity, and Material Deprivation.

OBJECTIVE: Our aim in this study was to implement a newly validated algorithm to identify pregnant women with type 1 diabetes mellitus (T1DM), type 2 diabetes mellitus (T2DM), and gestational diabetes mellitus (GDM), and to identify temporal trends in rates over the last decade. We also compared obstetric and neonatal outcomes of pregnancies with and without diabetes mellitus (DM). METHODS: Among women with live births between 2005 and 2018 in Alberta, we calculated yearly rates of T1DM, T2DM, and GDM, overall, and stratified by ethnicity, urban or rural residence, material deprivation score, and maternal age. RESULTS: Between 2005 and 2018, GDM rates increased from 42.3 to 101.8 per 1,000 deliveries (p<0.0001), T2DM rates increased from 2.6 to 6.4 per 1,000 deliveries (p<0.0001), whereas T1DM remained constant at 3.0 per 1,000 deliveries each year (p=0.4301). Higher GDM and T2DM rates were observed among Chinese and South Asian women, respectively, and among women who were materially deprived and living in urban areas. Women with T2DM were older and had the highest rates of pre-existing hypertension (16%). In contrast, women with T1DM were younger and had the highest rates of gestational hypertension (12%), pre-eclampsia (12%), and cesarean section deliveries (62%). Children of women with T1DM had the highest rates of large for gestational age (46%), neonatal hypoglycemia (41.1%), respiratory distress syndrome (7.7%), and jaundice (29.3%). CONCLUSIONS: Diabetes-in-pregnancy rates have more than doubled over the last decade, driven primarily by increases in GDM and T2DM. These trends may have significant implications for the future health of mothers and children in Alberta.

Association Between Maternal Glucose Levels in Gestational Diabetes Screening and Subsequent Hypertension.

BACKGROUND: We assessed the association between maternal glucose levels in pregnancy and subsequent hypertension. METHODS: This population-level, retrospective cohort study examined women aged 12 to 54 years with singleton pregnancies completed at ≥29 weeks of gestation from October 1, 2008 to December 1, 2018 followed until March 31, 2019 in Alberta, Canada. Women were stratified by results in the 50-gram glucose challenge test and by 75-gram oral glucose tolerance test subtypes (normal oral glucose tolerance test, elevated fasting plasma glucose only [elevated fasting], elevated postload glucose only, or both elevated fasting and postload glucose [combined]. Time to development of hypertension was modeled using Cox proportional hazards models. RESULTS: Of 313 361 women, 231 008 (79.1%) underwent a glucose challenge test only while 60 909 (20.9%) underwent either an oral glucose tolerance test only or both. Nine thousand five hundred eighty (3.1%) developed hypertension, and 2824 (0.9%) developed cardiovascular disease over a median follow-up of 5.7 years. Every 1-mmol/L increase in glucose in the glucose challenge test increased the risk of subsequent hypertension by 15% (adjusted hazard ratio and 95% CI, 1.15 [1.14-1.16]). Among those who underwent the oral glucose tolerance test, the combined group conferred the highest risk of subsequent hypertension, followed by elevated fasting, then elevated postload glucose only (reference: glucose challenge test ≤7.1 mmol/L, adjusted hazard ratio [95% CI]: elevated postload glucose only, 1.83 [1.68-2.00]; elevated fasting 2.02 [1.70-2.40]; combined, 2.65 [2.33-3.01]). No significant associations between maternal glucose levels and cardiovascular disease were observed. CONCLUSIONS: Increasing maternal glucose levels in pregnancy were associated with increasing risk of subsequent hypertension. These findings may help identify higher-risk women who should be targeted for earlier postpartum cardiovascular risk reduction.

Identifying Sex-Specific Differences in Young-Onset Metabolic Syndrome Using Primary Care Electronic Medical Record.

Objectives: To apply a case definition to a Northern Alberta-based primary care practice population and to assess the sex-specific characteristics of young-onset metabolic syndrome (MetS). Design: We carried out a cross-sectional study to identify and estimate the prevalence of MetS using electronic medical record (EMR) data and perform descriptive comparative analyses of demographic and clinical characteristics between males and females. Setting: Northern Alberta Primary Care Research Network (NAPCReN) consists of EMR patient data from 77 physicians among 18 clinics. Participants: Patients with one or more clinic visit between 2015 and 2018, between 18 and 40 years old, residing in Northern Alberta. Main Outcome Measures: Comparison of prevalence in MetS between sexes as well as sex-specific distribution of MetS characteristics [body mass index (BMI), fasting blood glucose, glycated hemoglobin, triglycerides, and high-density lipoprotein cholesterol (HDL-C), presence of hypertension, and presence of diabetes]. Results: Of 15,766 patients, 4.4% (n = 700) had young-onset MetS based on recorded data, prevalence was nearly twice as high in males (6.1%, n = 354) compared with females (3.5%, n = 346). The most prevalent risk factor for MetS consisted of having an elevated BMI for both females (90.9%) and males (91.5%). In the presence of MetS, more females had lower HDL-C [68.2% females (F) vs. 52.5% males (M)], and higher prevalence of diabetes (21.4% F vs. 9.0% M), whereas more males had hypertriglyceridemia (60.4% F vs. 79.7% M) and hypertension (12.4% F vs. 15.8% M). Females also had consistently higher percentages of absent laboratory data compared with males when identified as having MetS and BMI ≥25 kg/m2. Conclusions: Males have nearly twice the prevalence of young-onset MetS compared with females, with notable sex-specific differences in the manifestation of MetS, although we suspect that this is partially due to underreporting where the absence of anthropomorphic and laboratory investigations point to a lack of testing. Sex-specific screening for MetS, especially among young females of childbearing years, is important for downstream prevention.

Health care providers' perspectives on challenges and opportunities of intercultural health care in diabetes and obesity management: a qualitative study.

BACKGROUND: Migrants often face worse health outcomes in countries of transit and destination because of challenges such as financial constraints, employment problems, lack of a network of social support, language and cultural differences, and difficulties accessing health services. As understanding how the migrant context affects patient-provider engagement is critical to the provision of contextually appropriate care, this study aimed at understanding primary health care provider perspectives on challenges and opportunities of the intercultural care process for migrant patients with diabetes and obesity. METHODS: This qualitative study within a multimethod, participatory research project involved primary care providers in clinics and primary care networks in Edmonton, Alberta, between September 2019 and February 2020. We explored health care providers' approaches to diabetes and obesity management, and experiences of and challenges with intercultural care. We conducted a thematic analysis using an interpretive qualitative approach. RESULTS: We conducted 9 interviews and 4 focus groups and identified 3 themes: a shift from traditional weight loss-centred approaches; relationships and navigating cultural distance; and importance of and limitations in identifying and addressing root causes and barriers. Health care providers encounter considerable nonmedical challenges when supporting immigrant patients, such as navigating cultural distance and working with patients' financial constraints. INTERPRETATION: The nonmedical challenges we identified can hinder the process of chronic disease management. Thus, in addition to educational programs and trainings to enhance the cultural competency of health care providers, incorporating avenues for cultural brokering in health care can provide invaluable support in patient-provider engagements to mitigate these challenges.