Where to Start? Physical Assessment, Readiness, and Exercise Recommendations for People With Type 1 or Type 2 Diabetes.

Exercise plays an important role in the management of diabetes and is associated with many benefits such as decreased morbidity and mortality. For people exhibiting signs and symptoms of cardiovascular disease, pre-exercise medical clearance is warranted; however, requiring broad screening requirements can lead to unnecessary barriers to initiating an exercise program. Robust evidence supports the promotion of both aerobic and resistance training, with evidence emerging on the importance of reducing sedentary time. For people with type 1 diabetes, there are special considerations, including hypoglycemia risk and prevention, exercise timing (including prandial status), and differences in glycemic responses based on biological sex.

Behavioral Programs for Type 1 Diabetes Mellitus: A Systematic Review and Meta-analysis.

BACKGROUND: Whether behavioral approaches for self-management programs benefit individuals with type 1 diabetes mellitus is unclear. PURPOSE: To determine the effects of behavioral programs for patients with type 1 diabetes on behavioral, clinical, and health outcomes and to investigate factors that might moderate effect. DATA SOURCES: 6 electronic databases (1993 to June 2015), trial registries and conference proceedings (2011 to 2014), and reference lists. STUDY SELECTION: 36 prospective, controlled studies involving participants of any age group that compared behavioral programs with usual care, active controls, or other programs. DATA EXTRACTION: One reviewer extracted and another verified data. Two reviewers assessed quality and strength of evidence (SOE). DATA SYNTHESIS: Moderate SOE showed reduction in glycated hemoglobin (HbA1c) at 6 months after the intervention compared with usual care (mean difference, -0.29 [95% CI, -0.45 to -0.13] percentage points) and compared with active controls (-0.44 [CI, -0.69 to -0.19] percentage points). At the end of the intervention and 12-month follow-up or longer, there were no statistically significant differences in HbA1c (low SOE) for comparisons with usual care or active control. Compared with usual care, generic quality of life at program completion did not differ (moderate SOE). Other outcomes had low or insufficient SOE. Adults appeared to benefit more for glycemic control at program completion (-0.28 [CI, -0.57 to 0.01] percentage points) than did youth (-0.12 [CI, -0.43 to 0.19] percentage points). Program intensity appeared not to influence effectiveness; some individual delivery appears beneficial. LIMITATIONS: All studies had medium or high risk of bias. There was scarce evidence for many outcomes. CONCLUSION: Behavioral programs for type 1 diabetes offer some benefit for glycemic control, at least at short-term follow-up, but improvement for other outcomes has not been shown. (PROSPERO registration number: CRD42014010515). PRIMARY FUNDING SOURCE: Agency for Healthcare Research and Quality. (PROSPERD registration number: CRD42014010515).

Behavioral Programs for Type 2 Diabetes Mellitus: A Systematic Review and Network Meta-analysis.

BACKGROUND: Behavioral programs may improve outcomes for individuals with type 2 diabetes mellitus, but there is a large diversity of behavioral interventions and uncertainty about how to optimize the effectiveness of these programs. PURPOSE: To identify factors moderating the effectiveness of behavioral programs for adults with type 2 diabetes. DATA SOURCES: 6 databases (1993 to January 2015), conference proceedings (2011 to 2014), and reference lists. STUDY SELECTION: Duplicate screening and selection of 132 randomized, controlled trials evaluating behavioral programs compared with usual care, active controls, or other behavioral programs. DATA EXTRACTION: One reviewer extracted and another verified data. Two reviewers independently assessed risk of bias. DATA SYNTHESIS: Behavioral programs were grouped on the basis of program content and delivery methods. A Bayesian network meta-analysis showed that most lifestyle and diabetes self-management education and support programs (usually offering ≥ 11 contact hours) led to clinically important improvements in glycemic control (≥ 0.4% reduction in hemoglobin A1c [HbA1c]), whereas most diabetes self-management education programs without added support-especially those offering 10 or fewer contact hours-provided little benefit. Programs with higher effect sizes were more often delivered in person than via technology. Lifestyle programs led to the greatest reductions in body mass index. Reductions in HbA1c seemed to be greater for participants with a baseline HbA1c level of 7.0% or greater, adults younger than 65 years, and minority persons (subgroups with ≥ 75% nonwhite participants). LIMITATIONS: All trials had medium or high risk of bias. Subgroup analyses were indirect, and therefore exploratory. Most outcomes were reported immediately after the interventions. CONCLUSION: Diabetes self-management education offering 10 or fewer hours of contact with delivery personnel provided little benefit. Behavioral programs seem to benefit persons with suboptimal or poor glycemic control more than those with good control. PRIMARY FUNDING SOURCE: Agency for Healthcare Research and Quality. (PROSPERO registration number: CRD42014010515).

Cardiac rehabilitation completion is associated with reduced mortality in patients with diabetes and coronary artery disease.

AIMS: Cardiac rehabilitation (CR) reduces the risks of mortality and hospitalisation in patients with coronary artery disease and without diabetes. It is unknown whether patients with diabetes obtain the same benefits from CR. METHODS: We retrospectively examined patients referred to a 12 week CR programme between 1996 and 2010. Associations between CR completion vs non-completion and death, hospitalisation rate and cardiac hospitalisation rate were assessed by survival analysis. RESULTS: Over the study period, 13,158 participants were referred to CR (mean ± SD, age 59.9 ± 11.1 years, 28.9% female, 2,956 [22.5%] with diabetes). Patients with diabetes were less likely to complete CR than those without diabetes (41% vs 56%, p < .0001). Over a median follow-up of 6.6 years, there were 379 deaths in patients with diabetes vs 941 deaths among those without diabetes (12.8% vs 8.9%). Of the non-completers, patients with diabetes had a higher mortality rate compared with those without diabetes (17.7% vs 11.3%). In patients who completed CR, mortality was lower: 11.1% in patients with diabetes vs 7.0% in those without diabetes. In patients with diabetes, CR completion was associated with reduced mortality (HR 0.46 [95% CI 0.37, 0.56]), reduced hospitalisation (HR 0.86 [95% CI 0.76, 0.96]) and reduced cardiac hospitalisation (HR 0.67 [95% CI 0.54, 0.84]). The protective associations were similar to those of patients without diabetes. In multivariable adjusted analyses, all of these associations remained significant. CONCLUSIONS: Patients with diabetes were less likely to complete CR than those without diabetes. However, patients with diabetes who completed CR derived similar apparent reductions in mortality and hospitalisation to patients without diabetes.

Moving beyond cardio: the value of resistance training, balance training, and other forms of exercise in the management of diabetes.

IN BRIEF Traditionally, aerobic training has been a central focus of exercise promotion for diabetes management. However, people with diabetes have much to gain from other forms of exercise. This article reviews the evidence and recommendations on resistance, balance, and flexibility training, as well as other, less traditional, forms of exercise such as yoga and Tai Chi.

The Feasibility and Effects of Self-Acupressure on Symptom Burden and Quality of Life in Hemodialysis Patients: A Pilot RCT.

Background: Symptom burden among long-term hemodialysis (HD) patients is high, and addressing symptoms has been identified as a key research priority by patients. Acupressure has shown some effectiveness in management of symptoms in patients with HD. Objective: The purpose of this study was to explore the feasibility and the effect of implementing a self-administered acupressure intervention on symptom burden and quality of life for in-center HD patients. Design: A pilot randomized controlled study. Setting: Two outpatient community HD clinics between in Calgary, Alberta, Canada. Patients or Sample or Participants: Patients on HD for at least 3 months and with at least one symptom score rated greater than moderate were eligible for the study. Methods: Participants were randomized into either the (1) self-acupressure + usual care or (2) usual care alone group. Participants in the acupressure group were given a wooden acupressure tool and taught how to self-administer protocol on 6 acupressure sites for the 4-weeek study duration. Feasibility outcomes were assessed through satisfaction surveys and attrition. Other outcomes included quality of life and symptom scores by validated questionnaires (EQ-5D-5L and Integrated Palliative Outcome Score-Renal [IPOS-Renal]). Results: Thirty-two participants were successfully enrolled in the study; acceptability was high with study completion at 98% in the intervention group and 82% adherence rate to the 4-week protocol. Participants in the intervention group reported an improved change score in quality of life (EQ-5D-5L Index Score change = +0.053; EQ-5D-5L visual analog scale score change = +6.7). Participants in the intervention group also reported improved symptom scores (IPOS-Renal overall change = -2.8). Limitations: Small sample size and intervention duration are limitations of this pilot study. Conclusions: The results from this study suggest that self-acupressure was acceptable and feasible in this sample of HD patients. Self-acupressure may have a role for supporting the management of symptoms in HD patients. These pilot results can be used to inform larger more definitive investigations.

Contexte: Les symptômes associés à la maladie représentent un lourd fardeau pour les patients traités par hémodialyse (HD) chronique. Ces derniers ont d'ailleurs identifié le traitement des symptômes comme une de leurs principales priorités de recherche. Dans cette population, la digitoponcture a montré une certaine efficacité pour la gestion des symptômes. Objectif: Cette étude visait à explorer la faisabilité de la mise en œuvre d'une intervention de digitoponcture autoadministrée et à évaluer son effet sur le fardeau des symptômes et la qualité de vie des patients sous HD en center. Conception: Étude pilote randomisée et contrôlée. Cadre: Deux cliniques ambulatoires communautaires d'HD à Calgary, en Alberta (Canada). Sujets: Étaient admissibles tous les patients sous HD depuis au moins 3 mois et présentant au moins un symptôme jugé plus « sévère ¼ que « modéré ¼. Méthodologie: Les participants ont été répartis aléatoirement dans deux groupes: a) digitoponcture autoadministrée + soins habituels (intervention) ou b) soins habituels seulement. Les participants du groupe intervention ont reçu un outil de digitoponcture en bois et ont appris le protocole pour s'autoadministrer le traitement sur 6 sites pendant quatre semaines (durée de l'étude). La faisabilité a été évaluée au moyen de sondages sur la satisfaction et par l'attrition. Les autres critères de jugement comprenaient la qualité de vie et les scores d'évaluation des symptômes obtenus par le biais de questionnaires validés (EQ-5D-5L et IPOS-Renal). Résultats: Trente-deux participants ont intégré l'étude avec succès; l'acceptabilité était élevée dans le groupe intervention, comme en témoignent les taux très élevés d'achèvement de l'étude (98 %) et d'adhésion (82 %) au protocole de 4 semaines. Les participants du groupe intervention ont signalé une amélioration des scores de changement de la qualité de vie (changement du score de l'indice EQ-5D-5L = +0,053; changement du score sur l'échelle visuelle analogique EQ-5D-5L = +6,7). Ce même groupe a également signalé une amélioration des scores associés aux symptômes (changement global pour IPOS-Renal = -2,8). Limites: Les résultats de cette étude pilote sont limités par la petite taille de l'échantillon et la courte durée de l'intervention. Conclusion: Les résultats de cette étude montrent que l'auto-administration d'un protocole de digitoponcture a été faisable et bien accepté dans cet échantillon de patients sous HD. La digitoponcture autoadministrée pourrait soutenir la prise en charge des symptômes chez les patients sous HD. Ces résultats issus d'une étude pilote peuvent être utilisés pour éclairer des études plus vastes et plus définitives.

Personalising haemodialysis treatment with incremental dialysis for incident patients with end-stage kidney disease: an implementation study protocol.

INTRODUCTION: Incremental dialysis is a personalised dialysis prescription based on residual kidney function that allows for the initial use of shorter duration, less frequent and less intense dialysis. It has been associated with enhanced quality of life and decreased healthcare costs when compared with conventional dialysis. While nephrologists report prescribing incremental dialysis, few dialysis programmes offer a systematic approach in offering and evaluating its use. To move evidence into practice, and in order to improve the safety and quality of providing incremental dialysis care, we have designed an implementation study. This study aims to evaluate the systematic assessment of patients starting facility-based haemodialysis for eligibility for incremental dialysis, and the prescription and monitoring of incremental dialysis treatment. METHODS AND ANALYSIS: A hybrid effectiveness and implementation study design is being used to evaluate the implementation of the programme at dialysis sites in Alberta, Canada. The Reach, Effectiveness, Adoption, Implementation and Maintenance framework will be used to capture individual-level and organisational-level impact of the project. Clinical outcomes related to kidney function will be monitored on an ongoing basis, and patient-reported outcomes and experience measures will be collected at baseline and then quarterly throughout the first year of dialysis. ETHICS AND DISSEMINATION: The study was approved by the Health Research Ethics Board of the University of Alberta. The study is funded by the Strategic Clinical Networks of Alberta Health Services. The study will help answer important questions on the effectiveness of incremental dialysis, and inform the acceptability, adoption, feasibility, reach and sustainability of incremental dialysis within provision of haemodialysis care.

Population-Based Analysis of Nonsteroidal Anti-inflammatory Drug Prescription in Subjects With Chronic Kidney Disease.

Background: Pain is a prevalent symptom experienced by patients with chronic kidney disease (CKD) and appropriate management of pain is an important element of comprehensive care. Nonsteroidal anti-inflammatory drugs (NSAID) are known to be nephrotoxic in persons with CKD. Objective: This study examined the pattern of NSAID prescribing practices in a population based-cohort of patients with CKD. Design: Retrospective cohort study using linked population-based health care data. Setting: Entire province of Alberta, Canada. Participants: All adults in Alberta with eGFR defined CKD G3 or greater between 2009 and 2017 were included. Measurements: CKD was defined using at least 2 outpatient serum creatinine (SCr) greater than 90 days apart; the date of second SCr measurement was used as index date. We determined the incidence of hyperkalemia using the peak serum potassium. Prescription drug information was obtained from the Pharmaceutical Information Network (PIN) database. Methods: All patients were followed from the index date until March 31, 2019, with a minimum follow-up of 2 years. Prescription drug information and the follow-up laboratory testing of serum creatinine and serum potassium were obtained. Patients with kidney failure defined as eGFR < 15 mL/min per 1.73 m2, receiving chronic dialysis, or prior kidney transplant at baseline were excluded. Results: A total of 170 574 adults (mean age 76.3; 44% male) with CKD were identified and followed for a median of 7 years; 27% were dispensed at least 1 NSAID prescription. While there was a trend toward fewer prescriptions in patients with more advanced CKD (P < .001), 16% of those with CKD G4 were prescribed an NSAID. Primary care providers provided 79% of the prescriptions. Among NSAID users, 21% had a follow-up serum creatinine (SCr) within 30 days of the index prescription. Limitations: Data collected were from clinical and administrative databases not created for research purposes. The study cohort is limited to subjects who sought medical care and had a serum creatinine measurement obtained. Measurement of NSAID use is limited to those who were dispensed a prescription, over-the-counter NSAIDs use is not captured. Conclusions: Despite guidelines advocating cautious use of NSAIDs in patients with CKD, this study indicates that there is a discrepancy from best practice recommendations. Effective strategies to better support and educate prescribers, as well as patients, may help reduce inappropriate prescribing and adverse events.

Contexte: La douleur est un symptôme fréquent chez les patients atteints d'insuffisance rénale chronique (IRC); sa prise en charge appropriée est un élément important des soins complets. Les anti-inflammatoires non stéroïdiens (AINS) sont connus pour être néphrotoxiques dans cette population de patients. Objectif: Cette étude a examiné les tendances de prescription d'AINS dans une cohorte de patients atteints d'IRC. Conception: Étude de cohorte rétrospective menée à partir des données couplées de santé de la population étudiée. Cadre: L'ensemble de la province de l'Alberta (Canada). Sujets: Tous les adultes de l'Alberta dont la mesure du DFGe correspondait à une IRC de stade 3 ou plus entre 2009 et 2017. Mesures: L'IRC a été définie par au moins deux mesures espacées de plus de 90 jours du taux de créatinine sérique (Crs) en consultation externe; la date de la deuxième mesure de Crs a servi de date indice. Le pic de potassium sérique a servi à déterminer l'incidence de l'hyperkaliémie. Les renseignements sur les médicaments d'ordonnance sont tirés de la base de données du réseau d'information pharmaceutique. Méthodologie: Tous les patients ont été suivis de leur date indice jusqu'au 31 mars 2019, soit pour un minimum de deux ans. Les renseignements sur les médicaments d'ordonnance et les résultats des tests de suivi pour la créatinine et le potassium sériques ont été obtenus. Les patients qui, au moment de l'inclusion, étaient atteints d'une insuffisance rénale définie par un DFGe inférieur à 15 mL/min/1.73 m2, sous dialyze chronique ou qui avaient reçu une greffe rénale ont été exclus. Résultats: En tout, 170 574 adultes atteints d'IRC (âge moyen: 76,3 ans; 44 % d'hommes) ont été répertoriés et suivis sur une période médiane de 7 ans; 27 % avaient reçu au moins une ordonnance d'AINS. Bien qu'on ait observé une tendance à réduire les prescriptions chez les patients atteints d'un stade plus avancé d'IRC (p < 0,001), 16 % des patients atteints d'IRC G4 avaient reçu une ordonnance d'AINS. Les prestataires de soins primaires étaient responsables de 79 % des ordonnances. Parmi les utilisateurs d'AINS, 21 % avaient une mesure de suivi pour la Crs dans les 30 jours suivant la prescription indice. Limites: Les données proviennent de bases de données cliniques et administratives qui ne sont pas créées à des fins de recherche. La cohorte est limitée aux sujets ayant requis des soins médicaux et pour qui on avait une mesure de créatinine sérique. La mesure de l'utilization d'AINS est limitée aux personnes ayant reçu une ordonnance, l'utilization d'AINS en vente libre n'est pas saisie. Conclusion: Bien que les lignes directrices prônent la prudence en ce qui concerne la prescription d'AINS chez les patients atteints d'IRC, cette étude indique que la pratique diverge des recommandations. Des stratégies efficaces pour soutenir et mieux éduquer les prescripteurs et les patients pourraient contribuer à réduire les prescriptions inappropriées et les effets indésirables.

Clinical Utility of Pre-Exercise Stress Testing in People With Diabetes.

BACKGROUND: Although suggested by practice guidelines, the need for pre-exercise stress testing in asymptomatic people with diabetes remains controversial. We examined the utility of screening with pre-exercise stress testing in patients with diabetes. METHODS: We completed a cohort study, evaluating patients with diabetes who attended an exercise program intake session between 2007 and 2012. The exposure of interest was referral for pre-exercise stress testing determined by an algorithm requiring sedentary patients with diabetes and ≥ 1 cardiac risk factor to undergo testing. Outcomes included cardiac catheterization, revascularization, cardiovascular-related admissions, mortality, and change in care. RESULTS: Among 1705 people with diabetes, 676 (40%) were referred for pre-exercise stress testing. In patients who were referred for stress testing compared with those who were not, there was no difference in the composite of cardiovascular outcomes (revascularization, cardiovascular-related admissions, and cardiovascular-related death) within 1 year (2.8% vs 1.9%, P = 0.250), or subsequent to the first year (3.1% vs 4.6%, P = 0.164). Within 1 year, more revascularizations were performed in patients referred for stress testing compared with those who were not (2.1% vs 0.8%, P = 0.027) but not during longer-term follow-up (mean 3.4 years). CONCLUSIONS: The rates of cardiovascular outcomes in both tested and untested patients were low. Patients undergoing stress testing had no difference in adverse cardiovascular outcomes over the follow-up periods. Referral for stress testing did not result in a change in care for most patients. Our findings suggest stress testing before beginning an exercise program is not necessary for most asymptomatic patients with diabetes.

Preparticipation Screening Prior to Physical Activity in Community Lifestyle Interventions.

Behavioral lifestyle interventions in the community setting are effective in reducing the risk and burden of chronic diseases. The promotion and implementation of physical activity plays a key role in these community-based lifestyle programs. New guidelines on preparticipation screening for cardiovascular disease prior to physical activity have been released which include substantive modifications. These updated recommendations represent a substantial paradigm shift toward a more liberal approach that results in fewer individuals needing to seek medical clearance before starting a physical activity program. This shift has significant implications for those promoting physical activity within the community setting. The objectives of this commentary are to review the updated recommendations within the context of community-based lifestyle intervention programs such as those currently being offered throughout the United States for the primary purpose of diabetes prevention and to discuss the implications for those providers developing and implementing such programs.