The Contribution of Gestational Diabetes to Diabetes Risk Among First Nations and Non-First Nations Women in Saskatchewan: Results From the DIP: ORRIIGENSS Project.

OBJECTIVES: Our aim in this study was to determine the risk for diabetes mellitus (DM) among Saskatchewan First Nations (FN) and non-FN women with prior gestational DM (GDM). METHODS: Using Ministry of Health administrative databases, we conducted a retrospective cohort study of DM risk by GDM occurrence among FN and non-FN women giving birth from 1980 to 2009 and followed to March 31, 2013. We determined frequencies and odds ratios (ORs) of DM in women with/without prior GDM after stratifying by FN status, while adjusting for other DM determinants. Survival curves of women until DM diagnosis were obtained by prior GDM occurrence and stratified by ethnicity and total parity. RESULTS: De-identified data were obtained for 202,588 women. Of those who developed DM, 2,074 of 10,114 (20.5%) had previously experienced GDM (811 of 3,128 [25.9%]) FN and 1,263 of 6,986 [18.1%] non-FN). Cumulative survival of women with prior GDM until DM was higher for FN than for non-FN women (82% vs 46%), but prior GDM was a stronger predictor of DM within the non-FN cohort (prior GDM vs no GDM: OR, 9.64 for non-FN; OR, 7.05 for FN). Finally, higher total parity interacted with prior GDM to increase DM risk in both groups. With prior GDM and parity ≥3, 93% of FN and 57% of non-FN women subsequently developed DM. CONCLUSIONS: GDM is a leading determinant of T2DM among FN and non-FN women, amplified by higher parity. This contributes to earlier onset diabetes, affecting subsequent pregnancies and increasing risk for chronic diabetic complications. It may also factor into higher type 2 DM rates observed in FN women compared with men.

Risk of kidney disease following a pregnancy complicated by diabetes: a longitudinal, population-based data-linkage study among Aboriginal women in the Northern Territory, Australia.

AIMS/HYPOTHESIS: The aim of this work was to investigate the risk of developing chronic kidney disease (CKD) or end-stage kidney disease (ESKD) following a pregnancy complicated by gestational diabetes mellitus (GDM) or pre-existing diabetes among Aboriginal women in the Northern Territory (NT), Australia. METHODS: We undertook a longitudinal study of linked healthcare datasets. All Aboriginal women who gave birth between 2000 and 2016 were eligible for inclusion. Diabetes status in the index pregnancy was as recorded in the NT Perinatal Data Collection. Outcomes included any stage of CKD and ESKD as defined by ICD-10 coding in the NT Hospital Inpatient Activity dataset between 2000 and 2018. Risk was compared using Cox proportional hazards regression. RESULTS: Among 10,508 Aboriginal women, the mean age was 23.1 (SD 6.1) years; 731 (7.0%) had GDM and 239 (2.3%) had pre-existing diabetes in pregnancy. Median follow-up was 12.1 years. Compared with women with no diabetes during pregnancy, women with GDM had increased risk of CKD (9.2% vs 2.2%, adjusted HR 5.2 [95% CI 3.9, 7.1]) and ESKD (2.4% vs 0.4%, adjusted HR 10.8 [95% CI 5.6, 20.8]). Among women with pre-existing diabetes in pregnancy, 29.1% developed CKD (adjusted HR 10.9 [95% CI 7.7, 15.4]) and 9.9% developed ESKD (adjusted HR 28.0 [95% CI 13.4, 58.6]). CONCLUSIONS/INTERPRETATION: Aboriginal women in the NT with GDM or pre-existing diabetes during pregnancy are at high risk of developing CKD and ESKD. Pregnancy presents an important opportunity to identify kidney disease risk. Strategies to prevent kidney disease and address the social determinants of health are needed.

Congenital Anomalies of the Kidney and Urinary Tract (CAKUT): An Emerging Relationship With Pregestational Diabetes Mellitus Among First Nations and Non-First Nations People in Saskatchewan-Results From the DIP: ORRIIGENSS Project.

OBJECTIVES: Because congenital anomalies of the kidneys and urinary tract (CAKUT) represent a frequent cause of end stage renal disease (ESRD) in the young, we explored the epidemiology of CAKUT and the role of diabetes in pregnancy. METHODS: This was a retrospective cohort study of CAKUT, by maternal diabetes status, from among all 1980‒2009 births in Saskatchewan First Nations (FN) and non-First Nations (non-FN) people. We determined frequencies, predictors and complications of CAKUT, as well as cumulative survival (to 2014) of affected persons until ESRD and death. RESULTS: Of the 411,055 babies (204,167 mothers) in the Saskatchewan maternal-infant database, 2,540 had CAKUT (391 FN and 2,149 non-FN). Overall annual CAKUT incidence was 0.63% for non-FN and 0.57% for FN (p=0.082), but 5-year CAKUT incidence only increased among FN (0.40% in 1980‒1984 and 0.76% in 2005‒2009, p<0.0001) and was highest among offspring of FN mothers with pregestational diabetes (pre-G/DM) (0% before 1995, 2.51% in 2000‒2004 and 1.66% in 2005-2009). Pre-G/DM, but not gestational diabetes mellitus (GDM), was an independent predictor of CAKUT in non-FN (odds ratio, 1.79; 95% confidence interval, 1.20 to 2.69), and in FN interacting with maternal history of stillbirth (odds ratio, 7.90; 95% confidence interval, 1.14 to 54.6). ESRD was >100-fold more likely among offspring with CAKUT compared with all other offspring and was responsible for 40% of ESRD cases in young FN and non-FN people. CONCLUSIONS: In Saskatchewan, pre-G/DM is an emerging cause of CAKUT, accounting for 40% of ESRD cases in FN/non-FN children and young adults. Because pre-G/DM‒related CAKUT is potentially preventable with optimal glycemic management, increased recognition of this serious complication is required.

'Turning the tide' on hyperglycemia in pregnancy: insights from multiscale dynamic simulation modeling.

INTRODUCTION: Hyperglycemia in pregnancy (HIP, including gestational diabetes and pre-existing type 1 and type 2 diabetes) is increasing, with associated risks to the health of women and their babies. Strategies to manage and prevent this condition are contested. Dynamic simulation models (DSM) can test policy and program scenarios before implementation in the real world. This paper reports the development and use of an advanced DSM exploring the impact of maternal weight status interventions on incidence of HIP. METHODS: A consortium of experts collaboratively developed a hybrid DSM of HIP, comprising system dynamics, agent-based and discrete event model components. The structure and parameterization drew on a range of evidence and data sources. Scenarios comparing population-level and targeted prevention interventions were simulated from 2018 to identify the intervention combination that would deliver the greatest impact. RESULTS: Population interventions promoting weight loss in early adulthood were found to be effective, reducing the population incidence of HIP by 17.3% by 2030 (baseline ('business as usual' scenario)=16.1%, 95% CI 15.8 to 16.4; population intervention=13.3%, 95% CI 13.0 to 13.6), more than targeted prepregnancy (5.2% reduction; incidence=15.3%, 95% CI 15.0 to 15.6) and interpregnancy (4.2% reduction; incidence=15.5%, 95% CI 15.2 to 15.8) interventions. Combining targeted interventions for high-risk groups with population interventions promoting healthy weight was most effective in reducing HIP incidence (28.8% reduction by 2030; incidence=11.5, 95% CI 11.2 to 11.8). Scenarios exploring the effect of childhood weight status on entry to adulthood demonstrated significant impact in the selected outcome measure for glycemic regulation, insulin sensitivity in the short term and HIP in the long term. DISCUSSION: Population-level weight reduction interventions will be necessary to 'turn the tide' on HIP. Weight reduction interventions targeting high-risk individuals, while beneficial for those individuals, did not significantly impact forecasted HIP incidence rates. The importance of maintaining interventions promoting healthy weight in childhood was demonstrated.

Epidemiology of Diabetes in Pregnancy Among First Nations and Non-First Nations Women in Saskatchewan, 1980‒2013. Part 2: Predictors and Early Complications; Results From the DIP: ORRIIGENSS Project.

OBJECTIVES: Because of disparities in incidence of diabetes in pregnancy (DIP) among First Nations (FN) and non-First Nations (non-FN) women in Saskatchewan, we compared predictors and early maternal/child complication rates of gestational diabetes (GDM) and pre-GDM between the 2 populations from 1980 to 2013. METHODS: Using Ministry of Health administrative databases, we examined overall GDM and pre-GDM predictors among a cohort of FN and non-FN women using logistic regression models. We compared early birth complications by ethnicity and DIP status using chi-square analysis. RESULTS: Deidentified data were obtained for 69,176 FN and 344,410 non-FN pregnancies. Important GDM and pre-GDM predictors for FN and non-FN pregnancies were increasing maternal age, a previous high birthweight (HBW) or stillborn infant, and, most importantly, previous maternal GDM. Both GDM and pre-GDM were over 2.3-fold as likely to occur among FN in multivariable analysis. FN and non-FN pregnancies with GDM and pre-GDM had higher rates of prematurity, shoulder dystocia, caesarean section, HBW and stillborn and infant death than those with no DIP. The largest rate disparities between FN and non-FN with DIP occurred with stillborn, HBW and shoulder dystocia. CONCLUSIONS: Along with previously recognized predictors of GDM and pre-GDM, FN ethnicity was an independent determinant of DIP in Saskatchewan from 1980 to 2013. Early mother/child birth complications were increased in both FN and non-FN with DIP, but more so in FN. Effective DIP prevention strategies, and improvements in preconception, prenatal and perinatal care, are required to remove ethnicity-based disparities in DIP rates and outcomes.

Closing the indigenous health gap in Canada: Results from the TransFORmation of IndiGEnous PrimAry HEAlthcare delivery (FORGE AHEAD) program.

AIMS: TransFORmation of IndiGEnous PrimAry HEAlthcare Delivery (FORGE AHEAD) partnered with local clinical and community teams in 11 First Nations (FN) communities across Canada to develop quality improvement (QI) initiatives aimed at improving T2DM. METHODS: Pre-post mixed-methods case study design was used. The 18-month intervention included community and clinical readiness, development of a community diabetes registry and clinical system, and QI activities. Participants consisted of community members, 18 yrs and older, with diabetes. Changes in clinical outcomes and clinical practice guideline (CPG) recommendations were assessed pre and post intervention using multilevel regression (patients nested within communities) adjusted forindividual andcommunity baseline characteristics. RESULTS: No significant change in HbA1c orsBP, but a small reduction indBP(-0.75 mmHg, p < 0.05) and LDL (-0.09 mmol/L, p < 0.05) was observed in 2008 adults with T2DM (mean age: 60·5 (SD:14·6) years; female: 57·2%). Individuals not at CPG targets at baseline had significant reductions in: %HbA1c (N = 616): -0.40 (95%CI:-0·55,-0·24),sBP (N = 561): -7·67 mmHg (95%CI:-9·23, -5·72),dBP (N = 291): -7·46 mmHg (95%CI:-8·69, -6·26), LDL (N = 450): -0·37mmo/l (95%CI:-0·44, -0·29).Annual HbA1c (OR: 1·95; 95%CI:1·66, 2·29), BP (OR: 1·78; 95%CI:1·52, 2·09), LDL (OR: 1·27; 95%CI:1·10, 1·47) and CKD screening (OR: 6·37; 95%CI:5·16, 7·92)increased but retinopathy screening decreased (OR: 0·68; 95%CI:0·57, 0·82). No significant change in foot exams (OR: 0·97; 95%CI:0·76, 1·23) or BMI recordings (OR: 0·96; 95%CI:0·82, 1·12) was seen. Overall, individualsweremorelikely to receive ≥75% of CPG recommended services compared to baseline (OR: 1·51; 95%CI:1·27, 1·80). CONCLUSIONS: FORGE AHEAD is the first Canadian study to demonstrate that a FN community-led QI intervention can lead to diabetes improvements.

Epidemiology of Diabetes in Pregnancy Among First Nations and Non-First Nations Women in Saskatchewan, 1980‒2013. Part 1: Populations, Methodology and Frequencies (1980‒2009); Results From the DIP: ORRIIGENSS Project.

OBJECTIVES: Because of the immediate and long-term consequences of diabetes in pregnancy (DIP) for mother and child, we compared frequencies of gestational diabetes (GDM) and pre-GDM between First Nations (FN) and non-FN people in Saskatchewan from 1980 to 2009. METHODS: Using Ministry of Health administrative databases, we conducted a retrospective cohort study of GDM and pre-GDM rates within all FN and non-FN pregnancies in Saskatchewan. Annual crude and 10-year age-adjusted incidence of GDM and pre-GDM were determined as were maternal age-specific rates of DIP. RESULTS: De-identified data were obtained for 69,176 FN and 344,410 non-FN pregnancies. The crude annual incidence of GDM rose from 1.0% to 6.6% among FN and from 0.4% to 3.6% among non-FN between 1980 and 2009. The crude annual incidence of pre-GDM rose from 0.7% to 2.0% among FN and from 0.4% to 0.9% among non-FN over the same period. The 10-year age-standardized incidence of GDM increased from 3.53% in 1980-1989 to 8.37% in 2000-2009 for FN, and from 1.55% to 3.13% for non-FN. For pre-GDM, the corresponding increases were from 1.65% to 3.26% for FN and from 0.5% to 0.91% for non-FN. Both GDM and pre-GDM rates increased with increasing maternal age, reaching 10.9% and 8.0% of FN pregnancies, and 7.7% and 1.1% of non-FN pregnancies, respectively, for mothers >40 years old. CONCLUSIONS: The proportion of pregnancies complicated by DIP increased steadily among FN and non-FN women in Saskatchewan in 1980‒2009, but the incidence of GDM and pre-GDM is 2- to 3-fold higher among FN.

Diabetes during pregnancy and birthweight trends among Aboriginal and non-Aboriginal people in the Northern Territory of Australia over 30 years.

BACKGROUND: Early-life risk factors, including maternal hyperglycaemia and birthweight, are thought to contribute to the high burden of cardiometabolic disease experienced by Indigenous populations. We examined rates of pre-existing diabetes in pregnancy, gestational diabetes mellitus (GDM) and extremes of birthweight over three decades in the Northern Territory (NT) of Australia. METHODS: We performed a retrospective cohort analysis of the NT Perinatal Data Collection from 1987 to 2016, including all births >20 weeks gestation, stratified by maternal Aboriginal identification. Key outcomes were annual rates of pre-existing diabetes, GDM, small-for-gestational-age, large-for-gestational-age, low birthweight (<2500 g), and high birthweight (>4000 g). Logistic regression was used to assess trends and interactions. FINDINGS: 109 349 babies were born to 64 877 mothers, 36% of whom identified as Aboriginal ethnicity. Among Aboriginal women, rates of GDM and pre-existing diabetes, respectively, were 3 ·â€¯4% and 0 ·â€¯6% in 1987 and rose to 13% and 5 ·â€¯7% in 2016 (both trends p<0 ·â€¯001). Among non-Aboriginal women, rates of GDM increased from 1 ·â€¯9% in 1987 to 11% in 2016 (p<0 ·â€¯001), while pre-existing diabetes was uncommon (≤0 ·â€¯7% throughout). Rates of small-for-gestational-age decreased, while rates of large-for-gestational-age and high birthweight increased in both groups (all trends p<0 ·â€¯001). Multivariable modelling suggests that hyperglycaemia was largely responsible for the growing rate of large-for-gestational-age births among Aboriginal women. INTERPRETATION: The burden of hyperglycaemia in pregnancy has grown substantially in the NT over three decades and is impacting birthweight trends. The prevalence of pre-gestational diabetes in Aboriginal women is among the highest in the world. FUNDING: Diabetes Australia Research Program.

Risk factors, incidence, and prevalence of diabetes among rural farm and non-farm residents of Saskatchewan, Canada; a population-based longitudinal cohort study.

PURPOSE: Saskatchewan has a high prevalence of diabetes. It is the largest, rurally populated, predominantly agricultural province in Canada. This research aims to determine the risk factors associated with the incidence and longitudinal changes in the prevalence of diabetes among Saskatchewan's adult rural farm and non-farm residents. METHODS: The Saskatchewan Rural Health Study (SRHS) is a prospective cohort study conducted in two phases: a baseline survey (2010, 8261 participants) and a follow-up survey (2014, 4867 participants). Generalized estimation equations and survival analysis techniques were used to determine diabetes prevalence and incidence risk factors, respectively. RESULTS: Incidence of diabetes among rural residents was 2.75%. Positive family history, high BMI, sleep apnea and an abnormal Epworth Sleepiness Score (ESS) were significant predictors for diabetes incidence. A substantial increase (1.98%) of diabetes prevalence was observed after four years of follow-up. Risk factors of diabetes prevalence were increasing age, male, low income, positive family history, high BMI, hypertension and heart attack. CONCLUSION: A mix of individual and contextual factors interacting in complex pathways were responsible for the high incidence and prevalence of diabetes among rural residents. The most original finding of that study was a positive association of sleep apnea, and ESS with incident diabetes warrants further research to identify a causal linkage. Increased diabetes risk among rural male insecticide users indicates an adverse consequence of unprotected chemical exposures in the agricultural field. Urgent population-based preventive measures should initiate to slow the increasing trend of diabetes prevalence among rural residents.

The association between endotoxin and beta-(1 → 3)-D-glucan in house dust with asthma severity among schoolchildren.

BACKGROUND: Asthma severity can be affected by microbial exposures. However, less is known about the specific indoor agents aggravating the disease in children. We examined the associations between indoor endotoxin and beta-(1 → 3)-D-glucan exposures and asthma severity in children with asthma. METHODS: A clinical cross-sectional study of schoolchildren (aged 7-17 years) was conducted in the province of Saskatchewan, Canada. Children with asthma (n = 116) were identified from 335 participants using a combination of survey responses and objective clinical assessments. We then ascertained asthma severity based on recommended guidelines (continuous daytime asthma symptoms, frequent nighttime asthma symptoms, and ≤ 60% predicted FEV1). Levels of indoor endotoxin and beta-(1 → 3)-D-glucan were measured in dust samples obtained from play area floors and child's mattresses. RESULTS: The study population of 116 children with asthma was comprised of 75.9% mild asthma and 24.1% moderate/severe asthma. Higher mattress endotoxin concentration was associated with increased odds of moderate/severe asthma [adjusted odds ratio (aOR) = 11.40, 95% confidence interval (CI): 1.45-89.43] while higher beta-(1 → 3)-D-glucan concentration (aOR = 0.16, 95% CI: 0.03-0.89) and load (aOR = 0.10, 95% CI: 0.02-0.72) in play areas were inversely associated with moderate/severe asthma. Furthermore, higher mattress endotoxin concentration was associated with lower FVC (p = 0.01) and FEV1 (p = 0.03). These associations were not seen for beta-(1 → 3)-D-glucan. CONCLUSION: Our results showed differential effects of microbial exposures on childhood asthma severity and further highlight domestic endotoxin exposure effects on respiratory health outcomes in children with asthma.

The association between endotoxin in house dust with atopy and exercise-induced bronchospasm in children with asthma.

BACKGROUND: Studies have reported protective and adverse associations between microbial exposure and childhood asthma. However, among children with asthma the relationships between endotoxin and exercise-induced bronchospasm (EIB) is less clear. OBJECTIVE: We investigated the association between exposure to endotoxin in house dust with atopy and EIB in children with asthma. METHODS: A cross-sectional survey was conducted among schoolchildren (aged 7-17 years) in the province of Saskatchewan, Canada. A subpopulation with asthma (n = 116) were identified from 335 participants using a validated asthma algorithm. We determined atopy among the asthma subpopulation by skin prick testing (SPT) while EIB was evaluated using exercise challenge testing (ECT). Dust samples were collected from mattress and play area floors, and endotoxin was measured in dust extracts. Logistic regression analyses were used to explore associations between endotoxin with atopy and EIB. RESULTS: Among the 116 children with asthma, 99 completed SPT and all had completed ECT. Of these, 71/99 (71.7%) were atopic and 26/116 (22.4%) had EIB. Exposure to high play area endotoxin concentration [adjusted odds ratio (aOR) = 0.15, 95% CI: 0.03-0.85] and load (aOR = 0.11, 95% CI: 0.02-0.73) were negatively associated with atopy. In contrast, EIB was positively associated with high mattress endotoxin concentration (aOR = 6.01, 95% CI: 1.20-30.13). CONCLUSION: Indoor microbial endotoxin exposure has varied associations with atopy and exercise-induced bronchospasm among children with asthma.

Low Birth Weight, Cumulative Obesity Dose, and the Risk of Incident Type 2 Diabetes.

BACKGROUND: Obesity history may provide a better understanding of the contribution of obesity to T2DM risk. METHODS: 17,634 participants from the 1958 National Child Development Study were followed from birth to 50 years. Cumulative obesity dose, a measure of obesity history, was calculated by subtracting the upper cut-off of the normal BMI from the actual BMI at each follow-up and summing the areas under the obesity dose curve. Hazard ratios (HRs) for diabetes were calculated using Cox regression analysis. Three separate models compared the predictive ability of cumulative obesity dose on diabetes risk with the time-varying BMI and last BMI. RESULTS: In final models, 341 of 15,043 (2.27%) participants developed diabetes; male sex and low birth weight were significant confounding variables. Adjusted HRs were 1.080 (95% CI: 1.071, 1.088) per 10-unit cumulative obesity dose, 1.098 (95% CI: 1.080, 1.117) per unit of the time-varying BMI, and 1.146 (95% CI: 1.084, 1.212) per unit of the last BMI. Cumulative obesity dose provided the best predictive ability for diabetes. CONCLUSIONS: Cumulative obesity dose is an improved method for evaluating the impact of obesity history on diabetes risk. The link between low birth weight and T2DM is strengthened by adjusting for cumulative obesity dose.

Correction to: Cohort profile: the Saskatchewan Rural Health Study-adult component.

Following publication of the original article [1] the authors notified Production that the names of three authors-Valerie Elliot, Louise Hagel, and Roland Dyck-had been unintentionally omitted in the final online version of the manuscript. The corrected author list is shown in this Correction.

Asthma diagnosis among children along an urban-rural gradient.

OBJECTIVE: Studies have reported lower asthma prevalence in rural compared to urban areas. While environmental factors have mostly been implicated for these differences, the lower asthma prevalence could also be linked to asthma under-diagnosis in rural children. We investigate if rural children experience under-diagnosis of asthma more compared to urban children. METHODS: In 2013, we conducted a cross-sectional survey of schoolchildren across an urban-rural gradient in Saskatchewan, Canada. The participants formed sampling frame for future studies. In 2015, we approached those who gave consent in 2013 for further testing, repeated the survey, and conducted clinical testing. Based on survey responses, children were classified into "no asthma," "at-risk-for-asthma," and "diagnosed asthma." We then classified asthma status as either "no asthma" or "probable asthma" based on a validated asthma algorithm. RESULTS: The study population of 335 schoolchildren (aged 7-17 years) comprised of 73.4% from large urban, 13.7% from small urban, and 12.8% from rural areas. Proportion with report of physician-diagnosed asthma was 28.5% (Large urban), 34.8% (Small urban), and 20.9% (Rural). Mean percent predicted FEV1 and FEF25%-75% were lower in rural compared to small urban and large urban children (p < 0.05). Among those not classified as with "diagnosed asthma" by the survey, the algorithm further identified presence of asthma in 5.5% large urban, 8.1% small urban, and 18.8% rural children (p = 0.03). CONCLUSION: The study revealed evidence of asthma underdiagnosis in rural areas and further supports the use of objective measures in addition to symptoms history when investigating asthma across urban-rural gradients.

Racial discrimination and depression among on-reserve First Nations people in rural Saskatchewan.

OBJECTIVES: To determine among rural-dwelling on-reserve Saskatchewan First Nations people whether racial discrimination is associated with depression, and in turn, if this relationship is moderated by gender. METHODS: As a component of a community-based participatory research project, a cross-sectional, interviewer-administered survey of 874 adults living on 2 Cree First Nation reserves in rural north-central Saskatchewan was conducted during May-August in 2012 and 2013. Self-reported, health-provider diagnosis of depression was the dependent variable and experiences of interpersonal racial discrimination was the primary exposure. Chi-square and multiple logistic regression were the main analytic techniques. Generalized estimating equations were applied to account for clustering within households. RESULTS: Overall, 64% of participants reported being treated unfairly in 1 or more situations because of their ethnicity; 38% indicated discrimination occurring in 3 or more situations. Nineteen percent reported a diagnosis of depression. Adjusted analyses indicated that compared to those with no experience of racial discrimination, those reporting 1-2 and 3 or more situations were 1.77 times (95% CI: 1.06-2.95) and 1.91 times (95% CI: 1.19-3.04) more likely to have diagnosed depression respectively. The relationship between racial discrimination and depression was not modified by gender, although women were 1.85 times (95% CI: 1.24-2.76) more likely to report depression than men. CONCLUSION: Interpersonal racial discrimination was associated with depression among First Nations women and men in rural Saskatchewan. Research directed at identifying the most efficacious interventions, programs and policies to combat racism is required to advance the goal of health equity.

Cohort profile: the Saskatchewan Rural Health Study-adult component.

OBJECTIVES: Less is known about the respiratory health of general farming and non-framing populations. A longitudinal Saskatchewan Rural Health Study (SRHS) was conducted to explore the association between individual and contextual factors with respiratory health outcomes in these populations. Hence, the objectives are to: (i) describe the updated methodology of longitudinal SRHS-an extension of baseline survey methodology published earlier; (ii) compare baseline characteristics and the prevalences of respiratory health outcomes between drops-outs and completers; and (iii) summarize key findings based on baseline survey data. RESULTS: The SRHS was a prospective cohort study conducted in two phases: baseline survey in 2010 and a follow-up in 2014. Each survey consisted of two components, self-administered questionnaire and clinical assessments. At baseline, 8261 participants (≥ 18 years) (4624 households) and at follow-up, 4867 participants (2797 households) completed the questionnaires. Clinical assessments on lung functions and/or allergies were conducted among a sub-group of participants from both the surveys. To date, we published 15 peer-reviewed manuscripts and 40 abstracts in conference proceedings. Findings from the study will improve the knowledge of respiratory disease etiology and assist in the development and targeting of prevention programs for rural populations in Saskatchewan, Canada.

Projecting prevalence, costs and evaluating simulated interventions for diabetic end stage renal disease in a Canadian population of aboriginal and non-aboriginal people: an agent based approach.

BACKGROUND: Diabetes-related end stage renal disease (DM-ESRD) is a devastating consequence of the type 2 diabetes epidemic, both of which disproportionately affect Indigenous peoples. Projecting case numbers and costs into future decades would help to predict resource requirements, and simulating hypothetical interventions could guide the choice of best practices to mitigate current trends. METHODS: An agent based model (ABM) was built to forecast First Nations and non-First Nations cases of DM-ESRD in Saskatchewan from 1980 to 2025 and to simulate two hypothetical interventions. The model was parameterized with data from the Canadian Institute for Health Information, Saskatchewan Health Administrative Databases, the Canadian Organ Replacement Register, published studies and expert judgement. Input parameters without data sources were estimated through model calibration. The model incorporated key patient characteristics, stages of diabetes and chronic kidney disease, renal replacement therapies, the kidney transplant assessment and waiting list processes, costs associated with treatment options, and death. We used this model to simulate two interventions: 1) No new cases of diabetes after 2005 and 2) Pre-emptive renal transplants carried out on all diabetic persons with new ESRD. RESULTS: There was a close match between empirical data and model output. Going forward, both incidence and prevalence cases of DM-ESRD approximately doubled from 2010 to 2025, with 250-300 new cases per year and almost 1300 people requiring RRT by 2025. Prevalent cases of First Nations people with DM-ESRD increased from 19% to 27% of total DM-ESRD numbers from 1990 to 2025. The trend in yearly costs paralleled the prevalent DM-ESRD case count. For Scenario 1, despite eliminating diabetes incident cases after 2005, prevalent cases of DM-ESRD continued to rise until 2019 before slowly declining. When all DM-ESRD incident cases received a pre-emptive renal transplant (scenario 2), a substantial increase in DM-ESRD prevalence occurred reflecting higher survival, but total costs decreased reflecting the economic advantage of renal transplantation. CONCLUSIONS: This ABM can forecast numbers and costs of DM-ESRD in Saskatchewan and be modified for application in other jurisdictions. This can aid in resource planning and be used by policy makers to evaluate different interventions in a safe and economical manner.

The FORGE AHEAD clinical readiness consultation tool: a validated tool to assess clinical readiness for chronic disease care mobilization in Canada's First Nations.

BACKGROUND: Given the astounding rates of diabetes and related complications, and the barriers to providing care present in Indigenous communities in Canada, intervention strategies that take into account contextual factors such as readiness to mobilize are needed to maximize improvements and increase the likelihood of success and sustainment. As part of the national FORGE AHEAD Program, we sought to develop, test and validate a clinical readiness consultation tool aimed at assessing the readiness of clinical teams working on-reserve in First Nations communities to participate in quality improvement (QI) to enhance diabetes care in Canada. METHODS: A literature review was conducted to identify existing readiness tools. The ABCD - SAT was adapted using a consensus approach that emphasized a community-based participatory approach and prioritized the knowledge and wisdom held by community members. The tool was piloted with a group of 16 people from 7 provinces and 11 partnering communities to assess language use, clarity, relevance, format, and ease of completion using examples. Internal reliability analysis and convergence validity were conducted with data from 53 clinical team members from 11 First Nations communities (3-5 per community) who have participated in the FORGE AHEAD program. RESULTS: The 27-page Clinical Readiness Consultation Tool (CRCT) consists of five main components, 21 sub-components, and 74 items that are aligned with the Expanded Chronic Care Model. Five-point Likert scale feedback from the pilot ranged from 3.25 to 4.5. Length of the tool was reported as a drawback but respondents noted that all the items were needed to provide a comprehensive picture of the healthcare system. Results for internal consistency showed that all sub-components except for two were within acceptable ranges (0.77-0.93). The Team Structure and Function sub-component scale had a moderately significant positive correlation with the validated Team Climate Inventory, r = 0.45, p < 0.05. CONCLUSIONS: The testing and validation of the FORGE AHEAD CRCT demonstrated that the tool is acceptable, valid and reliable. The CRCT has been successfully used to support the implementation of the FORGE AHEAD Program and the health services changes that partnering First Nations communities have designed and undertaken to improve diabetes care. TRIAL REGISTRATION NUMBER: Current ClinicalTrial.gov protocol ID NCT02234973 . Date of Registration: July 30, 2014.

Building Research Capacity: Results of a Feasibility Study Using a Novel mHealth Epidemiological Data Collection System Within a Gestational Diabetes Population.

Public health researchers have traditionally relied on individual self-reporting when collecting much epidemiological surveillance data. Data acquisition can be costly, difficult to acquire, and the data often notoriously unreliable. An interesting option for the collection of individual health (or indicators of individual health) data is the personal smartphone. Smartphones are ubiquitous, and the required infrastructure is well-developed across Canada, including many remote areas. Researchers and health professionals are asking themselves how they might exploit increasing smartphone uptake for the purposes of data collection, hopefully leading to improved individual and public health. A novel smartphone-based epidemiological data collection and analysis system has been developed by faculty and students from the CEPHIL (Computational Epidemiology and Public Health Informatics) Lab in the Department of Computer Science at the University of Saskatchewan. A pilot feasibility study was then designed to examine possible relationships between smartphone sensor data, surveys and individual clinical data within a population of pregnant women. The study focused on the development of Gestational Diabetes (GDM), a transient condition during pregnancy, but with serious potential post-birth complications for both mother and child. The researchers questioned whether real-time smartphone data could improve the clinical management and outcomes of women at risk for developing GDM, enabling earlier treatment. The initial results from this small study did not show improved prediction of GDM, but did demonstrate that real-time individual health and sensor data may be readily collected and analyzed efficiently while maintaining confidentiality. Because the original version of the data collection software could only run on Android phones, this often meant the study participants were required to carry two phones, and this often meant the study phone was not carried, and therefore data not collected. The lessons learned will greatly inform future research.

Childhood asthma, asthma severity indicators, and related conditions along an urban-rural gradient: a cross-sectional study.

BACKGROUND: Asthma prevalence is generally lower in rural locations with some indication of an urban-rural gradient. However, among children with asthma, certain rural exposures thought to protect against the development of asthma could aggravate the condition. We examined childhood asthma prevalence and related conditions along an urban-rural gradient and also examined the characteristics of those with asthma along the urban-rural gradient. METHODS: In 2013 we completed a cross-sectional survey of 3509 children aged 5-14 years living in various population densities of Saskatchewan, Canada. Location of dwelling was identified as belonging to one of the following population densities: large urban region (approximately 200,000), small urban (approximately 35,000), or rural (small town of <1,500 or farm dweller). Physician-diagnosed asthma and asthma-related symptoms were ascertained from responses in the parental-completed questionnaires. RESULTS: Of the study population, 69% lived in a large urban region, 11% lived in a small urban centre and 20% were rural dwellers. Overall, asthma prevalence was 19.6% with differences in asthma prevalence with differences between locations (large urban = 20.7%; small urban = 21.5%; rural = 15.1%; p = 0.003). After adjustment for potential confounders, the association between location of dwelling and asthma remained significant. Despite a lower prevalence of asthma in the rural area, the prevalence and risk of ever wheeze and having more than 3 wheezing episodes in the past 12 months among those who reported asthma, was higher in rural locations after adjustment for potential confounders. CONCLUSIONS: The results of this study support the evidence of a difference in childhood asthma prevalence between urban and rural locations and that once a child has asthma, certain rural exposures may aggravate the disease.