Patrick Campbell

An analysis of questionnaires from more than 400 diabetic patients diabetes is offering further insight into how the ongoing pandemic has impacted diabetes management, including glycemic control, body weight, and stress levels.

Results of the study describe a situation where diabetics have experienced increases in stress, anxiety, and body weight, but no deterioration of glycemic control in patients with type 1 and type 2 diabetes during lockdown periods.

“We show that in people with relatively well controlled type 1 and type 2 diabetes the COVID-19 pandemic and lockdown measures increased stress and resulted in weight gain and less physical exercise during this short observational period. However, despite these factors no deterioration in glycemic control was observed,” wrote investigators.

To learn more about the effects of lockdown measures on various aspects of diabetes management, investigators from Leiden University Medical Center designed the current study as a short-term observational cohort study of patients treated at the outpatient diabetes clinic at the medical center. For inclusion in the study, patients needed to be at least 18 years of age and be sufficient enough in Dutch to perform fingerpicks and complete an online questionnaire.

Of note, patients were excluded if they were pregnant, diagnosed with a malignancy within the previous 6 months, were receiving immunotherapy or chemotherapy, or were admitted to a hospital or rehabilitation center. In total, 435 people were identified for inclusion in the current study—280 with type 1 diabetes and 155 with type 2 diabetes.

Of the 435 patients included in the study, 76.8% were using a basal-bolus regimen and 8.3% were using basal insulin only. In comparison to their counterparts with type 1 diabetes, patients with type 2 diabetes were on average 12.3 years older and had a higher BMI. Of the 435 included in the study, 399 completed the questionnaire on daily routines, physical activity, psychological stress, glycemic control, and medication use. For the purpose of analysis, HbA1c measurements during the lockdown were compared with the last known HbA1c prior to lockdown.

During the lockdown, 34.1% of respondents reported elevated stress—33.6% of type 1 diabetics and 35.1% of type 2 diabetics. Additionally, 27.3% of all participants reported increased levels of anxiety—27.5% of type 1 diabetics and 26.9% of type 2 diabetics. In analyses, changes in perceived stress was associated with a change in HbA1c (95% CI, 0.015-0.38; 

=.034) but changes in anxiety levels were not associated with changes in HbA1c.

When assessing exercise and weight gain, investigators found 40.9% of patients reported weight gain and 45.7% reported getting less exercise during the pandemic. Investigators noted 12% of respondents reported losing weight and 10% reported more exercise. In an analysis, change in exercise or weight gain was not associated with changes in HbA1c.

In regard to glycemic control, there was improvements among those in the highest HbA1c tertile in both type 1 (-0.39% [-4.3 mmol/mol], 

 <.0001) and type 2 (-0.62% [-6.8 mmol/mol], 

=.0036) diabetics. Further analysis indicated time in range was higher (60.5% vs 63.4%; 

=.0009) and time above range was lower (34.6% vs 32.1%; 

 <.003) during the lockdown period than in the pre-lockdown period for the entire study cohort.

“Our short-term observational study shows that lockdown measures resulted in increased levels of perceived stress, weight gain and less exercise in both people with relatively well-controlled type 1 and type 2 diabetes, however this did not negatively impact glycemic control,” wrote investigators.

Increased stress, weight gain and less exercise in relation to glycemic control in people with type 1 and type 2 diabetes during the COVID-19 pandemic

Articles

Data from questionnaires given to type 1 and type 2 diabetes patients from an outpatient clinic is providing insight into how the COVID-19 pandemic has impacted diabetes management. 

Lockdowns Led to Weight Gain, Increases in Stress But No Changes in Glycemic Control Among Diabetics

A simple switch in electronic health records could lead to fewer deaths and rehospitalizations among patients with 

A new study from the Perelman School of Medicine at the University of Pennsylvania found making clinicians opt-out of cardiac rehabilitation instead of opt-in led to a 47-percentage point increase in referrals to cardiac rehabilitation.

"Referral for cardiac rehab has traditionally been a manual process that involved many stakeholders," said lead investigator Mitesh Patel, MD, director of Penn Medicine's Nudge Unit, 

. "By restructuring the pathway as an opt-out decision, we were able to leverage technology to automate the process and significantly reduce the burden on clinicians and patients."

With an interest in evaluating how changes in the cardiac rehabilitation referral decision pathways could influencereferral rates, Patel and a team of colleagues designed and conducted the current study at a trio of Penn Medicine hospital in Philadelphia, Pennsylvania. Beginning in January 2017, an opt-out referral decision pathway was implemented into the electronic health record to automatically identify eligible patients and notify staff through secure messaging at 1 of the 3 hospitals.

Check out this related study from Penn Medicine examining how an EHR ‘nudge’ might effect statin prescribing rates

All cardiac rehabilitation referrals were manually verified. Additionally, all patients received educational material on the importance and relevance of rehabilitation. For the purpose of analysis, investigators obtained data for 1 year before and 2 years after the intervention was implemented for comparison.

A linear probability model was used to perform a difference-in-differences analysis to evaluate changes in referral rates at the intervention site compared to the 2 control sites during the preintervention and post-intervention periods. Of note, all models were adjusted for age, sex, race/ethnicity, insurance, annual household income, body mass index, and history of myocardial infarction, congestive heart disease, cerebrovascular disease, chronic obstructive pulmonary disease, hypertension, diabetes, and smoking.

During the study period, a sample of 2832 patients with ischemic heart disease were identified for inclusion at the 3 Penn Medicine hospitals. This cohort had a mean age of 66.7 (SD, 11.4) years, 812 were female, 1870 were White, and 564 were Black. Initial analysis indicated trends in referral rates for cardiac rehabilitation did not differ between the intervention and control sites during the preintervention period.

At the completion of the study, the investigator’s comparison indicated the percentage of referrals at the intervention site reached 85.7% compared to 31.6% at the study’s control sites, which resulted in a 47-percentage point difference (95% CI, 39.2-55.1; 

"When we surveyed our providers prior to launching the intervention, we learned they were largely interested in having their patients participate in a cardiac rehab program after discharge, but they were not properly equipped to make that happen," said Elizabeth Jolly, RN, an interventional cardiology transitions coordinator at the Hospital of the University of Pennsylvania, in the aforementioned statement. "With our interventions, we saw that the opt-out pathway coupled with the list of facilities made the referral process effortless."

Referral Rates for Cardiac Rehabilitation Among Eligible Inpatients After Implementation of a Default Opt-Out Decision Pathway in the Electronic Medical Record

A quality improvement study conducted at a trio of Penn Medicine hospitals suggests changing cardiac rehabilitation referrals from an opt-in to an opt-out decision in their EHR could drastically improve referral rates.

Simple EHR Switch Could Dramatically Improve Referral Rates for Cardiac Rehabilitation

Confirming what many already suspected, a new analysis of data from the UK Biobank cohort study indicates there was no limit to the cardiovascular benefits derived from physical activity.

Results of the analysis, which included data from more than 90,000 patients without cardiovascular disease at baseline, demonstrated the lowest risk of cardiovascular disease was seen among the most active participants—indicating there was no threshold for how much physical activity could lower 

“This is the largest ever study of exquisite device-measured physical activity and cardiovascular disease. It shows that physical activity is probably even more important for the prevention of cardiovascular disease than we previously thought,” said study investigator Aiden Doherty, PhD, an associate professor at the University of Oxford’s Nuffield Department of Population Health, 

. “Our findings lend further weight to the new WHO guidelines on physical activity which recommend at least 150 to 300 minutes of moderate to vigorous aerobic activity per week for all adults.”

In an effort to more clearly define the effects of physical activity on risk cardiovascular disease, Doherty and colleagues from Oxford designed the current analysis as a retrospective cohort study of patients form within the UK Biobank database. While many studies have examined associations between physical activity and risk of cardiovascular disease, investigators noted most of these have relied on self-reported data and few, if any, had examined associations using accelerometer data.

As part of the UK Biobank study, patients were asked to wear an accelerometer over a 7-day period during a time period lasting from 2013-2015. Using this group, investigators identified 90,211 participants without prior or concurrent cardiovascular disease.

From the accelerometer data, investigators extracted total volume of physical activity and this was used to estimate number of minutes spent in moderate and vigorous physical activity per week. Of note, total activity volume and each intensity of physical activity were categorized into equal quarters for the purpose of analysis. The primary outcomes of the study was incident cardiovascular disease, which was defined as the first hospital admission or death from cardiovascular disease.

In their initial assessment, investigators found those in the lowest category of physical activity smoked more, had a higher BMI, had increased levels of C-reactive protein, and were more likely to have been diagnosed with hypertension than those in categories defined by increased physical activity. During 440,004 person-years of follow-up, investigators found there were 3617 incident cases of cardiovascular disease. Analysis revealed a linear dose-response relationship for physical activity, whether measured as moderate-intensity, vigorous-intensity, or as total volume, with risk of incident of cardiovascular disease.

In their analyses, investigators compared risk of incident cardiovascular disease for each category with the lowest category of physical activity. For moderate-intensity physical activity the hazard ratios for each increasing quarter of physical activity relative to the lowest were: 0.71 (0.65-0.77), 0.59 (0.54-0.65), and 0.46 (0.41-0.51). For vigorous-intensity physical activity, the hazard ratios for increasing quarters compared to the lowest quarter were: 0.70 (0.64-0.77), 0.54 (0.49-0.59), and 0.41 (0.37-0.46). For total volume of physical activity, the hazard ratios for increasing quarters compared to the lowest quarter were: 0.73 (0.67-0.79), 0.63 (0.57-0.69), and 0.47 (0.43-0.52).

Investigators cautioned clinicians to consider the limitations of their study and the potential for confounding and reverse causality when interpreting the results of their study.

“The results of this study enhance confidence that physical activity is likely to be an important way of preventing cardiovascular disease. The potential risk reduction estimated in those engaging in relatively high levels of activity is substantial and justifies a greater emphasis on measures to increase levels of physical activity in the community,” said lead investigator Terry Dwyer, MD, a professor in the University of Oxford’s Nuffield Department of Women’s and Reproductive Health, in the aforementioned statement.

Accelerometer measured physical activity and the incidence of cardiovascular disease: Evidence from the UK Biobank cohort study

An analysis of nearly 100k people from the UK Biobank study suggests there was no upper threshold on the reduction in risk of cardiovascular disease derived from physical activity. 

No Limit to Benefits from Physical Activity on Risk of Cardiovascular Disease

While some previous research suggests a glass of wine per day could improve heart health, new data from a study of more than 100,000 people is sounding the alarm that a single alcoholic drink per day could increase a person's risk of 

Results of the study, which was conducted by a team of European researchers, indicate consuming one alcoholic drink per day was associated with a 16% in risk of developing atrial fibrillation.

"To our knowledge, this is the largest study on alcohol consumption and long-term incidence of atrial fibrillation in the community,” said lead investigator Renate Schnabel, a consultant cardiologist at the University Heart and Vascular Center at Hamburg-Eppendorf, in a 

statement from the European Society of Cardiology

. “Previous studies have not had enough power to examine this question, although they have been able to show a relationship between alcohol intake and other heart and blood vessel problems, such as heart attack and heart failure. In our study, we can now demonstrate that even very low regular alcohol consumption may increase the risk of atrial fibrillation.”

With previous research drawing conflicting or uncertain conclusions on the effects of alcohol intake at lower doses and cardiovascular health, Schnabel and a team of colleagues sought to more clearly define relationships between alcohol intake, biomarkers, and incident atrial fibrillation. For their study, investigators obtained data from 5 community-based cohorts from within the Monica Risk, Genetics, Archiving and Monograph (MORGAM) Biomarker for Cardiovascular Risk Assessment across Europe (BiomarCaRE) projects.

In total, investigators identified 107,845 patients with baseline exams between 1982-2010. Investigators excluded 7753 individuals who had a self-reported or physician-diagnosed history of atrial fibrillation or atrial flutter. The remaining 100,092 participants had a median age of 47.8 years, an age range of 24-97 years at baseline, 51.7% were women, and the median follow-up time was 13.9 years. The median alcohol consumption among those included in the study was 3 grams per day and the mean alcohol consumption was 8.7 grams per day.

Drinking patterns were classified as lifelong abstainer, ex-drinker, less than once a week, 1–2, 3–5, and 6–7 days per day week. Investigators noted adjusted analyses accounted for demographics factors and biomarkers including NTproBNP and high-sensitivity troponin 1.

During the follow-up period, 5854 individuals developed atrial fibrillation. In sex- and cohort-stratified Cox regression analysis alcohol consumption as non-linearly and positively associated with incident atrial fibrillation (HR, 1.16; 95% CI, 1.11-1.22; 

 <.001). In an analysis adjusted for cardiovascular risk factors, one drink per day was associated with an 18% increase in risk of atrial fibrillation (HR, 1.18; 95% CI, 1.12-1.25; 

Further analysis indicated consuming up to two drinks per day was associated with a 28% increase in risk and consuming more than two but less than four was associated with a 47% increase in risk of developing atrial fibrillation. Investigators pointed out associations between alcohol consumption and incident atrial fibrillation were not fully explained by cardiac biomarker concentrations or by the occurrence of heart failure.

"These findings are important as the regular consumption of alcohol, the 'one glass of wine a day' to protect the heart, as is often recommended for instance in the lay press, should probably no longer be suggested without balancing risks and possible benefits for all heart and blood vessel diseases, including atrial fibrillation,” added Schnabel.

Alcohol consumption, cardiac biomarkers, and risk of atrial fibrillation and adverse outcomes

An analysis of more than 100k people from five community-based cohorts indicates consuming one alcoholic drink per day could increase risk of atrial fibrillation by 16%, while consuming four per day increased risk by 47%.

Patrick Campbell

Articles

Lockdowns Led to Weight Gain, Increases in Stress But No Changes in Glycemic Control Among Diabetics

Simple EHR Switch Could Dramatically Improve Referral Rates for Cardiac Rehabilitation

No Limit to Benefits from Physical Activity on Risk of Cardiovascular Disease

One Drink Per Day Increases Risk of AFib 16% in Healthy Patients