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Our aim in this study was to determine the test characteristics of algorithms using hospitalization and physician claims data to predict gestational diabetes (GDM).Using population-level health-care administrative data, we identified all pregnant women in Ontario in 2019. The presence of GDM was determined based on glucose screening laboratory results. Algorithms using hospitalization records and/or physician claims were tested against this "gold standard." The selected algorithm was applied to administrative data records from 1999 to 2019 to determine GDM prevalence in each year.Identifying GDM based on either a diabetes mellitus code on the delivery hospitalization record, OR at least 1 physician claim with a diabetes diagnosis code with a 90-day lookback before delivery yielded a sensitivity of 95.9%, a specificity of 99.2% and a positive predictive value of 87.6%. The prevalence of GDM increased from 4.2% of pregnancies in 1999 to 12.0% in 2019.Algorithms using hospitalization or physician claims administrative data can accurately identify GDM.

OBJECTIVE Cardiovascular risk reduction is an important focus in the management of people with diabetes. Although event rates have been declining over the long term, they have been observed to plateau or reverse in recent years. Furthermore, the impact of income-related disparities in cardiovascular events is unknown. The objective of this study is to evaluate age-, sex-, and income-related trends in cardiovascular hospitalization rates among people with diagnosed diabetes. RESEARCH DESIGN AND METHODS We calculated rates of hospitalization for acute myocardial infarction, stroke, heart failure, and lower-extremity amputation in annual cohorts of the entire population of Ontario, Canada, with diagnosed diabetes, from 1995 to 2019. Event rates were stratified by age, sex, and income level. RESULTS We studied nearly 1.7 million people with diabetes. The rate of acute myocardial infarction declined throughout the 25-year study period (P < 0.0001), such that the rate in 2019 was less than half the rate in 1995. Rates of stroke (P < 0.0001), heart failure (P < 0.0001), and amputation (P < 0.0001) also changed over time, but hospitalization rates stabilized through the 2010s. This apparent stabilization concealed a growing income-related disparity: wealthier patients showed continued declines in rates of these outcomes during the decade, whereas rates for lower-income patients increased (P for interaction < 0.0001 for all four outcomes). CONCLUSIONS During a quarter-century of follow-up, cardiovascular hospitalization rates among people with diabetes fell. However, the apparent stabilization in rates of stroke, heart failure, and amputation in recent years masks the fact that rates have risen for lower-income individuals.

Early identification of people with diabetes or prediabetes enables greater opportunities for glycemic control and management strategies to prevent related complications. To identify gaps in screening for these conditions, we examined population trends in receipt of timely glucose testing overall and in specific clinical subgroups.Using linked administrative databases, we conducted a retrospective cohort study of people aged 40 years and older without diabetes at baseline. Our primary outcome was up-to-date glucose testing, defined as having received testing at least once in the 3 years before each index year from 2010 to 2017, using linked administrative databases of people residing in Ontario, Canada. We calculated rates of up-to-date testing by age group, sex, ethnicity (South Asian, Chinese, general population) and comorbidities (hypertension, hyperlipidemia, cardiovascular disease).Over the 8-year study period, up-to-date glucose testing rates were stable at 67% for men and 77% for women (both relative risk 1.00 per year; 95% confidence interval 1.00-1.00). Testing rates were significantly lower in men than in women (all age groupsWe found lower glucose testing rates in younger men and people with hypertension. Our findings reinforce the need for initiatives to increase awareness of glycemic testing.

OBJECTIVE Car dependency contributes to physical inactivity and, consequently, may increase the likelihood of diabetes. We investigated whether neighborhoods that are highly conducive to driving confer a greater risk of developing diabetes and, if so, whether this differs by age. RESEARCH DESIGN AND METHODS We used administrative health care data to identify all working-age Canadian adults (20–64 years) who were living in Toronto on 1 April 2011 without diabetes (type 1 or 2). Neighborhood drivability scores were assigned using a novel, validated index that predicts driving patterns based on built environment features divided into quintiles. Cox regression was used to examine the association between neighborhood drivability and 7-year risk of diabetes onset, overall and by age-group, adjusting for baseline characteristics and comorbidities. RESULTS Overall, there were 1,473,994 adults in the cohort (mean age 40.9 ± 12.2 years), among whom 77,835 developed diabetes during follow-up. Those living in the most drivable neighborhoods (quintile 5) had a 41% higher risk of developing diabetes compared with those in the least drivable neighborhoods (adjusted hazard ratio 1.41, 95% CI 1.37–1.44), with the strongest associations in younger adults aged 20–34 years (1.57, 95% CI 1.47–1.68, P < 0.001 for interaction). The same comparison in older adults (55–64 years) yielded smaller differences (1.31, 95% CI 1.26–1.36). Associations appeared to be strongest in middle-income neighborhoods for younger residents (middle income 1.96, 95% CI 1.64–2.33) and older residents (1.46, 95% CI 1.32–1.62). CONCLUSIONS High neighborhood drivability is a risk factor for diabetes, particularly in younger adults. This finding has important implications for future urban design policies.

In recent decades, the prevalence of obesity and diabetes has risen substantially in North America and worldwide. To address these dual epidemics, researchers and policymakers alike have been searching for effective means to promote healthy lifestyles at a population level. As a consequence, there has been a proliferation of research examining how the “built” environment in which we live influences physical activity levels, by promoting active forms of transportation, such as walking and cycling, over passive ones, such as car use. Shifting the transportation choices of local residents may mean that more members of the population can participate in physical activity during their daily routine without structured exercise programs. Increasingly, this line of research has considered the downstream metabolic consequences of the environment in which we live, raising the possibility that “healthier” community designs could help mitigate the rise in obesity and diabetes prevalence. This review discusses the evidence examining the relationship between the built environment, physical activity, and obesity-related diseases. We also consider how other environmental factors may interact with the built environment to influence metabolic health, highlighting challenges in understanding causal relationships in this area of research.

BACKGROUND Emerging adults living with type 1 diabetes (T1D) face a series of challenges with self-management and decreased health system engagement, leading to increased risk of acute complications and hospital admissions. Effective and scalable strategies are needed to support this population to transfer seamlessly from paediatric to adult care with sufficient self-management capability. While digital health interventions for T1D self-management are a promising strategy, it remains unclear which elements work, how, and for which group(s) of individuals. OBJECTIVE The present study aims to evaluate the design and implementation of a multi-component digital health intervention to support emerging adults living with T1D in real-world settings. Specifically, the objectives are to identify the intervention components and associated mechanisms that lead to improved user engagement and T1D healthcare transition experiences and determine the individual-level contextual factors that influence the implementation process. METHODS Embedded alongside a randomized controlled trial, this realist evaluation employs a sequential mixed-methods design to analyze data from multiple sources, including intervention usage data, patient-reported outcomes, and semi-structured interviews. In Step 1, we conducted a document analysis to develop a program theory that outlines the hypothesized relationships amongst individual-level contextual factors (C), intervention components and features (I), mechanisms (M), and target outcomes (O) with special attention paid to user engagement. In Step 2, we will conduct semi-structured interviews with the RCT intervention arm participants to validate the hypothesized C-I-M-O configurations. In Step 3, we will triangulate all sources of data using a Coincidence Analysis to identify the necessary combinations of conditions (i.e., factors, pathways, and context) that determine whether and how the desired outcomes are achieved and use these insights to refine the program theory. RESULTS For step 1 analysis, we have developed the initial program theory and the corresponding data collection plan. For step 2 analysis, participant enrollment for the randomized controlled trial started in January 2023. Participant enrollment for the present realist evaluation is anticipated to start in May 2023 and continue until we reach thematic saturation or achieve informational power. CONCLUSIONS Beyond contributing to knowledge on the multiple pathways that lead to successful engagement with a digital health intervention as well as target outcomes in T1D care transitions, embedding the realist evaluation alongside the trial may inform real-time intervention refinement to improve user engagement and transition experiences. The knowledge gained from this study may inform the design, implementation, and evaluation of future digital health interventions that aim to improve transition experiences.

Objective: Cardiovascular risk reduction is an important focus in the management of people with diabetes. Although event rates have been declining over the long-term, they have been observed to plateau or reverse in recent years. Furthermore, the impact of income-related disparities in cardiovascular events is unknown. The objective of this study was to evaluate age-, sex- and income-related trends in cardiovascular hospitalization rates among people with diagnosed diabetes. Research Design and Methods: We calculated rates of hospitalization for acute myocardial infarction, stroke, heart failure and lower extremity amputation in annual cohorts of the entire population of Ontario, Canada with diagnosed diabetes, from 1995 to 2019. Event rates were stratified by age, sex and income level. Results: We studied nearly 1.7 million people with diabetes. The rate of acute myocardial infarction declined throughout the 25-year study period (p Conclusions: During a quarter-century of follow-up, cardiovascular hospitalization rates among people with diabetes fell. However, the apparent stabilization in rates of stroke, heart failure and amputation in recent years masks the fact that rates have risen for lower-income individuals.

BACKGROUND: Minimal consideration has been given to understanding the challenges of managing diabetes while homeless from the perspective of those with lived or living experience. We used a community-based participatory approach to explore these challenges. METHODS: We recruited coresearchers with experiential knowledge of both homelessness and diabetes. Lead researchers conducted research training and facilitated research development by coresearchers. Coresearchers collectively chose to use photovoice methodology to illustrate the challenges of accessing healthy food while homeless and to explore how homelessness more broadly affects diabetes management. After training in photography technique and ethics, coresearchers took photos to address these objectives and created accompanying narratives using photo elicitation techniques. Lead researchers analyzed photos and narratives, and extracted themes, refined through group discussion. RESULTS: The 8 coresearchers had type 2 diabetes (diagnosed 18 months to 23 years previously) and had experienced homelessness for periods ranging from 8 months to 12 years. We identified 4 themes from the 17 photos and narratives they produced. Homelessness imposed major demands on emotional and mental health, impairing the ability of those affected to focus on diabetes self-management. Foods provided in shelters were often nutritionally poor or unpalatable. Obtaining housing facilitated diabetes management through stability and autonomy, but cost and lack of knowledge posed challenges to healthy food preparation. Homelessness also presented challenges to accessing diabetes care professionals and prescription medications. INTERPRETATION: The images and narratives provide a powerful firsthand, in-depth account of the challenges faced by people trying to manage diabetes while homeless. Understanding these challenges is the first step in enabling providers and policy-makers to meet the needs of this population.

BackgroundDiabetes is a chronic medical condition which demands that patients engage in self-management to achieve optimal glycemic control and avoid severe complications. Individuals who have diabetes and are experiencing homelessness are more likely to have chronic hyperglycemia and adverse outcomes. Our objective was to collaborate with individuals experiencing homelessness and care providers to understand the barriers they face in managing diabetes, as a first step in identifying solutions for enhancing diabetes management in this population.MethodsWe recruited individuals with lived experience of homelessness and diabetes (i.e. clients;n = 32) from Toronto and health and social care providers working in the areas of diabetes and/or homelessness (i.e. providers;n = 96) from across Canada. We used concept mapping, a participatory research method, to engage participants in brainstorming barriers to diabetes management, which were subsequently categorized into clusters, using the Concept Systems Global MAX software, and rated based on their perceived impact on diabetes management. The ratings were standardized for each participant group, and the average cluster ratings for the clients and providers were compared using t-tests.ResultsThe brainstorming identified 43 unique barriers to diabetes management. The clients’ map featured 9 clusters of barriers:Challenges to getting healthy food,Inadequate income,Navigating services, Not having a place of your own,Relationships with professionals,Diabetes education,Emotional wellbeing,Competing priorities, andWeather-related issues. The providers’ map had 7 clusters:Access to healthy food,Dietary choices in the context of homelessness,Limited finances, Lack of stable, private housing,Navigating the health and social sectors,Emotional distress and competing priorities, andMental health and addictions. The highest-rated clusters wereChallenges to getting healthy food(clients) andMental health and addictions(providers).Challenges to getting healthy foodwas rated significantly higher by clients (p = 0.01) andCompeting prioritieswas rated significantly higher by providers (p = 0.03).ConclusionsExperiencing homelessness poses numerous barriers to managing diabetes, the greatest of which according to clients, is challenges to getting healthy food. This study showed that the way clients and providers perceive these barriers differs considerably, which highlights the importance of including clients’ insights when assessing needs and designing effective solutions.

IntroductionHomelessness poses unique barriers to diabetes management. Population-level data on the risks of diabetes outcomes among people experiencing homelessness are needed to inform resource investment. The aim of this study was to create a population cohort of people with diabetes with a history of homelessness to understand their unique demographic and clinical characteristics and improve long-term health outcomes.MethodsOntario residents with diabetes were identified in administrative hospital databases between 2006 and 2020. A history of homelessness was identified using a validated algorithm. Demographic and clinical characteristics were compared between people with and without a history of homelessness. Propensity score matching was used to create a cohort of people with diabetes experiencing homelessness matched to comparable non-homeless controls.ResultsOf the 1,455,567 patients with diabetes who used hospital services, 0.7% (n=8,599) had a history of homelessness. Patients with a history of homelessness were younger (mean: 54 vs 66 years), more likely to be male (66% vs 51%) and more likely to live in a large urban centre (25% vs 7%). Notably, they were also more likely to be diagnosed with mental illness (49% vs 2%) and be admitted to a designated inpatient mental health bed (37% versus 1%). A suitable match was found for 5219 (75%) people with documented homelessness. The derived matched cohort was balanced on important demographic and clinical characteristics.ConclusionPeople with diabetes experiencing homelessness have unique characteristics that may require additional supports. Population-level comparisons can inform the delivery of tailored diabetes care and self-management resources.

Objectives Our aim in this study was to determine the distribution of glycated hemoglobin (A1C) in the Ontario diabetes population and identify subgroups with a high risk of poor glycemic control. Methods In this cross-sectional study, we used real-world clinical data linked with health-care administrative data to identify all people with prevalent diabetes on December 31, 2019. We then identified their most recent A1C result during the year. The distribution of A1C was assessed, and the proportion of those with an A1C of >8.0% was determined, stratified by various sociodemographic and clinical characteristics. Results In the population of 1,009,938 individuals with diabetes, mean ± standard deviation A1C was 7.2±1.4%, with 43.4% of them having an A1C of >7.0% and 19.0% with an A1C of >8.0%. Younger age, remote location of residence, longer diabetes duration and other surrogates for diabetes severity were associated with poor control. Conclusions The mean A1C among people with diabetes in Ontario was 7.2%, but nearly 20% had an A1C of >8%. There were notable disparities in glycemic control that identified several high-risk groups, including younger people, people with longer disease duration and people living in remote areas. Better clinical and policy approaches are needed to improve diabetes care for these populations.

Summary Background Diabetes prevalence is increasing in most places in the world, but prevalence is affected by both risk of developing diabetes and survival of those with diabetes. Diabetes incidence is a better metric to understand the trends in population risk of diabetes. Using a multicountry analysis, we aimed to ascertain whether the incidence of clinically diagnosed diabetes has changed over time. Methods In this multicountry data analysis, we assembled aggregated data describing trends in diagnosed total or type 2 diabetes incidence from 24 population-based data sources in 21 countries or jurisdictions. Data were from administrative sources, health insurance records, registries, and a health survey. We modelled incidence rates with Poisson regression, using age and calendar time (1995–2018) as variables, describing the effects with restricted cubic splines with six knots for age and calendar time. Findings Our data included about 22 million diabetes diagnoses from 5 billion person-years of follow-up. Data were from 19 high-income and two middle-income countries or jurisdictions. 23 data sources had data from 2010 onwards, among which 19 had a downward or stable trend, with an annual estimated change in incidence ranging from −1·1% to −10·8%. Among the four data sources with an increasing trend from 2010 onwards, the annual estimated change ranged from 0·9% to 5·6%. The findings were robust to sensitivity analyses excluding data sources in which the data quality was lower and were consistent in analyses stratified by different diabetes definitions. Interpretation The incidence of diagnosed diabetes is stabilising or declining in many high-income countries. The reasons for the declines in the incidence of diagnosed diabetes warrant further investigation with appropriate data sources. Funding US Centers for Disease Control and Prevention, Diabetes Australia Research Program, and Victoria State Government Operational Infrastructure Support Program.

IntroductionTransition from paediatric to adult care can be challenging for youth living with type 1 diabetes (T1D), as many youth feel unprepared to transfer to adult care and are at high risk for deterioration of glycaemic management and acute complications. Existing strategies to improve transition experience and outcomes are limited by cost, scalability, generalisability and youth engagement. Text messaging is an acceptable, accessible and cost-effective way of engaging youth. Together with adolescents and emerging adults and paediatric and adult T1D providers, we co-designed a text message-based intervention, Keeping in Touch (KiT), to deliver tailored transition support. Our primary objective is to test the effectiveness of KiT on diabetes self-efficacy in a randomised controlled trial.Methods and analysisWe will randomise 183 adolescents with T1D aged 17–18 years within 4 months of their final paediatric diabetes visit to the intervention or usual care. KiT will deliver tailored T1D transition support via text messages over 12 months based on a transition readiness assessment. The primary outcome, self-efficacy for diabetes self-management, will be measured 12 months after enrolment. Secondary outcomes, measured at 6 and 12 months, include transition readiness, perceived T1D-related stigma, time between final paediatric and first adult diabetes visits, haemoglobin A1c, and other glycaemia measures (for continuous glucose monitor users), diabetes-related hospitalisations and emergency department visits and the cost of implementing the intervention. The analysis will be intention-to-treat comparing diabetes self-efficacy at 12 months between groups. A process evaluation will be conducted to identify elements of the intervention and individual-level factors influencing implementation and outcomes.Ethics and disseminationThe study protocol version 7 July 2022 and accompanying documents were approved by Clinical Trials Ontario (Project ID: 3986) and the McGill University Health Centre (MP-37-2023-8823). Study findings will be presented at scientific conferences and in peer-reviewed publications.Trial registration numberNCT05434754.

Ischemic heart disease (IHD) is one of the leading causes of death worldwide. While extreme summer surface air temperatures are thought to be a risk factor for IHD, it is unclear whether large-scale climate patterns also influence this risk. This multi-national population-based study investigated the association between summer Pacific and Atlantic sea surface temperature (SST) variability and annual acute myocardial infarction (AMI) or IHD event rates among older adults residing in North America and the United Kingdom. Overall, a shift from cool to warm phase of the El Niño Southern Oscillation (ENSO) was associated with reduced AMI admissions in western Canada (adjusted rate ratio [RR] 0.89; 95% CI, 0.80–0.99), where this climate pattern predominatly forces below-normal cloud cover and precipitation during summertime, and increased AMI deaths in western United States (RR 1.09; 95% CI, 1.04–1.15), where it forces increased cloud cover and precipitation. Whereas, the Atlantic Multidecadal Oscillation (AMO) during a strong positive phase was associated with reduced AMI admissions in eastern Canada (RR 0.93; 95% CI, 0.87–0.98) and increased IHD mortality during summer months in the United Kingdom (RR 1.08; 95% CI, 1.03–1.14). These findings suggest that SST variability can be used to predict changes in cardiovascular event rates in regions that are susceptible.

Background: There are limited data on the association of material deprivation with clinical care and outcomes after atrial fibrillation (AF) diagnosis in jurisdictions with universal health care. Methods: This was a population-based cohort study of individuals ≥66 years of age with first diagnosis of AF between April 1, 2007, and March 31, 2019, in the Canadian province of Ontario, which provides public funding and prohibits private payment for medically necessary physician and hospital services. Prescription medications are subsidized for residents >65 years of age. The primary exposure was neighborhood material deprivation, a metric derived from Canadian census data to estimate inability to attain basic material needs. Neighborhoods were categorized by quintile from Q1 (least deprived) to Q5 (most deprived). Cause-specific hazards regression was used to study the association of material deprivation quintile with time to AF-related adverse events (death or hospitalization for stroke, heart failure, or bleeding), clinical services (physician visits, cardiac diagnostics), and interventions (anticoagulation, cardioversion, ablation) while adjusting for individual characteristics and regional cardiologist supply. Results: Among 347 632 individuals with AF (median age 79 years, 48.9% female), individuals in the most deprived neighborhoods (Q5) had higher prevalence of cardiovascular disease, risk factors, and noncardiovascular comorbidity relative to residents of the least deprived neighborhoods (Q1). After adjustment, Q5 residents had higher hazards of death (hazard ratio [HR], 1.16 [95% CI, 1.13–1.20]) and hospitalization for stroke (HR, 1.16 [95% CI, 1.07–1.27]), heart failure (HR, 1.14 [95% CI, 1.11–1.18]), or bleeding (HR, 1.16 [95% CI, 1.07–1.25]) relative to Q1. There were small differences across quintiles in primary care physician visits (HR, Q5 versus Q1, 0.91 [95% CI, 0.89–0.92]), echocardiography (HR, Q5 versus Q1, 0.97 [95% CI, 0.96–0.99]), and dispensation of anticoagulation (HR, Q5 versus Q1, 0.97 [95% CI, 0.95–0.98]). There were more prominent disparities for Q5 versus Q1 in cardiologist visits (HR, 0.84 [95% CI, 0.82–0.86]), cardioversion (HR, 0.80 [95% CI, 0.76–0.84]), and ablation (HR, 0.45 [95% CI, 0.30–0.67]). Conclusions: Despite universal health care and prescription medication coverage, residents of more deprived neighborhoods were less likely to visit cardiologists or receive rhythm control interventions after AF diagnosis, even though they exhibited higher cardiovascular disease burden and higher risk of adverse outcomes.

Diabetes incidence is expected to increase following the COVID-pandemic due to widespread changes in physical activity, diet, and access to health care services. We used administrative health care databases from Ontario, Canada to examine monthly changes in diabetes screening during the pandemic (Mar 2020-Feb 2021) compared to the pre-pandemic period (Mar 2019-Feb 2020) among adults aged 20-85 without prior diabetes. The eligible population was 9,599,079 in Mar 20 and 9,941,336 in Feb 2021. Overall, the number of people screened for diabetes was 25.3% lower in the pandemic (N=4,060,348) versus pre-pandemic (N=5,437,284) period. However, the number of people screened each month declined by 65.6% between February and April 2020 (Figure 1; 1.53 vs. 4.44 per 100, -2.91 per 100) . Screening rates recovered by July 2020 (3.88 per 100) but remained 15.6% lower than in the pre-pandemic period. Similar patterns were observed in all age groups but declines in screening rates between February and April 2020 were greatest in adults aged 35-49 (-69.4%) and 50-64 (-69.5%) . Findings were also consistent across income groups. In summary, we observed a sudden decline in diabetes screening in Ontario, Canada, where laboratory tests and other health care services are universally insured. This may lead to delays in prediabetes and diabetes diagnosis, resulting in missed opportunities for diabetes prevention and early management. Disclosure G.S.Fazli: None. R.Moineddin: None. V.Ling: None. G.L.Booth: None. Funding Canadian Institute for Health Research

OBJECTIVE To examine whether neighborhood socioeconomic status (SES) is a predictor of non-drug-related health care costs among Canadian adults with diabetes and, if so, whether SES disparities in costs are reduced after age 65 years, when universal drug coverage commences as an insurable benefit. RESEARCH DESIGN AND METHODS Administrative health databases were used to examine publicly funded health care expenditures among 698,113 younger (20–64 years) and older (≥65 years) adults with diabetes in Ontario from April 2004 to March 2014. Generalized linear models were constructed to examine relative and absolute differences in health care costs (total and non-drug-related costs) across neighborhood SES quintiles, by age, with adjustment for differences in age, sex, diabetes duration, and comorbidity. RESULTS Unadjusted costs per person-year in the lowest SES quintile (Q1) versus the highest (Q5) were 39% higher among younger adults ($5,954 vs. $4,270 [Canadian dollars]) but only 9% higher among older adults ($10,917 vs. $9,993). Adjusted non-drug costs (primarily for hospitalizations and physician visits) were $1,569 per person-year higher among younger adults in Q1 vs. Q5 (modeled relative cost difference: 35.7% higher) and $139.3 million per year among all individuals in Q1. Scenarios in which these excess costs per person-year were decreased by ≥10% or matched the relative difference among seniors suggested a potential for savings in the range of $26.0–$128.2 million per year among all lower-SES adults under age 65 years (Q1–Q4). CONCLUSIONS SES is a predictor of diabetes-related health care costs in our setting, more so among adults under age 65 years, a group that lacks universal drug coverage under Ontario’s health care system. Non-drug-related health care costs were more than one-third higher in younger, lower-SES adults, translating to >$1 billion more in health care expenditures over 10 years.

Background Individuals with type 1 diabetes (T1D) are more likely to achieve optimal glycemic management when they have frequent visits with their health care team. There is a potential benefit of frequent, telemedicine interventions as an effective strategy to lower hemoglobin A1c (HbA1c). Objective The objective is this study was to understand the provider- and system-level factors affecting the successful implementation of a virtual care intervention in type 1 diabetes (T1D) clinics. Methods Semistructured interviews were conducted with managers and certified diabetes educators (CDEs) at diabetes clinics across Southern Ontario before the COVID-19 pandemic. Deductive analysis was carried out using the Theoretical Domains Framework, followed by mapping to behavior change techniques to inform potential implementation strategies for high-frequency virtual care for T1D. Results There was considerable intention to deliver high-frequency virtual care to patients with T1D. Participants believed that this model of care could lead to improved patient outcomes and engagement but would likely increase the workload of CDEs. Some felt there were insufficient resources at their site to enable them to participate in the program. Member checking conducted during the pandemic revealed that clinics and staff had already developed strategies to overcome resource barriers to the adoption of virtual care during the pandemic. Conclusions Existing enablers for high-frequency virtual care for T1D can be leveraged, and barriers can be overcome with targeted clinical incentives and support.

Background The Portfolio Diet, or Dietary Portfolio, is a therapeutic dietary pattern that combines cholesterol-lowering foods to manage dyslipidemia for the prevention of cardiovascular disease. To translate the Portfolio Diet for primary care, we developed the PortfolioDiet.app as a patient and physician educational and engagement tool for PCs and smartphones. The PortfolioDiet.app is currently being used as an add-on therapy to the standard of care (usual care) for the prevention of cardiovascular disease in primary care. To enhance the adoption of this tool, it is important to ensure that the PortfolioDiet.app meets the needs of its target end users. Objective The main objective of this project is to undertake user testing to inform modifications to the PortfolioDiet.app as part of ongoing engagement in quality improvement (QI). Methods We undertook a 2-phase QI project from February 2021 to September 2021. We recruited users by convenience sampling. Users included patients, family physicians, and dietitians, as well as nutrition and medical students. For both phases, users were asked to use the PortfolioDiet.app daily for 7 days. In phase 1, a mixed-form questionnaire was administered to evaluate the users’ perceived acceptability, knowledge acquisition, and engagement with the PortfolioDiet.app. The questionnaire collected both quantitative and qualitative data, including 2 open-ended questions. The responses were used to inform modifications to the PortfolioDiet.app. In phase 2, the System Usability Scale was used to assess the usability of the updated PortfolioDiet.app, with a score higher than 70 being considered acceptable. Results A total of 30 and 19 users were recruited for phase 1 and phase 2, respectively. In phase 1, the PortfolioDiet.app increased users’ perceived knowledge of the Portfolio Diet and influenced their perceived food choices. Limitations identified by users included challenges navigating to resources and profile settings, limited information on plant sterols, inaccuracies in points, timed-logout frustration, request for step-by-step pop-up windows, and request for a mobile app version; when looking at positive feedback, the recipe section was the most commonly praised feature. Between the project phases, 6 modifications were made to the PortfolioDiet.app to incorporate and address user feedback. At phase 2, the average System Usability Scale score was 85.39 (SD 11.47), with 100 being the best possible. Conclusions By undertaking user testing of the PortfolioDiet.app, its limitations and strengths were able to be identified, informing modifications to the application, which resulted in a clinical tool that better meets users’ needs. The PortfolioDiet.app educates users on the Portfolio Diet and is considered acceptable by users. Although further refinements to the PortfolioDiet.app will continue to be made before its evaluation in a clinical trial, the result of this QI project is an improved clinical tool.

BACKGROUND The Portfolio Diet, or Dietary Portfolio, is a therapeutic dietary pattern that combines cholesterol-lowering foods to manage dyslipidemia for the prevention of cardiovascular disease. To translate the Portfolio Diet for primary care, we developed the PortfolioDiet.app as a patient and physician educational and engagement tool for PCs and smartphones. The PortfolioDiet.app is currently being used as an add-on therapy to the standard of care (usual care) for the prevention of cardiovascular disease in primary care. To enhance the adoption of this tool, it is important to ensure that the PortfolioDiet.app meets the needs of its target end users. OBJECTIVE The main objective of this project is to undertake user testing to inform modifications to the PortfolioDiet.app as part of ongoing engagement in quality improvement (QI). METHODS We undertook a 2-phase QI project from February 2021 to September 2021. We recruited users by convenience sampling. Users included patients, family physicians, and dietitians, as well as nutrition and medical students. For both phases, users were asked to use the PortfolioDiet.app daily for 7 days. In phase 1, a mixed-form questionnaire was administered to evaluate the users’ perceived acceptability, knowledge acquisition, and engagement with the PortfolioDiet.app. The questionnaire collected both quantitative and qualitative data, including 2 open-ended questions. The responses were used to inform modifications to the PortfolioDiet.app. In phase 2, the System Usability Scale was used to assess the usability of the updated PortfolioDiet.app, with a score higher than 70 being considered acceptable. RESULTS A total of 30 and 19 users were recruited for phase 1 and phase 2, respectively. In phase 1, the PortfolioDiet.app increased users’ perceived knowledge of the Portfolio Diet and influenced their perceived food choices. Limitations identified by users included challenges navigating to resources and profile settings, limited information on plant sterols, inaccuracies in points, timed-logout frustration, request for step-by-step pop-up windows, and request for a mobile app version; when looking at positive feedback, the recipe section was the most commonly praised feature. Between the project phases, 6 modifications were made to the PortfolioDiet.app to incorporate and address user feedback. At phase 2, the average System Usability Scale score was 85.39 (SD 11.47), with 100 being the best possible. CONCLUSIONS By undertaking user testing of the PortfolioDiet.app, its limitations and strengths were able to be identified, informing modifications to the application, which resulted in a clinical tool that better meets users’ needs. The PortfolioDiet.app educates users on the Portfolio Diet and is considered acceptable by users. Although further refinements to the PortfolioDiet.app will continue to be made before its evaluation in a clinical trial, the result of this QI project is an improved clinical tool.

Persons with lived experience of homelessness face many challenges in managing their diabetes, including purchasing and storing medications, procuring healthy food and accessing health-care services. Not only do these individuals have challenges in accessing primary care, they are also seen by diabetes specialists (endocrinologists, diabetes educators, foot- and eye-care specialists) less frequently.We conducted a qualitative descriptive study using open-ended interviews of 96 health and social care providers across 5 Canadian cities (Calgary, Edmonton, Ottawa, Vancouver, Toronto). We used NVivo qualitative software to facilitate thematic analysis of the data, focussing on homelessness-related patient barriers to diabetes specialty care.Barriers identified included patients' competing priorities and previous negative experiences with specialists, long wait times from referral to appointment, difficulty in contacting patients and location of the clinics. Primary care providers were confident in managing diabetes in most patients and believed that patients were best served under their care. Other barriers included specialists' limited understanding of patients' complex social situations and medication coverage as well as out-of-pocket costs associated with some specialist care. Recommendations for improving access to diabetes specialty care for these medically and socially complex patients included holding diabetes specialty clinics at community health centres, providing physician-to-physician direct referrals, and selecting specialists with an interest in health of the homeless population.Barriers to diabetes specialty care for persons with lived experience of homelessness are due largely to the physical and social environment of the clinics. Innovative solutions may be implemented to address these challenges and improve access for this population.

IntroductionParticipatory research is a study method that engages patients in research programs, ideally from study design through to dissemination. It is not commonly used in diabetes health services research. Our objectives were to describe the process and challenges of conducting a participatory research project and to highlight the experiences of both patient co-researchers and academic researchers.Research design and methodsWe recruited people with lived experience of homelessness (PWLEH) and diabetes in Toronto, Canada to become patient co-researchers. They were asked to commit to attending biweekly meetings. We undertook two major research projects: concept mapping to choose a research focus; and photovoice to explore accessing healthy food while homeless. We used a convergent mixed-methods design to evaluate their experience.ResultsA diverse group of eight PWLEH had an average attendance of 82% over 21 meetings—despite this success, we encountered a number of challenges of conducting this research: funding, ethics approval and recruitment were particularly difficult. Group members reported that participation improved their ability to self-advocate in their diabetes care and provided them with tangible skills and social benefits. Group members stated that they valued being involved in all aspects of the research, in particular knowledge translation activities, including advocating for nutritious food at shelters; presenting to stakeholders; and meeting with policymakers.ConclusionsThe use of participatory research methods enables academic researchers to support community members in pursuing research that is pertinent to them and which has a positive impact. In our study, co-researchers contributed in meaningful ways and also valued the experience.

This study uses administrative health care data from Ontario, Canada, to assess whether changes in diabetes management practices have affected trends in the association between diabetes vs prior cardiovascular disease and risk of cardiovascular events from 1994 to 2019 among adults aged 20 to 84 years.

Introduction Greater risk of adverse health outcomes and public health measures have increased distress among people with diabetes during the COVID-19 pandemic. The objectives of this study were to explore how the experiences of people with diabetes during the COVID-19 pandemic differ according to sociodemographic characteristics and identify diabetes-related psychosocial correlates of COVID distress. Methods Patients with type 1 or 2 diabetes were recruited from clinics and community health centres in Toronto, Ontario as well as patient networks. Participants were interviewed to explore the experiences of people with diabetes with varied sociodemographic and clinical identities, with respect to wellness (physical, emotional, social, financial, occupational), level of stress, and management strategies. Multiple linear regression was used to assess the relationships between diabetes distress, diabetes self-efficacy, and resilient coping with COVID distress. Results Interviews revealed that specific aspects of psychosocial wellness affected by the pandemic, and stress and illness management strategies utilized by people with diabetes differed based on socioeconomic status, sex, type of diabetes, and race. Resilient coping (β = -0.0517; 95% CI: -0.0918,-0.0116; P-value = 0.012), diabetes distress (β = 0.0260; 95% CI: 0.0149,0.0371; P-value < 0.0001), and diabetes self-efficacy (β = -0.0184; 95% CI: -0.0316,-0.0052; P-value = 0.007) were significantly associated with COVID distress. Conclusions Certain subgroups of people with diabetes have experienced a disproportionate amount of COVID distress. Assessing correlates of COVID distress among people with diabetes will help inform interventions such as diabetes self-management education to address the psychosocial distress caused by the pandemic.

Objective To determine if expansion of multi-use physical activity trails in an urban centre is associated with reduced rates of cardiovascular disease (CVD). Methods This was a natural experiment with a difference in differences analysis using administrative health records and trail-based cycling data in Winnipeg, Canada. Prior to the intervention, each year, 314,595 (IQR: 309,044 to 319,860) persons over 30 years without CVD were in the comparison group and 37,901 residents (IQR: 37,213 to 38,488) were in the intervention group. Following the intervention, each year, 303,853 (IQR: 302,843 to 304,465) persons were in the comparison group and 35,778 (IQR: 35,551 to 36,053) in the intervention group. The natural experiment was the construction of four multi-use trails, 4-7 km in length, between 2010 and 2012. Intervention and comparison areas were based on buffers of 400 m, 800 m and 1200 m from a new multi-use trail. Bicycle counts were obtained from electromagnetic counters embedded in the trail. The primary outcome was a composite of incident CVD events: CVD-related mortality, ischemic heart disease, cerebrovascular events and congestive heart failure. The secondary outcome was a composite of incident CVD risk factors: hypertension, diabetes and dyslipidemia. Results Between 2014 and 2018, 1,681,125 cyclists were recorded on the trails, which varied ~ 2.0-fold across the four trails (2358 vs 4264 counts/week in summer months). Between 2000 and 2018, there were 82,632 CVD events and 201,058 CVD risk events. In propensity score matched Poisson regression models, the incident rate ratio (IRR) was 1.06 (95% CI: 0.90 to 1.24) for CVD events and 0.95 (95%CI: 0.88 to 1.02) for CVD risk factors for areas within 400 m of a trail, relative to comparison areas. Sensitivity analyses indicated this effect was greatest among households adjacent to the trail with highest cycling counts (IRR = 0.85; 95% CI: 0.75 to 0.96). Conclusions The addition of multi-use trails was not associated with differences in CVD events or CVD risk factors, however the differences in CVD risk may depend on the level of trail use. Trial registration Trial registration number: NCT04057417.

AIM To compare glycaemic control and adverse outcomes between transition-aged and early adults with type 1 diabetes, and the impact of continuous subcutaneous insulin infusion (CSII) therapy funded through a government Assisted Devices Program. METHODS This retrospective cohort study using healthcare administrative databases from Ontario, Canada included adults aged 18-35 with type 1 diabetes between 1 April 2011 and 31 March 2014. Mean HbA1c was compared between transition-aged (18-24 years) and early adults (25-35 years), overall and stratified by whether or not they received government-funded CSII therapy (CSII vs. non-CSII). Secondary outcomes included rates of hospitalizations/emergency department visits for hyperglycaemia and hypoglycaemia over a 3-year follow-up. Comparisons were adjusted for relevant covariates. RESULTS Among 7157 participants with type 1 diabetes, mean HbA1c was significantly higher for transition-aged compared to early adults (71 mmol/mol [8.68%] vs. 64 mmol/mol [8.04%], p

Background: Acute inpatient hospital admissions account for more than half of all health care costs related to diabetes. We sought to identify the most common and costly conditions leading to hospital admission among patients with diabetes compared with patients without diabetes. Methods: We used data from the General Internal Medicine Inpatient Initiative (GEMINI) study, a retrospective cohort study, of all patients admitted to a general internal medicine service at 7 Toronto hospitals between 2010 and 2015. The Canadian Institute for Health Information (CIHI) Most Responsible Diagnosis code was used to identify the 10 most frequent reasons for admission in patients with diabetes. Cost of hospital admission was estimated using the CIHI Resource Intensity Weight. Comparisons were made between patients with or without diabetes using the Pearson χ2 test for frequency and distribution-free confidence intervals (CIs) for median cost. Results: Among the 150 499 hospital admissions in our study, 41 934 (27.8%) involved patients with diabetes. Compared with patients without diabetes, hospital admissions because of soft tissue and bone infections were most frequent (2.5% v. 1.9%; prevalence ratio [PR] 1.28, 95% CI 1.19–1.37) and costly (Can$8794 v. Can$5845; cost ratio [CR] 1.50, 95% CI 1.37–1.65) among patients with diabetes. This was followed by urinary tract infections (PR 1.16, 95% CI 1.11–1.22; CR 1.23, 95% CI 1.17–1.29), stroke (PR 1.13, 95% CI 1.07–1.19; CR 1.19, 95% CI 1.14–1.25) and electrolyte disorders (PR 1.11, 95% CI 1.03–1.20; CR 1.20, 95% CI 1.08–1.34). Interpretation: Soft tissue and bone infections, urinary tract infections, stroke and electrolyte disorders are associated with a greater frequency and cost of hospital admissions in patients with diabetes than in those without diabetes. Preventive strategies focused on reducing hospital admissions secondary to these disorders may be beneficial in patients with diabetes.

IntroductionParticipatory research is a study method that engages patient partners in research programs from study design through to completion. It has seldom been used in diabetes health services research. Our objectives were to describe the process and challenges of conducting a patient-engagement project and to highlight the experiences of patient participants and academic researchers.Research Design & MethodsWe recruited PWLEH and diabetes in Toronto, Canada to be patient partners. Group members were asked to commit to attending biweekly meetings. We undertook two major research projects: Concept mapping to choose a research focus; and photovoice to explore accessing healthy food while homeless. We used a convergent mixed methods design to evaluate their experience.ResultsA diverse group of 8 PWLEH had an average attendance of 82% over 21 meetings – despite this success, we encountered a number of challenges to conducting this research. Group members reported that participation improved their ability to be self-advocates in their diabetes care and provided them with tangible skills and social benefits. Group members stated that they valued being involved in all aspects of the research, in particular knowledge translation activities, including advocating for nutritious food at shelters; presenting to stakeholders; and meeting with policy makers.ConclusionsThe use of participatory patient engagement research methods enables academic researchers to support community members in pursuing research that is pertinent to them and which has a positive impact. In our study, group members contributed in meaningful ways and also valued the experience.What is already known about this subject?Patient oriented research is important to public health research as it helps with the development of relevant interventions and knowledge translation.Participatory research is a form of research that maximally involves patients in all phases of the research.Participatory research has rarely been used in research on diabetes and diabetes-related interventions.What are the new findings?Patient engagement is important for studies involving socially disadvantaged populations with diabetes.Community members involved in research contribute substantially to research projects but also find the experience to be enriching and valuable.How might these results change the focus of research or clinical practice?Those who conduct research with and develop programs to provide diabetes care, especially to socially disadvantaged populations, should involve community members through all phases of the process to ensure the intervention is maximally useful for patients.

Background To develop and validate a drivability index for the City of Toronto and examine its association with transportation mode choice. Methods We used exploratory factor analysis to derive distinct factors (clusters of one or more environmental characteristics) that reflect the degree of car dependency in each neighborhood, drawing from candidate variables that capture density, diversity, design, destination accessibility, distance to transit, and demand management. Area-level factor scores were then combined into a single composite score, reflecting neighborhood drivability. Negative binomial generalized estimating equations were used to test the association between driveability quintiles (Q) and primary travel mode (>50% of trips by car, public transit, or walking/cycling) in a population-based sample of 63,766 Toronto residents enrolled in the Transportation Tomorrow Survey (TTS), adjusting for individual and household characteristics, and accounting for clustering of respondents within households. Results The drivability index consisted of three factors: Urban sprawl, pedestrian facilities and parking availability. Relative to those living in the least drivable neighborhoods (Q1), those in high drivability areas (Q5) had a significantly higher rate of car travel (adjusted rate ratio (RR):1.80,95%CI:1.77-1.88), and lower rate of public transit use (RR:0.90,95%CI:0.85-0.94) and walking/cycling (RR:0.22,95%CI:0.19-0.25). Associations were strongest for short trips ( Conclusions This novel neighborhood drivability index predicted whether local residents drive or use active modes of transportation and can be used to investigate the association between drivability, physical activity, and chronic disease risk. Key messages The association between neighborhood drivability and car use was strongest for short trips. The drivability of the neighborhood where people work is a strong determinant of car use.

Objective: To examine whether neighborhood socioeconomic status (SES) is a predictor of non-drug-related health care costs among Canadian adults with diabetes, and if so, whether SES disparities in costs are reduced after age 65, when universal drug coverage commences as an insurable benefit. Methods: Administrative health databases were used to examine publicly-funded health care expenditures among 698,113 younger (20-64 years) and older adults (≥65 years) with diabetes in Ontario from April 2004 to March 2014. Generalized linear models were constructed to examine relative and absolute differences in health care costs (total and non-drug-related) across neighborhood socioeconomic status (SES) quintiles, by age, adjusting for differences in age, sex, diabetes duration, and comorbidity. Results: Unadjusted costs per person-year in the lowest (Q1) versus highest (Q5) SES quintile were 39% higher among younger adults ($5,954 vs. $4,270 Canadian dollars), but only 9% higher among older adults ($10,917 vs. $9,993). Adjusted non-drug costs (primarily for hospitalizations and physician visits) were $1,569 per person-year higher among younger adults in Q1 vs. Q5 (modeled relative cost difference: +35.7%) and $139.3 million per year among all individuals in Q1. Scenarios in which these excess costs per person-year were decreased by ≥10% or matched the relative difference among seniors suggested a potential for savings in the range of $26.0 to $128.2 million per year among all lower SES adults under age 65 (Q1-4). Conclusions: Socioeconomic status is a predictor of diabetes-related health care costs in our setting, more so among adults under age 65, a group that lacks universal drug coverage under Ontario’s health care system. Non-drug related health care costs were more than one-third higher in younger, low SES adults, translating to >$1 billion more in health care expenditures over 10 years.

IntroductionWe aimed to develop algorithms distinguishing type 1 diabetes (T1D) from type 2 diabetes in adults ≥18 years old using primary care electronic medical record (EMRPC) and administrative healthcare data from Ontario, Canada, and to estimate T1D prevalence and incidence.Research design and methodsThe reference population was a random sample of patients with diabetes in EMRPC whose charts were manually abstracted (n=5402). Algorithms were developed using classification trees, random forests, and rule-based methods, using electronic medical record (EMR) data, administrative data, or both. Algorithm performance was assessed in EMRPC. Administrative data algorithms were additionally evaluated using a diabetes clinic registry with endocrinologist-assigned diabetes type (n=29 371). Three algorithms were applied to the Ontario population to evaluate the minimum, moderate and maximum estimates of T1D prevalence and incidence rates between 2010 and 2017, and trends were analyzed using negative binomial regressions.ResultsOf 5402 individuals with diabetes in EMRPC, 195 had T1D. Sensitivity, specificity, positive predictive value and negative predictive value for the best performing algorithms were 80.6% (75.9–87.2), 99.8% (99.7–100), 94.9% (92.3–98.7), and 99.3% (99.1–99.5) for EMR, 51.3% (44.0–58.5), 99.5% (99.3–99.7), 79.4% (71.2–86.1), and 98.2% (97.8–98.5) for administrative data, and 87.2% (81.7–91.5), 99.9% (99.7–100), 96.6% (92.7–98.7) and 99.5% (99.3–99.7) for combined EMR and administrative data. Administrative data algorithms had similar sensitivity and specificity in the diabetes clinic registry. Of 11 499 711 adults in Ontario in 2017, there were 24 789 (0.22%, minimum estimate) to 102 140 (0.89%, maximum estimate) with T1D. Between 2010 and 2017, the age-standardized and sex-standardized prevalence rates per 1000 person-years increased (minimum estimate 1.7 to 2.56, maximum estimate 7.48 to 9.86, pConclusionsPrimary care EMR and administrative data algorithms performed well in identifying T1D and demonstrated increasing T1D prevalence in Ontario. These algorithms may permit the development of large, population-based cohort studies of T1D.

Background: Reliance on cars contributes to physical inactivity, and therefore may be a risk factor for type 2 diabetes. We investigated whether living in neighborhoods that are highly conducive to driving is associated with an increased incidence of diabetes. Methods: Working age adults (20-64 yrs) who were living in Toronto, Canada on April 1st 2011, were followed over 6 yrs for incident diabetes using a validated algorithm based on hospital records and physicians’ services claims. For neighborhood drivability, we used a novel index capturing three factors of the built environment: urban sprawl, pedestrian unfriendliness and parking options. Cox regression was used to examine the association between neighborhood drivability quintiles (Q) and diabetes incidence, adjusting for age, sex, income, ethnicity, immigration status and comorbidity, and censoring for death. Results: Among 1,473,994 individuals in our sample (mean age 40.9±12.2, 48.5% male), 77,835 developed diabetes. Overall, there was a direct relationship between drivability and diabetes incidence, however the magnitude of this effect varied by age and income. Among young adults (20-34 yrs), those living in the most drivable neighborhoods (Q5) had a 58% higher incidence of diabetes (adjusted HR: 1.58 (95%CI: 1.47-1.69)) relative to those in the least drivable neighborhoods (Q1), whereas the same comparison in older adults (55-64 yrs) yielded smaller differences (HR: 1.31 (95%CI: 1.26-1.36)). High drivability was most strongly associated with diabetes risk in the middle income neighborhoods with 96% increased risk for young residents (HR:1.96 (95%CI: 1.64-2.33) and a 46% increased risk for older residents (HR: 1.46 (95%CI:1.32-1.62). Associations between drivability and diabetes incidence were significant but of a lesser magnitude in low- and high-income neighborhoods. Conclusion: In our setting, neighborhood drivability is a risk factor for the diabetes incidence among working age adults, especially younger, middle-income populations. Disclosure N. den Braver: None. J. Beulens: None. J. Lakerveld: None. P. Gozdyra: None. F. Wu: None. F. Rutters: None. G.S. Fazli: None. R. Moineddin: None. G. Booth: None.

AIM To compare perinatal outcomes in women with undiagnosed diabetes with gestational diabetes alone, pre-existing diabetes and women without diabetes, and to identify risk factors which distinguish them from women with gestational diabetes alone. METHODS This population-based cohort study included administrative data on all women who gave birth in Ontario, Canada, during 2002-2015. Maternal/neonatal outcomes were compared across groups using logistic regression, adjusting for confounders. A nested case control study compared women with undiagnosed type 2 diabetes with women with gestational diabetes alone to determine risk factors that would help identify these women. RESULTS Among 995 990 women, 68 163 had gestational diabetes (6.8%) and, of those women with gestational diabetes,1772 had undiagnosed type 2 diabetes (2.6%). Those with undiagnosed type 2 diabetes were more likely to be older, from a lower income area, have parity > 3 and BMI ≥ 30 kg/m2 compared with gestational diabetes alone. Infants had a higher risk of perinatal mortality (OR 2.3 [1.6-3.4]), preterm birth (OR 2.6 [2.3-2.9]), congenital anomalies (OR 2.1 [1.7-2.5]), neonatal intensive care unit admission (OR 3.1 [2.8-3.5]) and neonatal hypoglycaemia (OR 406.0 [357-461]), which were similar to women with pre-existing diabetes. The strongest predictive risk factors included early gestational diabetes diagnosis, previous gestational diabetes and chronic hypertension. CONCLUSIONS Women diagnosed with gestational diabetes who develop diabetes within 1 year postpartum are at higher risk of adverse pregnancy outcomes, including perinatal mortality. This highlights the need for earlier diagnosis, preferably pre-pregnancy, and more aggressive treatment and surveillance of suspected type 2 diabetes during pregnancy.

IntroductionAspects of the built environment that support physical activity are associated with better population health outcomes. Few experimental data exist to support these observations. This protocol describes the study of the creation of urban trials on cardiovascular disease (CVD)-related morbidity and mortality in a large urban centre.Methods and analysisBetween 2008 and 2010, the city of Winnipeg, Canada, built four, paved, multiuse (eg, cycling, walking and running), two-lane trails that are 5–8 km long and span ~60 neighbourhoods. Linking a population-based health data with census and environmental data, we will perform an interrupted time series analysis to assess the impact of this natural experiment on CVD-related morbidity and mortality among individuals 30–65 years of age residing within 400–1200 m of the trail. The primary outcome of interest is a composite measure of incident major adverse CVD events (ie, CVD-related mortality, ischaemic heart disease, stroke and congestive heart failure). The secondary outcome of interest is a composite measure of incident CVD-related risk factors (ie, diabetes, hypertension and dyslipidaemia). Outcomes will be assessed quarterly in the 10 years before the intervention and 5 years following the intervention, with a 4-year interruption. We will adjust analyses for differences in age, sex, ethnicity, immigration status, income, gentrification and other aspects of the built environment (ie, greenspace, fitness/recreation centres and walkability). We will also assess trail use and trail user profiles using field data collection methods.Ethics and disseminationEthical approvals for the study have been granted by the Health Research Ethics Board at the University of Manitoba and the Health Information Privacy Committee within the Winnipeg Regional Health Authority. We have adopted an integrated knowledge translation approach. Information will be disseminated with public and government partners.Trial registration numberNCT04057417.