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"Nature prescriptions" are increasingly being adopted by health sectors as an adjunct to standard care to attend to health and social needs. We investigated levels of need and interest in nature prescriptions in adults with cardiovascular diseases, psychological distress and concomitants (e.g. physical inactivity, sedentary behaviour, obesity, loneliness, burn-out).A nationally-representative survey of 3,319 adults across all states and territories of Australia was completed in February 2021 (response 84.0%). Participants were classified across 15 target groups using validated health indicators and surveyed on (1) time and frequency of visits to green and blue spaces (nature spaces), (2) interest in a nature prescription, and (3) potential confounders (e.g. age, income). Analyses were done using weighted logistic regressions.The sample was 50.5% female, 52.0% were aged ≥45 years, 15.2% were living alone and 19.3% were born overseas in non-English-speaking countries. Two-thirds of the sample spent 2 hours or more a week in nature, but these levels were generally lower in target groups (e.g. 57.7% in adults with type 2 diabetes). Most participants (81.9%) were interested in a nature prescription, even among those spending fewer than 2 hours a week in nature (76.4%). For example, 2 hours a week or more in nature was lowest among sedentary adults (36.9%) yet interest in nature prescriptions in this group was still high (74.0%). Lower levels of nature contact in target groups was not explained by differences in access to or preference for local nature spaces.High levels of interest in nature prescriptions amid low levels of nature contact in many target health groups provides impetus for developing randomised trials of interventions that enable people to spend more time in nature. These findings can inform intervention co-design processes with a wide range of community stakeholders, end-users in target health groups, and the health professionals who support them.

BACKGROUND Individuals with type 1 diabetes (T1D) are more likely to achieve optimal glycemic control when they have frequent visits with their healthcare team. There is a potential benefit of frequent, telemedicine interventions as an effective strategy to lower hemoglobin A1c (HbA1c). OBJECTIVE To understand the provider- and system-level factors affecting successful implementation of a virtual care intervention into type 1 diabetes (T1D) clinics. METHODS Semi-structured interviews with managers and certified diabetes educators (CDEs) at diabetes clinics across Southern Ontario, prior to the COVID-19 pandemic. Deductive analysis using the Theoretical Domains Framework, then mapping to Behaviour 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 can be leveraged, and barriers can be overcome with targeted clinical incentives and support.

Objective To understand the provider- and system-level factors affecting successful implementation of a virtual care intervention into type 1 diabetes (T1D) clinics. Methods Semi-structured interviews with managers and certified diabetes educators (CDEs) at diabetes clinics across Southern Ontario, prior to the COVID-19 pandemic. Deductive analysis using the Theoretical Domains Framework, then mapping to Behaviour 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. Conclusion Existing enablers for high frequency virtual care can be leveraged, and barriers can be overcome with targeted clinical incentives and support.

Introduction: There is little experimental evidence of the impact of multi-use recreational trails that support physical activity on cardiovascular disease (CVD). Hypothesis: Neighbourhoods that added multi-use trails would experience a greater decline in CVD events and risk factors compared to neighbourhoods that did not. Methods: We used a difference in differences design to study the addition of four multi-use trails 4-7km in length on CVD-related outcomes using administrative health, census and built environment data available for all citizens 30 years of age and older from Winnipeg, Canada. A 400m buffer stratified intervention and comparison neighbourhoods. Bicycle counts were recorded via electromagnetic counters for 5 years on all trails. The primary and secondary outcomes were composite measures of incident CVD events (mortality, ischemic heart disease, cerebrovascular disease and congestive heart failure) and CVD risk factors (hypertension, diabetes and dyslipidemia) and assessed quarterly for 10 years prior to and 6 years following the intervention. Intervention and comparison areas were propensity score matched, using scores regressed from baseline measures of age, sex, socioeconomic indicators, and built environment attributes that support physical activity. Results: Between 2012 and 2018, 1,429,588 cyclists were recorded on the trails and cycling use varied ~2.0-fold across the trails. Between 2000 and 2018, there were 82,632 CVD events and 201,058 CVD risk events. During the 18-year natural experiment CVD event rates and risk factors declined ~33% in both comparison and intervention neighbourhoods. In propensity score matched regression models, the incident rate ratio was 1.06 (95% CI: 0.90 to 1.24) for CVD events and 0.92 (95% CI: 0.84 to 1.02) for CVD risk factors. Sensitivity analyses revealed greater effect sizes with increasing trail use (incident rate ratios for highest vs lowest cycling counts = 0.85; 95% CI: 0.75 to 0.96 vs 1.08; 95% CI: 0.92 to 1.27). Conclusions: The addition of recreational multi-use trails was not associated with changes in overall CVD events or risk factors in adjacent neighbourhoods, compared to distant neighbourhoods, however, the effects on CVD risk factors may be influenced by trail use.

Introduction: While sodium glucose cotransporter 2 inhibitors (SGLT2i) improve cardiovascular outcomes in type 2 diabetes (T2D) and cardiovascular disease (CVD), their uptake in clinical practice in this population is unclear. Therefore, we evaluated trends in SGLT2i use and identified predictors of use in patients with concomitant T2D and CVD. Methods: We conducted an observational study using population-based health data in Ontario, Canada from 4/2016-3/2020 of patients ≥65 years old with a first diagnosis of T2D plus CVD. In each yearly cohort, we estimated the prevalent use of SGLT2i (≥1 prescription) within 1 year, including by demographic and comorbidity subgroups. In the overall cohort, we used multivariable logistic regression models to identify factors associated with SGLT2i use. Results: We identified 208,303 patients with T2D and CVD [median age 74.0 years (IQR 68.0-80.0); 63.5% male]. The proportion of patients dispensed an SGLT2i increased over time, from 7.0% in 2016 to 20.1% in 2019. In 2019, use in those ≥75 years was 50% lower than those 75 years (OR 0.39, 95%CI:0.38-0.40), with high frailty score (OR 0.38, 95%CI:0.35-0.42), or serum creatinine 1.4-2mg/dL vs. Conclusions: In a real-world population of T2D and CVD, only 1 in 5 patients used an SGLT2i, although use increased over time. Markers of worse diabetes control were associated with increased SGLT2i use, while markers of more comorbidity were associated with less use.

One hundred years have passed since the discovery of insulin—an achievement that transformed diabetes from a fatal illness into a manageable chronic condition. The decades since that momentous achievement have brought ever more rapid innovation and advancement in diabetes research and clinical care. To celebrate the important work of the past century and help to chart a course for its continuation into the next, the Canadian Institutes of Health Research’s Institute of Nutrition, Metabolism and Diabetes and the U.S. National Institutes of Health’s National Institute of Diabetes and Digestive and Kidney Diseases recently held a joint international symposium, bringing together a cohort of researchers with diverse interests and backgrounds from both countries and beyond to discuss their collective quest to better understand the heterogeneity of diabetes and thus gain insights to inform new directions in diabetes treatment and prevention. This article summarizes the proceedings of that symposium, which spanned cutting-edge research into various aspects of islet biology, the heterogeneity of diabetic phenotypes, and the current state of and future prospects for precision medicine in diabetes.

The main objective of the current study is to examine the trend of congenital abnormalities among children born by women with and without diabetes, and to explore the impact of food fortification by folic acid on the rate of birth defects among these two groups of mothers.All children born alive in Ontario, Canada, during 1994 to 2009 and their mothers were included in study. Diagnosis of pregestational diabetes among mothers was identified using Diabetes registry, and diagnosis of birth defects among children were identified using hospital records.The prevalence of births among diabetic mothers increased by almost 200% during the study period. Among children born to mothers with diabetes, the prevalence for all anomalies combined was approximately 47% higher and for various cardiac and central nervous system anomalies up to a three- to fivefold higher than those born to nondiabetic mothers. While the rate of birth defects in both groups observed a considerable decline after food fortification in 1999, but the gap between two groups remained unchanged over time.While the prevalence of birth defects among diabetic pregnancies is still considerably higher that nondiabetic pregnancies, results of the current study indicate a declining trend in the prevalence of some congenital abnormalities among babies born to both diabetic and nondiabetic mothers after 1999. We need to be more aggressive in implementing preventive measures, including a national diabetes plan or the proposed universal policy of supra-dietary folic acid supplementation for women with diabetes who are of reproductive age. Birth Defects Research (Part A) 106:831-839, 2016. © 2016 Wiley Periodicals, Inc.

Intensive multifactorial intervention reduces end points in patients with diabetic nephropathy. Traditional clinics struggle to provide the intensity of care required to meet targets for this growing patient group. We designed a pharmacist-led, protocol driven clinic to offer stepwise intensive treatment to patients with diabetic nephropathy picked up at the traditional secondary care clinic. One hundred and sixteen individuals received more than one review. The clinic achieved significant improvements in blood pressure (BP): systolic 151±19 mmHg vs.133±15 mmHg (p