In This Issue

  • Annual Retreat
  • Report from the Chair
  • Project Update
  • ACHORD Seen & Heard
  • Recent Literature
  • ACHORD Accolades
  • Other ACHORD News
  • Events

Previous Issues

  • December 2012
  • September 2012
  • April 2012
  • December 2011
  • July 2011
  • all previous issues

ACHORD Seen & Heard

Recent Publications

Al Sayah F, Majumdar SR, Williams B, Robertson S, Johnson JA. Health literacy and health outcomes in diabetes: a systematic review. J Gen Intern Med. 2013 Mar;28(3):444-52. PMID: 23065575

Al Sayah F, Williams B, Johnson JA. Measuring health literacy in individuals with diabetes: a systematic review and evaluation of available measures. Health Educ Behav. 2013 Feb;40(1):42-55. PMID: 22491040

Asadi L, Eurich DT, Gamble JM, Minhas-Sandhu JK, Marrie TJ, Majumdar SR. Impact of guideline-concordant antibiotics and macrolide/β-lactam combinations in 3203 patients hospitalized with pneumonia: prospective cohort study. Clin Microbiol Infect. 2013 Mar;19(3):257-64. PMID: 22404691

Butalia S, Johnson JA, Ghali WA, Rabi DM. Clinical and socio-demographic factors associated with diabetic ketoacidosis hospitalization in adults with Type 1 diabetes. Diabet Med. 2013 May;30(5):567-73. PMID: 23323955

Comte M, Hobin E, Majumdar SR, Plotnikoff RC, Ball GD, McGavock J; MIPASS and Healthy Hearts Investigators Teams. Patterns of weekday and weekend physical activity in youth in 2 Canadian provinces. Appl Physiol Nutr Metab. 2013 Feb;38(2):115-9. PMID: 23438220

Evans CD, Eurich DT, Lu X, Remillard AJ, Shevchuk YM, Blackburn D. The association between market availability and adherence to antihypertensive medications: an observational study. Am J Hypertens. 2013 Feb;26(2):180-90. PMID: 23382402

Forbes LE, Downs SM, Fraser SN, Majumdar SR, Ball GD, Plotnikoff RC, Wozny PD, Torrance BD, McCargar LJ, Lewanczuk RZ, McGavock JM. Anthropometric and dietary predictors of insulin sensitivity in 10- to 14-year-old boys and girls. Appl Physiol Nutr Metab. 2013 Mar;38(3):320-5. PMID: 23537025

Gilani F, Majumdar SR, Johnson JA, Tsuyuki RT, Lewanczuk RZ, Spooner R, Simpson SH. Adding pharmacists to primary care teams increases guideline-concordant antiplatelet use in patients with type 2 diabetes: results from a randomized trial. Ann Pharmacother. 2013 Jan;47(1):43-8. PMID: 23324512

James MT, Samuel SM, Manning MA, Tonelli M, Ghali WA, Faris P, Knudtson ML, Pannu N, Hemmelgarn BR. Contrast-induced acute kidney injury and risk of adverse clinical outcomes after coronary angiography: a systematic review and meta-analysis. Circ Cardiovasc Interv. 2013 Feb;6(1):37-43. PMID: 23322741

Lau D, Agborsangaya C, Sayah FA, Wu X, Ohinmaa A, Johnson JA. Population-level response shift: novel implications for research. Qual Life Res. 2012 Nov;21(9):1495-8. PMID: 22094927

Johnson JA, Colmers IN. Balancing the risks and benefits for pioglitazone in type 2 diabetes. Diabetes Res Clin Pract. 2012 Oct;98(1):1-2. PMID: 22959125

MacIntyre EJ, Majumdar SR, Gamble JM, Minhas-Sandhu JK, Marrie TJ, Eurich DT. Stress hyperglycemia and newly diagnosed diabetes in 2124 patients hospitalized with pneumonia. Am J Med. 2012 Oct;125(10):1036.e17-23. PMID: 22863217

Majumdar SR, Leslie WD. Conventional computed tomography imaging and bone mineral density: opportunistic screening or “incidentaloporosis”? Ann Intern Med. 2013 Apr 16;158(8):630-1. PMID: 23588751

Majumdar SR, Lier DA, McAlister FA, Rowe BH, Siminoski K, Hanley DA, Russell AS, Johnson JA. Cost-effectiveness of osteoporosis interventions for ‘incidental’ vertebral fractures. Am J Med. 2013 Feb;126(2):169.e9-17. PMID: 23331449

McBrien K, Rabi DM, Campbell N, Barnieh L, Clement F, Hemmelgarn BR, Tonelli M, Leiter LA, Klarenbach SW, Manns BJ. Intensive and Standard Blood Pressure Targets in Patients With Type 2 Diabetes Mellitus: Systematic Review and Meta-analysis. Arch Intern Med. 2012 Sep 24;172(17):1296-303. PMID: 22868819

McMurtry MS, Southern DA, Lewin AM, Galbraith PD, Kaul P, Ghali WA, Knudtson ML, Graham MM. Recent temporal trends and geographic distribution of cardiac procedures in Alberta. Can J Cardiol. 2013 Apr;29(4):460-5. PMID: 22902156

Plotnikoff RC, Karunamuni N, Courneya KS, Sigal RJ, Johnson JA, Johnson ST. The Alberta Diabetes and Physical Activity Trial (ADAPT): a randomized trial evaluating theory-based interventions to increase physical activity in adults with type 2 diabetes. Ann Behav Med. 2013 Feb;45(1):45-56. PMID: 22922954

Sigal RJ, Armstrong MJ, Colby P, Kenny GP, Plotnikoff RC, Reichert SM, Riddell MC. Canadian Diabetes Association 2013 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada: Physical Activity and Diabetes. Canadian Journal of Diabetes, 2013:37 (suppl. 1). S1-S212.

Wozniak L, Rees S, Soprovich A, Al Sayah F, Johnson ST, Majumdar SR, Johnson JA. Applying the RE-AIM framework to the Alberta’s Caring for Diabetes Project: a protocol for a comprehensive evaluation of primary care quality improvement interventions. BMJ Open. 2012 Oct 26;2(5). PMID: 23103609


Internet Publications

Bowker SL, Johnson JA. Hyperinsulinemia and cancer [internet]. 2013 [cited 2013 Apr 15]; Diapedia 6104476165 rev. no. 13. Available from:

Bowker SL, Johnson JA. Diabetes-associated cancers [internet]. 2013 [cited 2013 Apr 15]; Diapedia 6104460142 rev. no. 16. Available from:


Recent Presentations

Armstrong MJ, Sigal RJ, Hauer TL, Austford LD, Arena R, Aggarwal S, Martin BJ. Cardiac Rehabilitation Completion is Associated with Reduced Mortality in Diabetic Subjects with Coronary Artery Disease [ORAL ABSTRACT PRESENTATION] American Heart Association Meeting, Los Angeles, California, November 3-7, 2012. Circulation, 2012: 126 A16447.

Armstrong MJ, Rabi DM, Sigal RJ. Exercise Stress Testing in Asymptomatic People with Type 2 Diabetes Referred to Exercise Programs: a Retrospective Data Linkage Study. [ORAL ABSTRACT PRESENTATION] Canadian Diabetes Association Annual Meeting, Vancouver, BC October 10-13, 2012. Can J Diabetes, 2012; 36(5): S15.

Armstrong MJ, Martin BJ, Hauer TL, Austford LD, Arena R, Aggarwal S, Sigal RJ. Adherence Rates and Cardiorespiratory Fitness Outcomes in People with and without Diabetes Completing a Cardiac Rehabilitation Program. [POSTER PRESENTATION] Canadian Diabetes Association Annual Meeting, Vancouver, BC October 10-13, 2012. Can J Diabetes, 2012; 36(5): S54-55.

Aborsangaya CB, Johnson ST, Van der Meer L, Avedzi H, Mathe N, Storey K, Murray T, Johnson JA. Understanding If and How Albertans are Eating Well with Canada’s Food Guide. 2013 Nutrition File Seminar hosted by Alberta Milk. Edmonton Marriott at River Cree Resort, Edmonton, AB February 5, 2013.

Johnson ST, Abrosyngasa C, Van der Meer L, Storey K, Murray TA. Awareness and use of Canada¹s Food Guide to Healthy Eating: A population-based study. Pan Pacific Conference of Medicine and Science in Sport. Honolulu, Hawaii, USA, February 18-20, 2013.

Johnson JA. Opportunity Knocks: The Role of Pharmacists in Enhancing the Care of Diabetes. Alberta Pharmacists’ Association Trusted Partners in Health Professional Development Event, Fantasyland Hotel, West Edmonton Mall, Edmonton, AB, March 9, 2013.

Khokhar B, Jones J, Ronksley PE, Caird J, Rabi D. The Effectiveness of Mobile Electronic Devices in Weight Loss among Overweight and Obese Populations: A Systematic Review and Meta Analysis. Society of General Internal Medicine (SGIM) Conference, Denver, Colorado April 24 – 27, 2013.



11th Annual ACHORD Retreat

March 6-7, 2014
The Banff Centre
Banff, Alberta, Canada









10th Annual ACHORD Retreat, the Banff Centre, March 7 & 8, 2013

DSC01330The 10th Annual ACHORD Retreat was held on March 7-8, 2013 at The Banff Centre. As in past years, this informal meeting provides an opportunity for ACHORD investigators, collaborators and trainees to share research updates, and plan for continued growth of the ACHORD Research program. This year we welcomed Ben Harrison from Great West Life, as our guest speaker, who provided a third party payer perspective on costs associated with diabetes, and chronic disease management strategies being devised within the insurance industry to offer employers who sponsor health benefit programs. As in years past, we were entertained by Jim Olver from the Banff Centre, who presented the renewed Vision of the Banff Centre. We were also fortunate to have several attendees from the University of Toronto as well as the Health Quality Council of Alberta, Alberta HealthAlberta Health Services, and Wilfrid Laurier University reflecting our growing alliance of health outcomes research in diabetes across Canada.

Thank you to all who presented at the Retreat (also available on our website,
– Trainee Project Presentations by Ahmed Abdelmoneim, Fatima Al Sayah, Marni Armstrong, Bushra Khokhar, Daniala Weir, Jongnam Hwang, Dima Omran and Nonsikelelo Mathe
– Ben Harrison on Diabetes in the Workplace: a private payer prospective
– Jim Olver on New Vision of the Banff Centre
Dean Eurich presented accolades celebrating ACHORD successes for both students and faculty in the past year
– Jeff Johnson on the ABCD Update
Gillian Booth on The Built Environment and Obesity Related Diseases
Lorraine Lipscombe on Improving diabetes prevention in women with recent gestational diabetes

Our organized physical activity event this year was B-Fit and was enjoyed by those who attended – it was a great workout!

Steve Johnson and Lisa Tjosvold led a student breakout session where the trainees discussed the third-party payer diabetes management programs introduced by Ben Harrison from Great West Life. As in past retreats, the trainees were able to participate and interact in a forum that is not always a part of their traditional course-based training.

Thank you to everyone who attended the 10th Annual Retreat. As is the case every year, this event is a success because of those of you that attend. Thank you to Steve Johnson and Sherry Lydynuik for planning the event and thank you to Daniala Weir for the icebreaker activity that was enjoyed prior to dinner on Thursday evening. Plans for the ACHORD Retreat 2014 at the Banff Centre are already underway; we are looking at March 6-7, 2014 as the dates for next year’s retreat, so mark those dates in your calendar!


Report from the Chair

Hello everyone! We are well into Spring and ACHORD is as busy as ever! Here is a quick update on what we have been doing since our last newsletter.

As you can see from the article above, we held the 10th Annual ACHORD Retreat in Banff in March. This was a very productive meeting.  It is always great to see everyone and hear about their research, especially the student work and the progress they are all making.

ACHORD members have been busy attending meetings/conferences during the first quarter of 2013. Some of the events that have been attended by ACHORD members are: the 2013 Nutrition Conference in Edmonton, the 4th International Diabetes and Cancer Research Consortium workshop in Goteborg, Sweden, and the Primary Care Initiative Spring Forum in Edmonton. I attended the Canadian Obesity Network Summit and will be at the upcoming Canadian Association for Health Services and Policy Research (CAHSPR) and American Diabetes Association (ADA) meetings along with other ACHORD Trainees and Investigators.

The Alberta’s Caring for Diabetes (ABCD) project team is still busy working away. The two quality-improvement interventions for people with type 2 diabetes that were supported by our partner PCNs came to a close earlier this year. As such, we’re shifting our attention from implementation to data analysis and dissemination of results. The ABCD Advisory Committee and Implementation & Evaluation Steering Committee meetings were held just this past week; with a focus on presentation of findings and knowledge translation strategies. I will be presenting results from the ABCD Project studies at the CAHSPR Conference in Vancouver in May and the ADA Conference in Chicago in June.  The Aquatic Physical EXercise for arthritis and Diabetes (APEXD), an aquatic-based physical activity program, has been launched with one of our partner PCNs, to determine efficacy of the program for glycemic control and functional status indicators. To date, 21 participants have been recruited. Recruitment for the third wave of participants who entered the pool for weekly sessions at the end of April is completed. The ABCD Cohort study is well underway. Recruitment will continue until the end of this year; I’m happy to report that approximately 1800 people with type 2 diabetes around the province have joined the study to date. We look forward to following this cohort for the next several years.

We will update you in late summer/early fall with our ongoing activities in ACHORD.  Have a great summer!


Project Update

Health Outcomes in Diabetic Patients with Multimorbidity.

Weir DL, McAlister FA, Majumdar SR, Eurich DT


Why is this project needed?

Diabetes is one of the most common chronic conditions in Canada, effecting approximately 8% of individuals and is the fourth leading cause of death in the population. Although the management of diabetes tends to be focused on the disease itself or acute complications associated with the disease, it is well recognized that diabetes does not exist in isolation. Indeed, most patients with diabetes have at least one comorbid chronic condition and as many as 25% have four or more concurrent chronic conditions. Thus, management approaches for diabetes cannot be conducted in isolation. Patients with diabetes can experience a range of multimorbid disorders (generally defined as two or more chronic conditions) adding to the clinical complexity of this high-risk population. Although multimorbidity is common and associated with poor health outcomes in the diabetic population, current clinical guidelines are not designed to consider the cumulative impact of treatment recommendations for those with several conditions due to the historic exclusion of patients with multimorbidity from clinical trials. Thus, the extent to which multimorbidity has a cumulative effect on risk is required to inform approaches to management in this high-risk population and is our principal area of interest.

How are we going to conduct this project?

We will utilize a unique international cohort with data derived from Canada, the United States and the United Kingdom consisting of both administrative, integrated laboratory and clinical data. We will conduct two separate projects to evaluate factors influencing health outcomes in diabetic patients with multimorbidity.
For our first project, we will evaluate the impact of multimorbidity in diabetic patients and potential clinical correlates on unplanned healthcare encounters (30 day hospital readmission, emergency department visits), mortality and overall health care costs (drug and healthcare utilization). Ultimately, the goal of this research is to establish ‘sentinel markers’ for front-line clinicians to identify diabetic patients with high risk ‘clusters’ of chronic disease.
In our second project, using the same international cohort of diabetes patients, our objective will be to determine whether continuity of primary care is associated with improvements in future health outcomes in patients with diabetes and whether this relationship is modified by multimorbidity status. Outcomes of interest will include death and hospitalizations, as well as ambulatory care sensitive conditions including COPD, asthma, heart failure, hypertension and angina. Continuity of primary care will be defined as Breslau’s Usual Provider of Continuity (UPC).

What would the findings of this study add?

Multimorbidity is escalating in our aging Canadian population creating the potential for significant health impacts. Considering the high degree of clustering of chronic diseases in patients with diabetes, determining the cumulative effect of multimorbidities on risk in the diabetic population is critical. The ability to better inform approaches for management for this complex population will contribute to evidence leading to increased quality of life, improved quality of care as well as a decreased burden on the health care system in terms of cost and utilization for diabetic patients with multimorbidity.


Recent Literature from the ACHORD Journal Club

(Paper discussed Tuesday, April 9, 2013; Commentary by Nonsikelelo Mathe)

Kirk JK, Craven T, Lipkin EW, Katula J, Pedley C, O’Connor PJ, Margolis KL. Longitudinal changes in dietary fat intake and associated changes in cardiovascular risk factors in adults with type 2 diabetes: The ACCORD trial
Diabetes Research in Clinical Practice. Epub 2013 Mar 12.  PMID: 23490598

What was this study about?

The Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial was initiated in 1999 to determine whether intensive glycemic control with a goal of glycated haemoglobin A1c (HbA1c<6%) versus standard control (HbA1c 7.0-7.9%) would reduce cardiovascular (CVD) mortality in patients with type 2 diabetes. The trial included dietary counseling following recommendations equivalent to an American Heart Association Step 1 diet, which encourages a modestly low fat, heart-health diet (≤30 total fat). The purposes of the study were: (1) to examine longitudinal self-reported fat intake using a brief assessment tool (PEP) as a proxy for dietary behavior change in ACCORD: (2) to determine which participant characteristics were related to greater change in self-reported fat intake: and (3) to determine whether changes in self-reported fat intake were related to changes in CVD risk factors and metabolic outcomes during follow up in ACCORD.

How was this study conducted?

10,251 participants with type 2 diabetes at high risk for CVD (previous history of CVD or multiple risk factors including hypertension, dyslipidemia, and hyperglycemia) were randomly assigned to one of two therapeutic strategies for glycemic control: an intensive strategy to achieve nearly normal glycemic control with HbA1c < 6.0% or a standard strategy to maintain HbA1c at 7.0–7.9. Using a double two-by-two factorial design each ACCORD participant was further assigned to one of two sub-trials: 1) 4733 were assigned to lower their blood pressure (BP) by receiving either intensive therapy (systolic BP target, <120 mm Hg) or standard therapy (systolic BP target, <140 mm Hg) and (2) 5518 were assigned to receive either fenofibrate or placebo while maintaining good control of low-density lipoprotein (LDL) cholesterol with simvastatin. A subsample of 2053 was randomly selected from the 10251 participants to complete additional questionnaires on diet, physical activity and quality of life, at baseline and at 12 and 36 months of follow up. A brief dietary assessment was conducted focusing on total fat consumption. Diet was assessed using the Puget Sound Eating Patterns (PEP) Questionnaire. Of the 2053 participants, 1781 (86%) completed the PEP questionnaire at baseline and were included in the analyses. When scored, the PEP questionnaire provides an overall summary measure of fat intake, as well as five subscales designed to describe: (1) substitution of lower-fat alternatives; (2) modification or reduction of meat intake; (3) avoidance of fried foods; (4) replacement of fat with non-fat alternatives; and (5) avoidance of dietary fat. Each subscale score and the summary score ranges from 1 to 4, with lower scores indicating a behavioral pattern leading to lower fat intake (each 1 point lower on the summary score corresponds to 13% lower percentage of total energy intake consumed as fat).

What did this study find?

This study found that participants in both intensive and standard glycemia treatment groups reported a similar eating pattern consistent with significantly reduced fat intake in the first year of follow up, and the patterns was sustained through 3 years. Subjects who were female, Caucasian, or had higher baseline hours per week of moderate-intensity physical activity were more likely to reduce their fat intake. In this population, which was simultaneously treated in a lipid or blood pressure trial, longitudinal reductions in dietary fat intake were associated with less weight gain at both 12 and 36 months and with lower triglycerides at 12 months but not with significant differences in blood pressure, low density lipoprotein (LDL) cholesterol, high density lipoprotein (HDL) cholesterol, or HbA1c.

What are the conclusions and implications of this study?

Study authors concluded that the dietary counseling participants received in ACCORD was associated with real and sustained changes in dietary fat intake. The non-significant effect of diet modification on HbA1c was attributed to the fact that subjects gained weight, rather than losing weight; moreover, that major changes in HbA1c-lowering drug therapy in ACCORD may have made it difficult to detect an independent effect of diet on HbA1c. However, these conclusions need to be interpreted with caution. Diet was not measured in this study; as the authors noted, the PEP questionnaire is a measure of behavior and not intake therefore conclusions related to fat intake may be inappropriate. However, focusing on fat intake alone does not account for energy from other sources. It has been shown in other studies using measures similar to the PEP questionnaire that although participants may replace high fat foods and behaviors there may be replacement of energy from fat with other micronutrients. Without a complete dietary assessment, this it is not possible to detect.


ACHORD Accolades

Congratulations to the following students/trainees/faculty on their latest accomplishments:

Hayford Avedzi on receiving a Faculty of Graduate Studies and Research Bursary and a University of Alberta Bursary,

Dean Eurich on receiving the CRC Tier II Nomination from the School of Public Health,

Bronwen Gould and Isabelle Colmers on receiving AIHS Summer Studentships,

Serena Humphries on her appointment as Assistant Director of the Obesity, Diabetes and Nutrition Scientific Clinical Network for Alberta Health Services,

Ahmed Abdelmoneim on receiving a Graduate Student Teaching Award, the Andrew Stewart Memorial Graduate Prize, and the Izaak Walton Killam Memorial Scholarship, all awarded by the University of Alberta. Ahmed also received a scholarship from the International Society for Pharmacoepidemiology,

Robin Lau on successfully completing his PhD Candidacy Exam.


Other ACHORD News

Welcome to:

Haley Breedlove, our ABCD Data Administrative Assistant and ACHORD Receptionist.

Congratulations to:

Jashu and Neek Sandhu on the addition of Sahiba Kaur to their family in January,

Clark, Tanya and Warrick Mundt on the addition of Ada Jane to their family in February,

Calypse and Precious Agborsangaya on the addition of Jayden Ozong to their family in April.

ACHORD Contact Information

Phone Numbers: General Inquiries: 780-248-1010 | Fax : 780-492-7455
University of Alberta | 2-040 Li Ka Shing Centre for Health Research Innovation | Edmonton, AB, T6G 2E1