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Beverage consumption and mortality among adults with type 2 diabetes: prospective cohort study



Study population

The Nurses’ Health Study, a prospective cohort study initiated in 1976, enrolled 121 700 female registered nurses aged 30 to 55 years.16 The Health Professionals Follow-Up Study cohort was established in 1986 and enrolled 51 529 male health professionals aged 40 to 75 years.17 In both studies, detailed information on dietary and lifestyle factors, medical history, and disease status was collected at baseline and updated every two to four years through validated questionnaires.18 The cumulative response rate exceeded 90% for both cohorts. In the current analysis, we included participants with prevalent type 2 diabetes at baseline (1980 for the Nurses’ Health Study, and 1986 for the Health Professionals Follow-Up Study, when dietary information was first collected using a validated food frequency questionnaire), as well as participants with a diagnosis of incident type 2 diabetes during follow-up to 2018. We excluded participants if they had type 1 diabetes, CVD, or cancer at baseline; reported CVD or cancer before the diagnosis of type 2 diabetes during follow-up; left more than nine blank responses on the food frequency questionnaire or reported implausible daily energy intakes (<2510 or >14 644 kJ/day for women, and <3347 or >17 573 kJ/day for men); or had incomplete information on beverage consumption or dietary data at diabetes diagnosis. After exclusions, a total of 11 399 participants of the Nurses’ Health Study and 4087 participants of the Health Professionals Follow-Up Study with type 2 diabetes were included in the current analysis. For the analysis of changes in beverage consumption from before to after the diabetes diagnosis, we further excluded participants with type 2 diabetes at baseline or those with missing data on beverage consumption assessed before the diabetes diagnosis (n=2715), which left 9252 women and 3519 men for the change analysis.

Assessment of beverage intake

Intake of beverages was assessed using the validated food frequency questionnaires administered every two to four years. Participants were asked how often, on average (never to >6 times per day), they had consumed SSBs, ASBs, fruit juice, coffee, tea, low fat milk (skimmed, 1% or 2% fat), full fat milk, or plain water of a prespecified portion size (cup, glass, can, or bottle). SSBs included caffeinated colas, caffeine-free colas, other carbonated SSBs, and non-carbonated SSBs (fruit punches, lemonades, or other fruit drinks). ASBs included low calorie cola with caffeine, low calorie caffeine-free cola, and other low calorie beverages. Fruit juices included orange, apple, grapefruit, or other fruit juices. Coffee included caffeinated and decaffeinated varieties. A validation study conducted among a subsample of the participants in the Health Professionals Follow-Up Study showed reasonable validity for the assessment of beverage intake.19 The correlation coefficients between the food frequency questionnaire and multiple diet records were 0.84 for colas, 0.73 for low calorie colas, 0.75-0.89 for fruit juices, 0.93 for coffee, 0.77 for tea, 0.88 for low fat milk, 0.67 for full fat milk, and 0.52 for plain water.19 Similar correlation coefficients were found in a validation study conducted among a subsample of participants in the Nurses’ Health Study.20 Our primary dietary factors of interest were specific types of beverage consumption assessed after the diabetes diagnosis, and changes in beverage consumption before and after the diagnosis. We assessed the pre-diabetes beverage intake from the most proximal questionnaires before diabetes was ascertained.

Ascertainment of type 2 diabetes

Participants who reported a physician diagnosis of diabetes mellitus in the biennial questionnaires were sent a validated supplementary questionnaire about diagnostic tests, symptoms, and hypoglycemic treatment. The National Diabetes Data Group and American Diabetes Association criteria were applied to ascertain a diagnosis of type 2 diabetes (see supplementary appendix).2122 We excluded from the current analysis those participants who reported a diagnosis of type 1 diabetes on the supplementary questionnaire. Studies among 62 participants in the Nurses’ Health Study and 59 participants in the Health Professionals Follow-Up Study showed high validity in the supplementary questionnaire, with 98% and 97% of questionnaire confirmed type 2 diabetes diagnoses validated by medical record review in these women and men, respectively.2324

Ascertainment of outcomes

The primary endpoint was all cause mortality. We also examined the secondary outcomes of CVD incidence and mortality. Deaths were identified from reports by the next of kin or postal authorities or from searches of the National Death Index (see supplementary appendix).25 ICD-9 (international classification of diseases, ninth revision) codes were used to classify deaths from CVD (codes 390-459), cancer (codes 140-208.32), or other causes. Incident CVD was defined as fatal and non-fatal coronary heart disease, including coronary artery bypass graft surgery and non-fatal myocardial infarction, and as fatal and non-fatal stroke (see supplementary appendix).


Assessment of covariates

In both cohorts, information on lifestyle factors and medical history was collected at baseline and in biennial questionnaires. The supplementary appendix provides details of the assessments of covariates. To assess overall diet quality, we calculated the Alternate Healthy Eating Index (AHEI) score based on intakes of 11 foods and nutrients predictive of chronic disease risk, including vegetables, fruits, whole grains, SSBs and fruit juice, nuts and legumes, red and processed meat, trans fatty acids, long chain omega 3 fatty acids, other polyunsaturated fats, sodium, and alcohol.26 In the current study, we modified the AHEI score by excluding the consumption of SSBs and fruit juices.

Statistical analysis

The Kolmogorov-Smirnov normality test was used to assess distributions of continuous variables for normality, and natural logarithm transformations of skewed variables were applied before analyses. In descriptive analyses, continuous variables were expressed as means (standard deviations) for normally distributed variables or medians (interquartile ranges) for skewed variables, and categorical variables were represented by frequency and percentage. General linear models were used to calculate mean characteristics of the study participants at the time of diabetes diagnosis, and a test for linear trend using the Wald test was performed by assigning the median value to each category of beverage consumption and modeling this variable as a continuous variable.

For each participant, we calculated person years of follow-up from the date of diabetes diagnosis to the date of occurrence of study outcomes, last return of a valid follow-up questionnaire, or end of follow-up (30 June 2018 for the Nurses’ Health Study, and 30 January 2018 for the Health Professionals Follow-Up Study), whichever came first. Because changes in diet after a diagnosis of cancer could distort the associations of interest, for the CVD incidence analyses we stopped updating dietary variables after participants reported a diagnosis of cancer. For mortality analyses, dietary intake was not updated after a diagnosis of cancer or CVD. Time varying Cox proportional hazards models, conditioned on age and follow-up cycle, were applied to estimate hazard ratios and 95% confidence intervals for the associations of each beverage intake with all cause mortality, CVD incidence, and CVD mortality. Changes in beverage intake from before to after the diabetes diagnosis were defined as the absolute difference in beverage consumption (time varying post-diabetes beverage intake minus pre-diabetes beverage intake). The time varying covariates assessed during follow-up were considered in the multivariable models. Missing data for beverage consumptions and covariates during follow-up were replaced by the most recent valid assessments. In the multivariable model, we adjusted for age (years), duration of diabetes (years), sex (men or women), white ethnicity (yes or no), physical activity (<3.0, 3.0-8.9, 9.0-17.9, 18.0-26.9, ≥27.0 metabolic equivalents of task-hours/week), smoking status (never, former, current 1-14 cigarettes/day, current ≥15 cigarettes/day), alcohol consumption (0, 0.1-4.9, 5.0-14.9, ≥15.0 g/day), menopausal status and post-menopausal hormone use (pre-menopause, post-menopause (never, former, or current hormone use), or missing; Nurses’ Health Study only), family history of type 2 diabetes (yes or no) or myocardial infarction (yes or no), intake of total energy, and modified AHEI score (all in fourths). To further reduce the impact of confounding by existing comorbidities, disease management, and weight change, we further included history of hypertension (yes or no) or hypercholesterolemia (yes or no), use of antihypertensive (yes or no) or lipid lowering drug (yes or no), aspirin use (yes or no), diabetes drug use (oral drug only, insulin use, or others), and change in body mass index (BMI) before to after the diabetes diagnosis in the fully adjusted model.27 We mutually adjusted for different types of beverage intakes in the analysis of specific types of beverages. To obtain overall estimates for men and women and to increase statistical power, we pooled the hazard ratios from each model from the two cohorts with the use of an inverse variance weighted meta-analysis by the random effects model, which accounted for between study heterogeneity.28 CVD incidence and mortality were also examined according to the per serving intake of beverages. In the analysis of changes in beverage consumption from before to after the diabetes diagnosis, we further adjusted for beverage intake before the diagnosis in the multivariable model.

In the current study, we tested the proportional hazards assumption by using a likelihood ratio test comparing models with and without multiplicative interaction terms between beverage consumptions and calendar year, and we did not find evidence of violation of the assumption. Tests for trend were performed by assigning a median value to each beverage consumption category as a continuous variable. To examine the dose-response relationships between beverage intake and the outcomes, we used restricted cubic spline regression with three knots. Tests for non-linearity were based on the likelihood ratio test comparing two models: one with only the linear term and the other with the linear and the cubic spline terms.

We estimated the association of substituting a serving of one beverage for another by including both as continuous variables in the same multivariable model. Differences in their β coefficients were used to calculate the hazard ratios for the substitution effects, and their variances and covariance matrix were used to derive the 95% confidence intervals for the point estimate.

Several sensitivity analyses were conducted to test the robustness of our findings. First, we restricted our analyses to adults with incident type 2 diabetes by excluding those with prevalent diabetes at baseline. Second, we excluded deaths that occurred within four years after the diabetes diagnosis to examine whether the results were impacted by reverse causation bias. Third, a four year and eight year lag were placed between the assessment of beverage intake and outcome incidence, respectively. In these analyses, beverage intake was used to predict disease occurring four years or eight years later. Fourth, given that weight change can be an intermediate outcome, in our final model we adjusted for BMI before the diabetes diagnosis, instead of change in BMI before to after the diagnosis to examine the robustness of our observed associations. Fifth, we examined potential confounding from measures of socioeconomic status by adding partner’s education and self-rated socioeconomic status to the final model. Sixth, we used beverage intake assessed before the diabetes diagnosis instead of the cumulative average after diagnosis to evaluate whether changes in consumption pattern immediately after the diagnosis might impact the associations of interest. Seventh, as it is likely that participants might quit drinking unhealthy drinks immediately after the diabetes diagnosis, we skipped the first food frequency questionnaire after the diagnosis and used the rest to calculate cumulative averages and re-examine the associations. Eighth, we also conducted a sensitivity analysis excluding current and former smokers to further reduce confounding by smoking status. Ninth, we performed an analysis restricted to adults with asymptomatic type 2 diabetes to assess the impact of diabetes screening on associations of interest. Tenth, we controlled for the number of diabetes related symptoms as a measure of disease severity. Lastly, to reduce potential confounding by glucose control, we further adjusted for the self-reported levels of glycated hemoglobin HbA1c in a subset of the participants (n=5192).

All statistical analyses were performed with SAS software, version 9.4 (SAS Institute, Cary, NC). Two sided P<0.05 was considered statistically significant.



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Wellness and rejuvenation on a Whistler weekend



Reviews and recommendations are unbiased and products are independently selected. Postmedia may earn an affiliate commission from purchases made through links on this page.

The freshness of spring is giving way to the languor of summer. It’s also that time of year when I step up my health and fitness habits, with the help of a wellness weekend getaway. Check out these ten wholesome ways to experience Whistler.

1. Eat well, be well at a new event series

Nourish by Cornucopia
Savour local cuisine at Nourish by Cornucopia from June 2 to 30. Photo by Darby Magill

Making its debut the Nourish Spring Series by Cornucopia celebrates the season every weekend in June with farm-to-table fare, farm tours, lavish wellness dinners, healthy brunches and activities to refresh both mind and body. Sit down to a four-course spring harvest tasting menu (Brome Lake duck breast with Pemberton beets, anyone?), brush up on grilling skills with an expert chef, pick up painting pointers on an art picnic or jump into an outdoor Zumba class. Order tickets online at

2. Chill at a spa

Scandinave Spa
For wellness treatments it’s hard to beat Scandinave Spa. Photo by Chad Chomlack

With more than 12 spa facilities in town, it could be said that Whistler has everyone’s back. Pop into the Whistler Day Spa for a 75-minute stress relief massage using Swedish relaxation techniques or the Taman Sari Royal Heritage Spa for an 80-minute herbal steam massage using pouches filled with Javanese turmeric, ginger and other spices. Have more time? Dip into the hot-cold-and-relaxing thermal journey at the silent Scandinave Spa Whistler, home to open-air pools, cold-plunge baths, a Finnish sauna, Nordic showers and solariums in a tranquil forest setting.


3. Lace up for new guided hikes

Hiking in Whislter
Fresh mountain air and beautiful views are two reasons to go hiking. Mark Mackay Photo by Mark Mackay

Trek past alpine meadows flush with wildflowers on the way to glacier-fed Garibaldi Lake or meander through a fragrant rainforest before taking a dip in Crater Rim’s warm Loggers Lake. These are just a couple of guided hike options from Mountain Skills Academy & Adventures. Prefer to stay close to town? Sign up for the Whistler Alpine Hike and explore the gondola-accessed terrain of Whistler Blackcomb.

4. Embark on an ebike adventure

Valley Trail
Explore Whistler’s car-free Valley Trail, a 46-km network of paved paths and boardwalks. Photo by Justa Jeskova

Sneak in some good clean fun with an ebike rental or guided tour. Explore Whistler’s car-free Valley Trail, a 46-km network of paved paths and boardwalks linking the resort town’s neighbourhoods and lakes, beaches, parks and viewpoints along the way. Go it alone or hop on a full-suspension electric-assist mountain bike with Whistler Eco Tours for a two-hour guided ride. Prefer an old-school ride or want to hit the alpine trails? Comfort cruisers, cross-country and downhill bikes are also on hand.

5. Expand the mind at an Indigenous exhibit

The Squamish Lil’wat Cultural Centre
The Squamish Lil’wat Cultural Centre is a cultural connector. Photo by Justa Jeskova Photography

You have until October to view, the Squamish Lil’wat Cultural Centre’s Unceded: A Photographic Journey into Belonging. Shot at striking locales throughout the Sea to Sky Corridor, the exhibit brings together aspects of ancient traditions, modern Indigenous life, and colonization and development. Behold the bear dancer on Blackcomb Mountain, the cultural chief in the Fairmont Chateau Whistler lobby and the Squamish Nation chair standing in the middle of downtown Vancouver’s West Cordova St.

6. Get down, be healthy at a new café

Rockit Coffee
The new Rockit Coffee in Whistler Creekside boasts a retro theme. Photo by Leah Kathryn Photography

Boogie back in time to the ’70s and ’80s at the new Rockit Coffee in Whistler Creekside. From the speaker-lined wall and vintage phones, radios and ghetto blasters to menu items like Espresso Greatest Hits and Drinks Just Wanna Have Fun, the colourful café exudes a decidedly retro vibe. Pull up a chair and order a nutritious Aero-Smoothie – choose from the Green Day, Bananarama or Strawberry Fields Forever – and pair it with a Veggie Eilish breakfast wrap or Prosciutto Rhapsody sandwich.

7. Check into wellness

Fairmont Chateau Whistler
The Fairmont Chateau Whistler. Photo by Tal Vardi

Go for the Fairmont Chateau Whistler’s healthful options like daily yoga classes, guided excursions and access to pools, steam rooms, the fitness centre, tennis court and (soon) new pickle ball courts. But stay for the regionally sourced seasonal menus ­– complemented by the rooftop garden’s bounty from May to October – and no-proof cocktail selection in the Mallard Lounge.

8. Float down a winding river

River of Golden Dreams
Canoeing the River of Golden Dreams. Photo by Mike Crane

Canoe, kayak or stand-up paddleboard along the meandering five-km-long River of Golden Dreams. After putting in at Alta Lake, paddle past riverbanks lined with wildflowers, foliage and forest, all the while keeping an eye out for beavers, otters, eagles and bears. Newbie paddlers are advised to go with a guide, as changing water levels can make for tricky steering and mandatory portages.

9. Connect with nature on a new birding trail

BC Bird Trail
Watching for activity on the BC Bird Trail. Photo by Tourism Whistler

Watch for whiskey jacks, Clark’s nutcrackers and, come summer, lots and lots of swallows along the Sea to Sky Bird Trail. The fifth and most recent route to be added to the BC Bird Trail network along the Pacific Flyway, the new trail takes birders to alpine heights (lift ticket required) where they can spot olive-sided flycatchers and various raptors. Then it’s off to Rainbow Park on Alta Lake to spy common yellow throats and merlins.

10. Wake up beside a lake

NIta Lake lodge
NIta Lake lodge is steps to the lake. Photo by Nita Lake Lodge

Perched along the southern tip of Nita Lake in Whistler Creekside, Nita Lake Lodge checks off all the boxes for a dreamy wellness escape. Start with stunning water and valley views from luxe suites, currently undergoing a modern refresh slated to wrap in time for summer. Then there’s the new onsite restaurant, The Den, where plant-based alternatives share space with meat and seafood items on the seasonal menus. Topping off a salubrious stay at Whistler’s only lakeside hotel is an award-winning spa with rooftop hot tubs.



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HIV stigma index researchers look for Manitobans with positive diagnoses to share experience



Manitoba researchers looking for people to take part in a national HIV Stigma Index project are only about halfway to their goal of hearing from at least 75 people living with a positive diagnosis.

The international peer-driven research project helps understand the stigma associated with HIV and supports those living with a diagnosis.

“I wouldn’t say that anybody ran out and said ‘I’m gonna go get HIV today and see how that happens.’ Things happen to people and it’s our duty as human beings to support people no matter what they’re going through,” research co-ordinator Arthur Miller told CBC Information Radio Wednesday.

The Canadian HIV Stigma Index is a community-led and community-based research study, part of the international implementation of the People Living with HIV Stigma Index project


Participants are interviewed by another person living with a positive diagnosis. Interviews are about an hour-and-a-half long and can be done in person, by phone or through a video conferencing platform, said Miller, a Mi’kmaw HIV activist based out of Nova Scotia and research co-ordinator of the project with REACH Nexus, under the MAP Centre for Urban Health Solutions at Unity Health Toronto.

The national project has been done in Ontario, Quebec, Atlantic Canada and British Columbia, and this is the second time it’s being done in Manitoba, with an updated survey.

Researchers collect information related to stigma, discrimination and human rights, with the aim of better understanding the social determinants and stigma across systems like health care, schools and legal fields. The research aims to help people develop supports and policies at both local and national levels.

Peer-driven aspect crucial

Jared Star, a research manager at Winnipeg’s Nine Circles Community Health Centre, which specializes in HIV prevention and care, said the HIV Stigma Index’s peer-driven aspect is crucial for participants.

“They know that they won’t be judged,” he said. “They won’t have to explain situations and details that come naturally for them, because they’re talking to somebody with the same experience.”

Star is also a research consultant and PhD student with expertise in sexual health, alongside his work with Nine Circles, which is working closely with Miller on the project.

“It’s better for the study if we can collect the data in a shorter period of time, but because it’s qualitative research, it tends to take longer than a survey,” said Star. “But the more we can get up front and faster, the better.”

Jared Star is a research manager for Nine Circles Community Health in Winnipeg. (Submitted by Jared Star)

Star said the information gained from the project will help people move from a place of supporting and sustaining stigma to actively challenging and resisting it.

“I think if we do a good job and we’re able to get that information and then develop interventions that target stigma, we will be able to contribute to a reduction in HIV infections in Manitoba,” he said.

Education key to understanding 

Much more is known about HIV now than 30 years ago — like how to prevent transmission and that it’s no longer a death sentence.

With proper care, people who are HIV positive can lead long, healthy lives.

Miller said education is key and pointed to the fact that many don’t understand somebody with an undetectable viral load who adheres to treatment can’t transmit HIV through sexual intercourse.

“This is big for people with HIV,” he said. “For me, it felt like I got part of my life back.”

Manitobans willing to share their experiences through the HIV Stigma Index project can contact Miller at or by phone at 1-877-347-1175 to begin the process.

“The great thing about this study is we’re building this network of people living with HIV,” Miller said. “You’re going to be talking with someone living with HIV, so they can relate and share some experiences.”



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May 27, 2023 coronavirus update for Oakville



This is Oakville’s coronavirus update for Saturday, May 27, 2023. New, active cases of COVID-19 in Halton have nearly doubled for the second week in a row, and outbreaks at local long-term care homes are growing.

Oakville is reporting 22 new cases this week, about the same as the week before. But these last two reports from Halton regional health are the highest numbers of new cases in months – and active cases are now trending upwards by 50-100% weekly.

The outbreak that opened earlier this month at Oakville’s West Oak Village long-term care home has been contained to the Harbour floor. But there are two new outbreaks that have opened this week in other parts of Halton, including one at Oakville’s Northridge home on the Chisholm floor.

Halton continues to fall behind on our booster shots: only 1 of every 10 people in Halton have a full series of immunization, and the percentage of residents with outdated immunization has grown every week since the start of 2023. Among those 40 and under, those fully immunized is now below 5%.


The United States this week has said they and the CDC will no longer be tracking new, aggregate daily COVID-19 cases and deaths or new nationwide testing data.

The World Health Organization (WHO) has declared that after more than three years, the COVID-19 global health emergency is now over. WHO has determined that “COVID-19 is now an established and ongoing health issue which no longer constitutes a public health emergency of international concern (PHEIC).”

765 million cases of COVID-19 have now been recorded worldwide since the start of the pandemic; 6.9 million people have died.



**Vaccine booking: Fourth doses (second booster doses) of vaccine are now available for anyone in Halton age 5 and up, though fourth doses must be at least five months since your last dose and 90 days since having COVID-19.

Halton continues to book first and second-dose vaccinations for all residents age six months and older, plus third-dose boosters for anyone age 5 and up.

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