B10 Weight and Wellbeing

Session B10

Weight and wellbeing: An interactive think tank around making healthy weights part of the healthy kids conversation at well-child visits in Ontario.

CFPC Conflict of Interest

Disclosure of Commercial Support Presenter Disclosure Presenter:

Imaan Bayoumi, Rupa Patel, Kendra Link Patricia Parkin, Catherine Birken Paula Brauer Tracey Hussey

Presenter:

Grants/Research Support: Janus Grant, CFPC Grants/Research Support: CIHR Grant/Research Support: CIHR Knowledge to Action and Supplement Grant/Research Support: indirect financial support from the MOHLTC (RD time)

Carla Kasdorf, Joanne Beyers , Andrea Feller Ruta Valaitis, Umberto Cellupica,

Relationships with commercial interests: • Grants/Research Support: None • Speakers Bureau/Honoraria: None • Consulting Fees: None • Other: None

Applying an Ecological Framework for Successful Primary Care and Public Health Collaboration Ruta Valaitis RN PHD Dorothy Hall Chair in Primary Health Care Nursing, McMaster University

Evaluation Research Need to share evaluation results FORMAL ORGANIZATIONAL - with all players LEADERS AS COLLABORATION COLLABORATIVE APPROACHES CHAMPIONS OPTIMAL USE OF HUMAN COLLABORATIVE TO PROGRAMS AND SERVICES PC and PH leaders at RESOURCES CULTURE ORGANIZATIONAL Successful Collaboration: DELIVERYadministrative level supported • PHN secondment; TRUSTING AND INCLUSIVE PC nurses expressed concerns • Interdisciplinary PC collaboration team works• Improved thoroughness OPTIMAL USE OF RESOURCES the • Time challenge for PC RELATIONSHIPS PERSONAL QUALITIES, 18 month that they were conducting the 18 EFFECTIVE implementing as interdisciplinary teams Moderate to extensive sharing of physicians; high levels of trust and KNOWLEDGE AND SKILLS month well babydifferent visit, buttime Very COMMUNICATION well baby visit • Initial goals were based on resources re well child constraints affecting physicians' extensive areas of common PHN valued

by PCturf staffparent as physicians were receiving Lack ofnot communication • Increased community needs, assessment and information ability between PC nurses and PHN extremely knowledgeable payment fortoitimplement particularlyasincefelt experienced among front satisfaction STRATEGIC COORDINATION AND community input about community resources they collaboration. were not compensated for line PC physicians • Increased PC nurses COMMUNICATION • other community programs (i.e.

• Challenging to add another their time to obtain training for PC nurses meeting with (enhanced MECHANISMS BETWEEN competency literacy programs) informally practice expectation regarding an this enhanced skill PHN regularly skills) and working to full PARTNERS joinedassessment in once they saw the- did not enhanced 18 month -scope of practice PC practice is extremely busy and share this problem.

ROLE CLARITY MDs perceived they were not collaboration in action to a busy PC workload therefore it was challenging find established early in partfor of the developmentRole of the Inadequate funding training; CLEAR MANDATES, VISION AND time •for the collaboration although not collaboration, thereforecollaboration were not • PC nurses not supported for GOALS FOR COLLABORATION communicated to all players in or in the know about it training activities;bought done on A formal contractual agreement personal time (MOU) developed between PC • H1N1 diverted collaboration and PH activities

The Case of the 18 Month Well Baby Visit • Case study acted as an intervention.

– Some PC physicians not informed about background and goals of the collaboration – PH recognized importance of involving front line providers when collaboration expands to include other sites or with staffing changes

Social Context Weight bias and stigma

Poverty

Weight to Expect When You're Expecting

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Rupa Patel,MD,FCFP

Prepregnancy BMI and increased gestational weight gain (GWG) are both highly associated with childhood obesity.

Fascinating new research is revealing that infant food and taste preferences are affected by maternal food choices.

Women will respond to guidance about healthy food choices and healthy activity levels if they understand the lifelong implications for themselves and their children.

http://www.youtube.com/watch?v=4m6FvR QssWw

- Building a Healthy Relationship with FoodFrom Birth Onwards Trust model

Traditional dietary approach

Division of responsibility between caregiver (food choices) and child (food intake)

Caregiver control of food choices and food intake

Scheduled, predictable eating times

Controlling environmental triggers

No portion control/restriction

Portion control

Family meals

Low-fat meals/restriction of foods

Building trust

Food portions using Food Guides

Respecting child’s hunger, appetite, satiety cues

Reading labels/calorie awareness

Eneli, et al. The Trust Model: A Different Feeding Paradigm for Managing Childhood Obesity 2008 – See more at: http://ellynsatterinstitute.org/res/articles.php#sthash.V3sPuCQx.dpuf

Healthy Beginnings Two Rivers Family Health Team Cara Kasdorf, RD June 4, 2014

Program Overview ∗ Two Rivers Family Health Team consists of 21 physicians and 25,000 rostered patients and is located in Cambridge, ON ∗ In 2011 – started a standardized 3 year old Well Child/Healthy Beginnings visit for all 3 year olds in the FHT ∗ Standardized intake visit with Nurse focuses on growth assessment, blood pressure assessment, Preschool NutriSTEP® screen ∗ Education is provided at that visit and family referred to appropriate provider if identified as high or moderate risk

Outcomes & Results ∗ 65% of all 3 year olds within the FHT have been seen for an intake visit since April 2011 ∗ Moderate and high risk children are followed up with physician, nurse or dietitian depending on issues identified ∗ 72% of children with initial moderate or high NutriSTEP® score showed an improvement in score, at 3 month follow up

Next Steps ∗ Expand program to other age groups ∗ July 2014 – 18 month Nutri-STEP® will be administered at each 18 month Well Baby Visit – nurses currently receiving training ∗ July 2014 – Children in clinic for acute visits or immunizations will have height, weight, BMI-for-age measured and appropriate follow up if required (referral to Dietitian, community program, follow up with physician or nurse etc) ∗ Plan to formally evaluate any change in obesity rates in the population that has gone through the program

Healthy Growth for Kids within a Large Urban FHT Tracy Hussey, MSc, RD

Healthy Futures  Chart reviews: aged 2-18 (n=323)  BMI done at 31% of visits  Of those with a BMI calculated, 80% received an intervention  29 obese (15%), 31 overweight (16%)  48 goals documented: limit juice > 5 fruit/ veg > limit pop > eat breakfast >fast food > TV  Exercise and RD referral mentioned once each

Learning  Usually <5 mins to complete the intervention, max 10  Most useful: stadiometer, small changes, prescriptions, BMI  Least useful: BMI, “another burden”, “lack of compensation”, “lack of long term impact”  Family/child responses were generally positive  Despite the time needed 9/10 would continue to use the tools

Non-completing Practices 1. NP did not want to weigh girls due to fear of eating disorders 2. Family death (“will use project tools later anyway”) 3. Inadequate pediatric population 4. “Swamped”, “Too much time required”, “Worthwhile idea”

Other Options Health Fairs • Call families in to “monitor and talk about healthy growth” • Multiple activities in the room to address complexity of the issues

Strategic Clinics • Use standard immunizations to gather data and discuss • Pull in high benefit patients eg 3-5, 5-10 yrs • Shared Medical Appointments eg. teens

Pediatric Office Practice • Traditionally, primary care monitored height and weight to screen for failure to thrive • More recently, shift towards monitoring BMI – Can use AAP/CDC definitions (overweight > 85th percentile, obesity > 95th percentile)

• On the horizon – Using WC along with BMI to determine metabolic risk – Waist to Height Ration (WtHR) not significantly better than WC

Multidisciplinary Community Obesity Clinic • Trialed at York Central Hospital (now Mackenzie Health) in the early 2000s • 2 pediatricians, kinesiologist, dietitian • Mixed funding – hospital provided clinic space and kinesiologist, pediatricians funded through OHIP, patients billed for dietician services • Very modest success; several children met goals for weight reduction and increased activity • Ultimately unsuccessful – Families balked at paying for services – Clinic hours were not robust enough; families unable to attend visits – Clinic did not survive hospital cuts

Pediatric Section - OMA • PSOMA through Ontario AAP chapter held a Summit on Children’s Nutrition and Wellness • Pediatricians Alliance of Ontario roundtable on Healthier Lifestyles • PAO has supported TarGet Kids! in applying for various grants aimed at obesity/lifestyle research

NutriSTEP® Nutrition Screening Tool for Every Preschooler

 Screening questionnaires assessing nutritional risk in toddlers (18 mths-age 3) and preschoolers (3-5 yrs)  17-item, parent administered, valid and reliable  Risk: low, moderate, high

 Multiple nutrition risk attributes  Physical growth and development/weight concerns  food and fluid intake  physical activity and screen time  factors affecting food intake such as responsive feeding and food security

Randall Simpson JA, Keller HH, Rysdale LA, Beyers JE. Nutrition Screening Tool for Every Preschooler (NutriSTEP trade mark): validation and test retest reliability of a parent-administered questionnaire assessing nutrition risk of preschoolers. Eur J Clin Nutr. 2008;62(6):770-80.

Implementation and Uptake  CIHR funded Think Tank with Canadian experts recommended many screening venues  Community settings: school registration; wellness fairs  Primary care: physicians’ offices, FHTs  Three separately funded process evaluations occurred in multiple public health settings, Family Health Teams, Community Health Centres (20072011)  Feasibility of screening and perceptions by parents and staff were assessed  Overall: well received by parents and staff (RN, RD, NP)  Less than 10% high risk; did not overwhelm follow-up services  Parents reported changing knowledge and behaviour after screen completion  Physician visit model needs buy-in  Training re pediatric nutrition for follow-up may be needed

by PHC provider “I would like to see NutriSTEP® used on an ongoing basis without the study and consent.”

So… how about your practice setting?

Ontario needs provincial data on young children’s nutritional health  What would you need to ensure uptake of NutriSTEP® in your setting?  Capacity? IT support for EMR? Financial incentives?

Specific pediatric training?...

 What would it take to have a collaborative delivery of such a screening program that could also be used for provincial population health assessment and surveillance purposes?

Love to hear from you: contact Jo Beyers at beyersj@sdhu.com For more info on NutriSTEP® www.nutristep.ca

Gaps To be Filled • What Counts Gets Counted – Canadian Health Measures Survey excludes children under 3 years

• Most preventive care recommendations in child health are graded ‘Insufficient Evidence’

TARGet Kids! Practice Based Research Network www.targetkids.ca

Obesity Prevention in Primary Care • Partnership SickKids and TPH • Expand to primary care settings • Identify Children at wellchild visit • Modified ‘Incredible Years’ Parenting Program • Home Visits to Implement goals

The Canadian Task Force on Preventive Health Care (CTFPHC) has been established by the Public Health Agency of Canada (PHAC) to develop clinical practice guidelines that support primary care providers in delivering preventive health care.

CHILD OBESITY WORKING GROUP Key Question: Do primary care-relevant prevention interventions (behaviorally-based) in normal weight children lead to improved health outcomes or sustained/short-term healthy BMI trajectories?

Systematic Review (McMaster Evidence Review and Synthesis Centre):  90 studies  prevention interventions showed a statistically significant, but very small effect, in terms of lowered BMI/BMIz  intervention vs control: BMI/BMIz SMD 0.07 (95% CI -0.10, -0.03)  groups in favour of intervention:  age: > 6 years  intervention type: diet + exercise  setting: educational

Three trials focused on interventions initiated in the first year of life

 Wen et al - eight home visits by community nurses beginning antenatally through to 24 months after birth, with outcomes reported at 24 months  Daniels et al - multiple group sessions co-led by a dietitian and psychologist beginning at 4-6 months, with outcomes reported at 13-15 months  Campbell et al - multiple group sessions led by a dietitian beginning at 4 months, with outcomes reported at 20 months Study or Subgroup

Experimental Control SD Total Weight Mean SD Total Mean

Campbell 2013-z Daniels 2012-z Wen, 2012

0.8 0.9 0.23 0.93 16.53 1.826

Total (95% CI)

Std. Mean Difference IV, Random, 95% CI

29.0% 0.0000 [-0.1832, 0.1832] 34.3% -0.2133 [-0.3741, -0.0524] 36.7% -0.1676 [-0.3197, -0.0156]

0.8 1 229 291 0.42 0.85 337 16.82 1.622

229 307 330

857

866 100.0% -0.1347 [-0.2544, -0.0151]

Heterogeneity: Tau² = 0.00; Chi² = 3.17, df = 2 (P = 0.21); I² = 37% Test for overall effect: Z = 2.21 (P = 0.03)

Std. Mean Difference IV, Random, 95% CI

0 1 -2 -1 Favours experimental Favours control

2

 Two studies showed a statistically significant reduction in BMI/BMIz in the intervention groups and one study did not  A meta-analysis of the three studies, with a total sample size of 857, showed a statistically significant (p=0.03) lowered BMI/BMIz in the intervention group as compared to the control group but the magnitude of the effect was very small This early period of growth and development may provide an opportunity for targeted obesity prevention interventions in primary care and public health settings

2003-2012 Search for PHC Studies

11 focus groups Hamilton FHT Providers and patients Initial idea generation

Scoping review

Prioritize Strategies

Reflect providers views first, Evidence to support

Draft Planning Framework

½ day in-person, revise, review

5 consensus workshops - 20 Teams

Considered feasible Cost not considered

Classification

Pregnancy to 2 years

3 -12 years

Raising Awareness Identification and Initial Management Follow-up Management Expanded Services Practice Initiatives

13-18 years

18+ Generally Healthy

18+ Medically Complex

Category Pregnancy to 2 3 -12 years Strategies years Identification and Initial management

13-18 years

Wellness Care /Health Check

[A] Consideration of weight within a wellness visit [not explicit in evidence - in research an additional visit]

Episodic Care

[B] - Episodic visit to identify risk

Drop-in clinics

[B] Drop-in clinics (baby weigh-ins, parental support)

Did not find any evidence for a wellness visit as a strategy for obesity prevention to 2012.

Provider rankings [A] = high priority (ranked 1-5) [B]= moderate priority (ranked 6-10) [C]= limited priority (ranked >10th) [D] = not mentioned