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.

Disclosure of Commercial Support CFPC Conflict of Interest

Presenter Disclosure Presenter: Imaan Bayoumi, Rupa Patel, Kendra Link Grants/Research Support: Janus Grant, CFPC Patricia Parkin, Catherine Birken Grants/Research Support: CIHR Paula Brauer Grant/Research Support: CIHR Knowledge to Action and Supplement Tracey Hussey Grant/Research Support: indirect financial support from the MOHLTC (RD time) Presenter: 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

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CLEAR MANDATES, VISION AND GOALS FOR COLLABORATION A formal contractual agreement (MOU) developed between PC and PH

PERSONAL QUALITIES, KNOWLEDGE AND SKILLS PHN valued by PC staff as extremely knowledgeable

STRATEGIC COORDINATION AND COMMUNICATION

MECHANISMS BETWEEN PARTNERS

MDs perceived they were not part of the development of the

collaboration, therefore were not bought in or in the know about it

EFFECTIVE COMMUNICATION Lack of communication experienced among front line PC physicians PC nurses meeting with PHN regularly - did not share this problem.

- OPTIMAL USE OF RESOURCES Moderate to extensive sharing of resources re well child assessment and information about community resources

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COLLABORATIVE ORGANIZATIONAL CULTURE PC nurses expressed concerns that they were conducting the 18 month well baby visit, but physicians were receiving payment for it particularly since they were not compensated for their time to obtain training for this enhanced skill PC practice is extremely busy and therefore it was challenging find time for the collaboration

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OPTIMAL USE OF HUMAN RESOURCES • PHN secondment; • Time challenge for PC physicians; different time constraints affecting physicians' ability to implement a collaboration. • Challenging to add another practice expectation regarding an enhanced 18 month assessment to a busy PC workload • Inadequate funding for training; • PC nurses not supported for training activities; done on personal time • H1N1 diverted collaboration activities

COLLABORATIVE APPROACHES TO PROGRAMS AND SERVICES DELIVERY • Interdisciplinary PC team works as interdisciplinary teams • Initial goals were based on community needs, not community input • other community programs (i.e. literacy programs) informally joined in once they saw the collaboration in action

TRUSTING AND INCLUSIVE

RELATIONSHIPS Very high levels of trust and extensive areas of common turf felt between PC nurses and PHN

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FORMAL ORGANIZATIONAL LEADERS AS COLLABORATION CHAMPIONS PC and PH leaders at administrative level supported the collaboration

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ROLE CLARITY Role established early in

collaboration although not communicated to all players

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Successful Collaboration: • Improved thoroughness implementing 18 month well baby visit • Increased parent satisfaction • Increased PC nurses competency (enhanced skills) and working to full scope of practice

Evaluation Research Need to share evaluation results with all players

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

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.

Rupa Patel,MD,FCFP

http://www.youtube.com/watch?v=4m6FvRQssWw

- Building a Healthy Relationship with Food- From Birth Onwards

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

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

Healthy Beginnings Two Rivers Family Health Team

Cara Kasdorf, RD June 4, 2014

∗ 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 Nutri-STEP® screen

∗ Education is provided at that visit and family referred to appropriate provider if identified as high or moderate risk

Program Overview

∗ 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 Nutri-STEP® score showed an improvement in score, at 3 month follow up

Outcomes & Results

∗ 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

Next Steps

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 (2007-2011) 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 well-child 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

Study or SubgroupCampbell 2013-zDaniels 2012-zWen, 2012

Total (95% CI)Heterogeneity: Tau² = 0.00; Chi² = 3.17, df = 2 (P = 0.21); I² = 37%Test for overall effect: Z = 2.21 (P = 0.03)

Mean0.8

0.2316.53

SD0.9

0.931.826

Total229291337

857

Mean0.8

0.4216.82

SD1

0.851.622

Total229307330

866

Weight29.0%34.3%36.7%

100.0%

IV, Random, 95% CI0.0000 [-0.1832, 0.1832]

-0.2133 [-0.3741, -0.0524]-0.1676 [-0.3197, -0.0156]

-0.1347 [-0.2544, -0.0151]

Experimental Control Std. Mean Difference Std. Mean DifferenceIV, Random, 95% CI

-2 -1 0 1 2Favours experimental Favours control

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

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

Draft Planning Framework ½ day in-person, revise, review

Prioritize Strategies

Initial idea generation

Scoping review

2003-2012 Search for PHC Studies 11 focus groups

Hamilton FHT Providers and patients

5 consensus workshops - 20 Teams

Reflect providers views first, Evidence to support

Considered feasible Cost not considered

Classification

Pregnancy to 2 years

3 -12 years

13-18 years

18+ Generally Healthy

18+ Medically Complex

Raising Awareness

Identification and Initial Management

Follow-up Management

Expanded Services

Practice Initiatives

Category Strategies

Pregnancy to 2 years

3 -12 years 13-18 years

Identification and Initial management 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)

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

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