Transcript New CDA Guidelines and Type 2 Diabetes Mellitus in

Interventions in Pediatric
Obesity
Endocrinology Rounds
3rd June, 2009
Cheril Clarson
Adipocytokines
*p<0.05 vs 0 months
§p<0.05 vs lifestyle
alone
r2 =0.19, p<0.05
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Insulin Sensitivity and Birthweight
r2 = 0.25, p<0.02
r2 = 0.25, p<0.02
Baseline LDL cholesterol correlates with birthweight, p<0.05
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REACH
Reduction of Adolescent Risk Factors for Type 2
Diabetes and Diabetes-related Cardiovascular Disease
Activity and metformin (as glumetza) intervention in obese
adolescents
Funded by:
 Canadian Institutes of Health Research:
Cardiovascular Complications of Diabetes Team Grant
 Children’s Health Foundation
Investigators: Cheril L Clarson, David J Hill, Stuart Harris
Michelle Jackman, Farid H Mahmud, Harry Prapavessis,
Kevin Shoemaker, Justine Wilson
Study Co-Ordinator: Maggie Watson Ext 56111
Study Administrator: Tracy Robinson
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Objectives
 Primary objective is reduction in BMI
Improved
BMI in risk factors
 Secondary objective
is an improvement
for T2DImproved
and CVD as measured
by: body
metabolic
health
composition, physical activity, physical fitness, insulin
Improved vascular health
resistance, glycemic status, serum lipids and
adipocytokines and vascular function
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Key Elements
Measures to optimize compliance
 Social work screening prior to study entry
 Group mediated cognitive behavioural interventions
 Long acting metformin, once daily dosing
Rigorous outcome measures
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DEXA for body composition
Objective measures of fitness and activity
Glycemic status detailed with OGTT as well as HOMA
Vascular assessment with PAT, 24 hr EKG, US
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Inclusion Criteria
 Age 10-16 years
 Obese, defined as BMI greater than the 95th
percentile for age and gender
 Metformin naïve subjects
 Able to swallow pills
 Able to function in a group
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Activity Intervention
Weeks 1 to 12, HSL, UWO
 Exercise sessions 3 per week, each session lasting for
1 hour and conducted with groups of 10 or more
 Intensive exercise group - cycle erogometer, treadmill,
stepper and resistance training equipment
 Moderate exercise group - steps, dynabands, fit balls and
weights
 GMCB 20 mins/week- aimed at developing self-regulatory
skills needed for exercise adherence
Weeks 13 to 104, Memorial Boy’s & Girls Club
 Moderate exercise sessions 1 per week
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Latino Families in Action
Implementing and Evaluating a Community-based Obesity
Prevention Program for a High-risk Paediatric Population
The Project Team
Betty Harvey
Stewart Harris
Meizi He
Cheril Clarson
Danielle Battram
Gillian Mandich
Linda Khoshaba
Funded By:
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Study Backgound
80% (1.5 million) Canada’s Latin immigrants live in Ontario
 Latino adults T2D 3-4 times >general population
 London has one of the fastest growing Latino populations in
Canada
 Pilot study of 150 Latino children aged 6-12 yrs:
35% overweight
24% obese
(24% and 12 % for London non-Latino children)
Harvey B, 2003 CDA
He M 2003 Public Health Report
Foreyt JP 2003 Permanente J
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Latino Families in Action
Program
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Culturally and linguistically sensitive 6-month program
Families undergo intensive one-on-one case management
Addresses key factors contributing to childhood obesity and
facilitates strategies to combat these factors
Location
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YMCA
Outcome Measures – Changes in:
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BMI and obesity
% body fat measured BIA
Fitness level by 20-meter shuttle
Physical & sedentary behaviours, self efficacy to active living
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Screened n = 178
Age 6-12 yrs
Enrolled n = 67
BMI > 85%
Intervention
6 month intensive risk management
linguistically, socioeconomically relevant
family-oriented program
Results
Junk food consumption -3.3 times/week
Fruit & vegetable consumption +1.1 servings/day
Screen-related activities -55 min/day
Physical activity level +46 min per day
BMI Z-score -0.1
Excluded n = 111
71 not overweight
or obese
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Delivered by trained
lay health advisors
A Group Based Lifestyle Intervention for
Obese Children and their Families
Shauna Burke
Albert Carron
Cheril Clarson
Jennifer Irwin
Jason Gilliland
Meizi He
Michelle Jackman,
Rob Petrella,
Harry Prapavessis
Kevin Shoemaker
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Program
Aim
 To develop, implement, and assess the effectiveness
of a 4-week lifestyle intervention for obese children
and their families
Objectives
 To increase physical activity behaviour
during and following the intervention
 To improve physiological and
psychological outcomes, as well as
dietary patterns and self-efficacy
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Assessments Prior to CHAMP
1) Initial Meeting (UWO)
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Demographic Questionnaire
Quality of Life
Acticals
DEXA Scan
Vessel Wall Imaging
2) Bloodwork and Physical Assessment (CH, LHSC)
 Fasting Bloodwork
 Physical Assessment
Phone Conversation with Dietitian
 Child Lifestyle Questionnaire
 Child’s Self-Efficacy Towards Healthy Living Questionnaire
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Intervention Components
 Group-based physical activity
for children
 Group-based educational
sessions related to nutrition,
physical activity, and
behaviour modification
 Weekly group-based family
training sessions
 Post-intervention group
support for children & families
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Program Details
 Children attended “CHAMP camp” for
4-weeks (9am-4pm) August 2008
 Transportation provided
 Primary location: Canadian Centre for Activity and Aging
UWO
 Secondary location: YMCA Central Branch
 Weekly field trips for children (Spikes, Laser Quest,
Fleetway, East Park)
 Family members attended 4 weekend family education
sessions (10am – 2pm) at UWO
 Cost per family for 4-week program: $200 (included
transportation, family membership at YMCA, field trips,
t-shirts, etc.
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Provincial Council for Children’s Health
PCCH Expert Panel for Child and Youth
Overweight and Obesity:
A Proposed Service Delivery Framework
for Healthy Weights for Children and
Youth across the Continuum of Care
August 2008
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Health Outcome Measures
 Ultimate Outcome:
To delay, reverse or prevent childhood and/or early
onset adult co-morbidities e.g. sleep disordered
breathing, CVD and T2D
 Primary Performance Measure:
Reduction in weight
 Secondary Outcome Measures:
Improvement in risk factors related to sleep
disordered breathing, CVD and T2D
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Health Outcome Measures
A BMI decrease of 0.3-0.5 SDS has been associated
with the following improvements:
Lipid profile 8-10% improvement (0.3-0.5 mmol/L)
BP 5% decrease (3-10 mm Hg)
HOMA-IR 30% decrease (1.5)
Improvement in apnea/hypopnea index
Improvement in QOL measures (Peds QL)
Nemet D, 2005, Pediatr
Savoye M, 2007, JAMA
Epstein LH, 1994, Health Psychol
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Tertiary Level of Care
Core Team
 Advanced practice nurse 0.5
 Clinic clerk
1.0
 Dietitian
1.0
 Exercise specialist
1.0
 Pediatrician
0.3
 Psychologist
0.3
 Social worker
1.0
Cost per team
Total annual operating budget $609,224
Start up costs $11,1539
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Assessment / Treatment Visits (Year
Assessment/Treatment
One) Visits (Year
Tertiary Staffing
One)
Time Required with Patient
Initial Assessment:
Medical
45 minutes
Psycho-Social
45
Nutrition
45
Fitness/Physical Activity
45
Ongoing Treatment
Medical/APN
Psycho-Social
Nutrition
Fitness/Physical Activity
Total
20 minutes every 3 mths x 1 yr as needed
30 minutes every 2 weeks for 3 mths
30 minutes monthly for 9 mos
30 minutes every 2 wks for 3 mths
30 minutes monthly for 9 mos
30 minutes every 2 weeks for 3 mths
30 minutes monthly for 9 mths
495 minutes per allied health
125 minutes per MD/APN
120 new patients per team
Cost per new patient: $5077
Follow-Up Visits (Year Two)
Tertiary Staffing
Time Required with Patient
Maintenance/Follow-Up
Medical/APN
Total
1 visit x 20 minutes
Psycho-Social
1-3 visits x 20 minutes
Nutrition
1-3 visits x 20 minutes
Fitness/Physical Activity
1-3 visits x 20 minutes
20 to 60 minutes per allied health
20 minutes for MD/APN
115 new patients per team
120 follow up patients per team
Average cost per patient $2592
HIP Kids
Subjects
 Age 8-18 years
 BMI >95%
Objectives
 Decreased rate of weight gain and BMI
 Improved nutrition
 Increased physical activity
 Improved QOL
 Reduction of metabolic risk factors for CVD and T2D
Program
 Screening for suitability for entry
 Assessment/Treatment visits as in PCCH Report
15 visits in year one
 Multidisciplinary team
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Future Directions
 Strategies to optimize screening and compliance
 Sustainability
 Genetic variance and scaling of intervention
 Key windows of development for intervention in
metabolic programming
 Maternal health and childhood obesity
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