New CDA Guidelines and Type 2 Diabetes Mellitus in
Download
Report
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
1
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
2
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
3
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
4
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
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
5
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
6
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
7
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:
8
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
9
Latino Families in Action
Program
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
YMCA
Outcome Measures – Changes in:
BMI and obesity
% body fat measured BIA
Fitness level by 20-meter shuttle
Physical & sedentary behaviours, self efficacy to active living
10
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
4 declined
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
12
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
13
Assessments Prior to CHAMP
1) Initial Meeting (UWO)
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
14
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
15
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.
16
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
17
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
18
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
19
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
20
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
23
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
24