Exploring the association between individual, family, and program characteristics and change in health outcomes 12 months after enrollment into the CANadian Pediatric Weight management Registry (CANPWR).

OBJECTIVES: To examine individual, family, and program characteristics associated with changes in anthropometric and cardiometabolic health indicators in children with overweight or obesity after participating in multidisciplinary obesity management for 12 months. METHODS: Participants included children 2-17 years old with overweight or obesity enrolled in the CANadian Pediatric Weight Management Registry (CANPWR). Multiple linear regression analyses were conducted to investigate the associations between individual, family, and program characteristics and changes in anthropometry (WHO BMI z-score) and cardiometabolic health indicators (systolic and diastolic blood pressure; fasting and 2-h glucose post-oral glucose tolerance test (OGTT); high density lipoprotein- (HDL) and non-HDL cholesterol and fasting triglycerides). RESULTS: BMI z-score data were available from 1065/1286 (82.8%) at 6-months post-baseline and 893/1286 (69.4%) at 12-months post-baseline. At 6-months, BMI z-score decreased relative to baseline (mean difference (MD) [95% confidence interval (CI)] = -0.08 [-0.10 to -0.06]; p < 0.001). BMI z-score (MD [95% CI] = -0.08 [-0.13 to -0.04); p = 0.001) and fasting triglycerides (MD [95% CI] = -0.07 [-0.13 to -0.02); p = 0.011) decreased at 12 months from baseline. Older age at baseline (estimated ß = 0.025; 95% CI [0.006, 0.042], p = 0.007) and female sex (estimated ß = 0.241; 95% CI [0.108, 0.329], p < 0.001) were associated with a worsened Δ BMI z-score at 12 months, while total hours with mental health provider (estimated ß = -0.015; 95% CI [-0.030, -0.001], p = 0.049) was associated with an improved Δ BMI z-score at 12 months. Hours with an exercise counselor (estimated ß = 0.023; 95% CI [0.008, 0.039], p = 0.003) were associated with improved HDL, while hours with a registered dietitian (estimated ß = -0.026; 95% CI [-0.051, -0.001], p = 0.044) were associated with improved non-HDL cholesterol. CONCLUSIONS: Male sex and hours spent with a mental health provider, exercise counselor, and registered dietitian were related to significant improvements in several anthropometric and cardiometabolic health indicators at 12 months post-baseline.

Using community-based participatory research methods to build the foundation for an equitable integrated health data system within a Canadian urban context.

Health inequalities amplified by the COVID-19 pandemic have disproportionately affected racialized and equity-deserving communities across Canada. In the Municipality of Peel, existing data, while limited, illustrates that individuals from racialized and equity-deserving communities continue to suffer, receive delayed care, and die prematurely. In response to these troubling statistics, grassroots community advocacy has called on health systems leaders in Peel to work with community and non-profit organizations to address the critical data and infrastructure gaps that hinder addressing the social determinants of health in the region. To support these advocacy efforts, we used a community-based participatory research approach to understand how we might build a data collection ecosystem across sectors, alongside community residents and service providers, to accurately capture the data about the social determinants of health. This approach involved developing a community engagement council, defining the problem with the community, mapping what data is actively collected and what is excluded, and understanding experiences of sociodemographic data collection from community members and service providers. Guided by community voices, our study focused on sociodemographic data collection in the primary care context and identified which service providers use and collect these data, how data are used in their work, the facilitators and barriers to data use and collection. Additionally, we gained insight into how sociodemographic data collection could be respectful, safe, and properly governed from the perspectives of community members. From this study, we identify a set of eight recommendations for sociodemographic data collection and highlight limitations. This foundational community-based work will inform future research in establishing data governance in partnership with diverse and equity-deserving communities.

Raising awareness of anti-fat stigma in healthcare through lived experience education: a continuing professional development pilot study.

BACKGROUND: Anti-fat attitudes and weight-based discrimination are prevalent in healthcare settings and among healthcare practitioners and clinical trainees, and can result in immense harm to patients. There is increasing recognition that anti-fat bias in healthcare is a critical issue that must be addressed, but there is a dearth of evidence demonstrating sustained attitude and behavioural change among clinicians, illustrating a need for more innovative educational approaches and rigorous evaluation. We describe the co-design and delivery of a narrative-based continuing professional development curriculum aimed at raising awareness of weight-based bias and stigma. METHODS: Our research team of lived experience educators, clinicians and researchers collaboratively developed a series of seven podcast episodes comprised of narrative descriptions of lived experiences with and impacts of weight bias, stigma and discrimination in healthcare settings, as well as a post-podcast workshop to facilitate reflection and discussion between participants. The curriculum was piloted among 20 clinicians practicing at a large urban hospital in Mississauga, Canada. We explored feasibility, acceptability and learning impact by analyzing responses to questionnaires completed following each podcast episode and responses shared during the workshops and follow-up feedback sessions. RESULTS: We observed high acceptability and feasibility of the curriculum. Participants experienced the podcast as a practical and convenient learning format and the workshop as a valuable opportunity to collectively debrief and reflect. The learning impact of the curriculum was strong; participants described a range of emotions elicited by the podcasts, engaged in self-reflection, and expressed a desire to modify clinical approaches. Barriers to the application of learnings identified by participants include pervasiveness of the use of body mass index (BMI) as an indicator of risk and a criterion for referral; discomfort with difficult conversations; prevalent biomedical understandings about the association between weight and health; and clinicians' defensiveness. CONCLUSION: This pilot study yielded promising findings and demonstrated potential impact on weight bias and stigma among healthcare providers. Necessary next steps include conducting larger scale, rigorous evaluations of the curriculum among broader populations, both health professions trainees and current healthcare providers.

Optimizing paediatric specialist referrals for short stature in an era of multiple growth hormone indications.

The assessment of growth during infancy and childhood is an essential component of paediatric medicine, as atypical growth may point to the existence of an underlying health condition. To reduce morbidity, it is vital that treatment for growth disorders is provided in a timely fashion. However, although there are guidelines regarding referral criteria for short stature in Europe and the USA, there are no such guidelines in Canada. To address this, a series of consultations and workshops with paediatricians, paediatric endocrinologists, family physicians and nurses were held, with the aim of developing a consensus-based set of recommendations for children in Canada showing atypical growth and to identify red flags for children who might benefit from early referral. To achieve this, a referral algorithm and referral form for primary care providers were developed to ensure timely and appropriate referrals, and transmission of the most relevant details to the secondary care consultant.

Individual and family characteristics associated with health indicators at entry into multidisciplinary pediatric weight management: findings from the CANadian Pediatric Weight management Registry (CANPWR).

OBJECTIVES: (1) To explore individual and family characteristics related to anthropometric and cardiometabolic health indicators and (2) examine whether characteristics that correlate with cardiometabolic health indicators differ across severity of obesity at time of entry to Canadian pediatric weight management clinics. METHODS: We conducted a cross-sectional analysis of 2-17 year olds with overweight or obesity who registered in the CANadian Pediatric Weight Management Registry (CANPWR) between May 2013 and October 2017 prior to their first clinic visit. Individual modifiable health behaviors included dietary intake, physical activity, screen time, and sleep. Family characteristics included parental BMI, family medical history, socioeconomic status and family structure. Linear mixed effects stepwise regression analysis was performed to determine which characteristics were related to each health indicator: BMI z-score; waist circumference; waist to height ratio; blood pressure; glycemia; HDL cholesterol; non-HDL cholesterol; triglycerides. RESULTS: This study included 1296 children (mean age ± standard deviation: 12.1 ± 3.5 years; BMI z-score: 3.55 ± 1.29; 95.3% with obesity). Hours spent sleeping (estimated ß = -0.10; 95% CI [-0.15, -0.05], p = 0.0001), hours per week of organized physical activity (estimated ß = -0.32; 95% CI [-0.53, -0.11], p = 0.0026), daily sugared drink intake (estimated ß = 0.06; 95% CI [0.01, 0.10], p = 0.0136) and maternal BMI (estimated ß = 0.03; 95% CI [0.02, 0.04], p < 0.0001) were associated with BMI z-score (adj. R2 = 0.2084), independent of other individual and family characteristics. Physical activity, total sugared drink intake and sleep duration were associated with glycemia and non-HDL cholesterol, independent of child BMI z-score. However, irrespective of obesity severity, little of the variance (0.86-11.1%) in cardiometabolic health indicators was explained by individual modifiable health behaviors. CONCLUSIONS: Physical activity, total sugared drink intake and hours spent sleeping were related to anthropometric and some cardiometabolic health indicators in children entering pediatric weight management programs. This highlights the importance of these modifiable health behaviors on multiple health indicators in children with obesity.

All together: Integrated care for youth with type 1 diabetes.

OBJECTIVE: We describe the implementation and evaluation of an integrated, stepped care model aimed to identify and address the concerns of adolescents with type 1 diabetes (T1D) associated with diabetes-related quality of life (DRQoL), emotional well-being, and depression. RESEARCH DESIGN AND METHODS: The care model with 4 steps: (1) Systematic identification and discussion of concerns salient to adolescents; (2) Secondary screening for depressive symptoms when indicated; (3) Developing collaborative treatment plans with joint physical and mental health goals; and (4) Psychiatric assessment and embedded mental health treatment; was implemented into an ambulatory pediatric diabetes clinic and evaluated using quantitative and qualitative methods. RESULTS: There were 236 adolescents (aged 13-18 years) with T1D that were enrolled in the care model. On average adolescents identified three concerns associated with their DRQoL and 25% indicated low emotional well-being. Fifteen adolescents received a psychiatric assessment and embedded mental health treatment. Both adolescents and caregivers were appreciative of a broader, more holistic approach to their diabetes care and to the greater focus of the care model on adolescents, who were encouraged to self-direct the conversation. Parents also appreciated the extra level of support and the ability to receive mental health care for their adolescents from their own diabetes care team. CONCLUSION: The initial findings from this project indicate the acceptability and, to limited extent, the feasibility of an integrated stepped care model embedded in an ambulatory pediatric diabetes clinic led by an interdisciplinary care team. The care model facilitated the identification and discussion of concerns salient to youth and provided a more holistic approach.

Using Person-Reported Outcomes (PROs) to Motivate Young People with Diabetes.

PURPOSE OF REVIEW: This manuscript describes how person-reported outcomes (PROs) can be utilized in care for young people with diabetes in the context of motivation. RECENT FINDINGS: The use of person-reported outcome measures (PROMS) in clinical care is feasible and acceptable, and helps focus the clinical encounter on life domains important to the person with diabetes. Results with regard to impact on self-management and glycemic outcomes are limited. Motivation is an important factor for self-management. Based on self-determination theory, autonomy-supportive, person-centered, and collaborative communication by diabetes care providers is associated with better outcomes. PROMs can facilitate this conversation. Understanding of youth motivation for maintaining or improving self-management behaviors requires a person-centered approach. PROMs can be used to facilitate an autonomy-supportive and person-centered conversation in clinical care. Training diabetes care providers in autonomy-supportive, person-centered conversation skills to discuss PROs might help to tap into youth's motivation, but further research is needed.

Pathways to eating in children and adolescents with obesity.

BACKGROUND: Paediatric obesity management remains generalised to dietary and exercise modifications with an underappreciation for the contributions of eating behaviours and appetitive traits in the development of obesity. OBJECTIVES: To determine whether treatment-seeking children and adolescents with obesity cluster into phenotypes based on known eating behaviours and appetitive traits ("eating correlates") and how socio-demographic and clinical characteristics associate with different phenotypes. METHODS: A cross-sectional, multi-centre questionnaire was administered between November 2015 and March 2017 examining correlates of eating in children and adolescents attending weight-management programmes in Canada. Latent profile analysis was used to cluster participants based on seven eating correlate scores obtained from questionnaires. Analysis of variance (ANOVA) was used to determine phenotype differences on socio-demographic and clinical characteristics. Multinomial logistic regression models assessed relative risk of specific characteristics associating with a disordered eating phenotype. RESULTS: Participants were 247 children and adolescents (45.3% male, mean BMI z-score = 3.4 ± 1.0 kg/m2) from six paediatric weight management centres in Canada. Seven eating correlates clustered into three distinct phenotypes: (1) loss of control eating, emotional eating, external eating, hyperphagia, impulsivity ("Mixed-Severe"; n = 42, 17%), (2) loss of control eating, emotional eating, external eating, hyperphagia ("Mixed-Moderate"; n = 138, 55.9%), and (3) impulsivity ("Impulsive"; n = 67; 27.1%). Social functioning scores and body esteem were significantly different across groups, with the Mixed-Severe participants having the poorest social functioning and lowest body esteem. Low body esteem indicated a greater risk of being in a multi-correlate group compared to the Impulsive group, while poor social function had a greater risk of clustering in the Mixed-Severe than Impulsive phenotype. CONCLUSIONS: Distinct eating phenotypes were found in treatment-seeking children and adolescents with obesity. Empirical evidence is needed, but these data suggest that tailored treatment approaches could be informed by these classifications to improve weight-management outcomes.

Testing an audit and feedback-based intervention to improve glycemic control after transfer to adult diabetes care: protocol for a quasi-experimental pre-post design with a control group.

BACKGROUND: When young adults transfer from pediatric to adult diabetes care they are at risk for deterioration of glycemic control, putting them at an increased risk of developing both acute and chronic complications. Despite increased awareness of these risks, there are gaps in care delivery during this vulnerable time and variability in the implementation of recommended transition practice. Audit and feedback (AF) interventions have a positive but variable effect on implementation of best practices. An expert group identified specific suggestions for optimizing the effectiveness of AF interventions. We aim to test an AF-based intervention incorporating these specific suggestions to improve transition practices and glycemic control in the first year after transfer from pediatric to adult diabetes care. METHODS: This is a pragmatic quasi-experimental study; a series of three cohort studies (pre-implementation, early-implementation, and post-implementation) to compare the baseline adjusted hemoglobin A1c (HbA1c) in the 12 months after the final pediatric visit in five pediatric diabetes centres within the Ontario Pediatric Diabetes Network in Ontario, Canada. The intervention includes three components: 1) centre-level feedback reports compiling data from chart abstraction, linked provincial administrative datasets, and patient-reported experience measures; 2) webinars for facilitated conversations/coaching about the feedback; and 3) online repository of curated transition resources for providers. The primary outcome will be analyzed using a multivariable linear regression model. We will conduct a qualitative process evaluation to understand intervention fidelity and to provide insight into the mechanisms of action of our results. DISCUSSION: There is a need to develop an innovative system-level approach to improve outcomes and the quality of care for young adults with type 1 diabetes during the vulnerable time when they transfer to adult care. Our research team, a collaboration of health services, implementation science, and quality improvement researchers, are designing, implementing, and evaluating an AF-based intervention using recommendations about how to optimize effectiveness. This knowledge will be generalizable to other care networks that aim to deliver uniformly high-quality care in diverse care settings. TRIAL REGISTRATION: ClinicalTrials.gov NCT03781973. Registered 13 December 2018. Date of enrolment of the first participant to the trial: June 1, 2019.

The CANadian Pediatric Weight management Registry (CANPWR): lessons learned from developing and initiating a national, multi-centre study embedded in pediatric clinical practice.

BACKGROUND: There is increasing recognition of the value of "real-world evidence" in evaluating health care services. Registry-based, observational studies conducted in clinical settings represent a relevant model to achieve this directive. Starting in 2010, we undertook a longitudinal, observational study (the CANadian Pediatric Weight management Registry [CANPWR]), which is embedded in 10 multidisciplinary, pediatric weight management clinics across Canada. The objective of this paper was to share the lessons our team learned from this multi-centre project. METHODS: Data sources included a retrospective review of minutes from 120 teleconferences with research staff and investigators, notes taken during clinical site visits made by project leaders, information from quality control processes to ensure data accuracy and completeness, and a study-specific survey that was sent to all sites to solicit feedback from research team members (n = 9). Through an iterative process, the writing group identified key themes that surfaced during review of these information sources and final lessons learned were developed. RESULTS: Several key lessons emerged from our research, including the (1) value of pilot studies and central research coordination, (2) need for effective and regular communication, (3) importance of consensus on determining outcome measures, (4) challenge of embedding research within clinical practice, and (5) difficulty in recruiting and retaining participants. The sites were, in spite of these challenges, enthusiastic about the benefits of participating in multi-centre collaborative studies. CONCLUSION: Despite some challenges, multi-centre observational studies embedded in pediatric weight management clinics are feasible and can contribute important, practical insights into the effectiveness of health services for managing pediatric obesity in real-world settings.

Routine behavioral and mental health screening in young children with type 1 diabetes mellitus.

BACKGROUND: The American Diabetes Association and International Society for Pediatric and Adolescent Diabetes recommend that providers of diabetes care receive training in the recognition of psychosocial problems related to diabetes. OBJECTIVE: To report the results of routine behavioral/mental health screening for children with type 1 diabetes mellitus (T1D) seen in a multidisciplinary pediatric diabetes program. SUBJECTS AND METHODS: This was a cross-sectional study of children with T1D ages 4-11 years, who underwent behavioral/mental health screening as part of their diabetes care. Screening utilized the Strengths and Difficulties Questionnaire (SDQ) Parent Proxy Version, and scores were reviewed by a social worker. SDQ scale and total difficulties scores were compared by gender, visit type, age, T1D duration, and HbA1c. Scores were also compared to age-appropriate normative data for children in United States of America (US). RESULTS: SDQ Parent Proxy Version total difficulties and scale scores did not differ by patient or visit characteristics. Compared with normative data for US children, a greater proportion of children with T1D ages 4-7 and 8-10 years had borderline/abnormal scores on the emotional symptoms scale (p = 0.01 and p = 0.03, respectively), suggesting risk for psychological disorders, such as anxiety and depression. CONCLUSIONS: Our findings suggest that children less than 11 years old with T1D may have greater emotional symptoms as compared to their age-matched healthy peers. Pediatric diabetes care providers, with access to mental health services, should consider incorporating routine behavioral/mental health screening for children less than 12 years old in their practice.

"I Am the Last Priority": Factors Influencing Diabetes Management Among South Asian Caregivers in Peel Region, Ontario.

OBJECTIVE: In this study, we aimed to identify sociocultural and systemic factors influencing diabetes management among South Asian (SA) caregivers in Peel Region, Ontario. METHODS: Twenty-one semistructured interviews were conducted with SA caregivers using a qualitative descriptive design. Data were analyzed using thematic analysis and intersectionality analysis. RESULTS: Themes identified included 1) prioritizing family caregiving over diabetes self-management; 2) labour market impacts on diabetes self-management; and 3) challenges navigating Canadian health and social service systems. SA caregivers described social, economic, and systemic challenges impacting type 2 diabetes management. Systemic factors influencing diabetes management included discrimination and inequities in labour policies and lack of social and health resources funding. Recommendations by caregivers included whole-family, community-based, culturally tailored approaches to diabetes prevention and management strategies. CONCLUSIONS: Providing support with system navigation, encouraging family-based approaches, and addressing the social determinants of health could be beneficial for supporting SA families with diabetes management and prevention.

An assessment of adaptation and fidelity in the implementation of an audit and feedback-based intervention to improve transition to adult type 1 diabetes care in Ontario, Canada.

BACKGROUND: The fit between an intervention and its local context may affect its implementation and effectiveness. Researchers have stated that both fidelity (the degree to which an intervention is delivered, enacted, and received as intended) and adaptation to the local context are necessary for high-quality implementation. This study describes the implementation of an audit and feedback (AF)-based intervention to improve transition to type 1 diabetes adult care, at five sites, in terms of adaptation and fidelity. METHODS: An audit and feedback (AF)-based intervention for healthcare teams to improve transition to adult care for patients with type 1 diabetes was studied at five pediatric sites. The Framework for Reporting Adaptations and Modifications to Evidence-based Implementation Strategies (FRAME-IS) was used to document the adaptations made during the study. Fidelity was determined on three different levels: delivery, enactment, and receipt. RESULTS: Fidelity of delivery, receipt, and enactment were preserved during the implementation of the intervention. Of the five sites, three changed their chosen quality improvement initiative, however, within the parameters of the study protocol; therefore, fidelity was preserved while still enabling participants to adapt accordingly. CONCLUSIONS: We describe implementing a multi-center AF-based intervention across five sites in Ontario to improve the transition from pediatric to adult diabetes care for youth with type 1 diabetes. This intervention adopted a balanced approach considering both adaptation and fidelity to foster a community of practice to facilitate implementing quality improvement initiatives for improving transition to adult diabetes care. This approach may be adapted for improving transition care for youth with other chronic conditions and to other complex AF-based interventions. TRIAL REGISTRATION: ClinicalTrials.gov NCT03781973. Registered 13 December 2018. Date of enrolment of the first participant to the trial: June 1, 2019.

Adolescent and Caregiver Perspectives on Family Navigation to Improve Healthcare Access and Use for Managing Pediatric Obesity.

We interviewed families to explore their views on the role of family navigation (FN) to improve access to and use of health services for managing pediatric obesity. From March to December, 2020, we conducted individual, structured telephone interviews with adolescents with obesity (13-17 years old) and their caregivers from Edmonton and Calgary, Canada. Among our 37 participants (14 adolescents, 23 caregivers), most (n = 27; 73.0%) reported FN could improve their access to obesity management. Participants recommended several activities to support healthcare access and use, including appointment reminders, evening/weekend appointments, parking/transportation support, and in-clinic childcare, all of which help families to attend appointments over an extended period to support obesity management. Most participants preferred FN be offered by healthcare professional 'navigators' who were approachable, empathic, and compassionate since issues regarding health and obesity can be sensitive, emotional topics to discuss. Overall, families supported integrating FN into multidisciplinary pediatric obesity management to improve healthcare access and use by navigators who apply a range of practical strategies and relational skills to enhance long-term access and adherence to care.

An Integrated Care Model to Support Adolescents With Diabetes-related Quality-of-life Concerns: An Intervention Study.

BACKGROUND: Our aim in this study was to determine whether participating in an integrated stepped care model for adolescents with type 1 diabetes (T1D) would lead to improvements in overall quality of life (QoL), diabetes-related quality of life (DRQoL) and glycated hemoglobin (A1C) levels compared with usual care. METHODS: A nonrandomized, 2-group, pre/post, delayed-intervention design was used for this study. The Mind Youth Questionnaire (MY-Q) was used to assess QoL and DRQoL. Adolescents attending the diabetes clinic using the stepped care model formed the intervention group (n=77). These adolescents completed the MY-Q, and the identified concerns were discussed and addressed with them by their care team as part of the care model. Adolescents attending a pediatric diabetes clinic on another site completed the MY-Q as a comparison group (n=39), results were not shared with their care team, and they received the standard care. RESULTS: There were 116 adolescents between 13 to 17 years of age, who completed the MY-Q on 2 occasions. Baseline data were obtained on the first occasion, and, on the second occasion, an average of 12 months later, there was a follow-up assessment. At follow-up, adolescents in the intervention group had a significantly higher overall QoL and reported significantly fewer concerns on DRQoL domains than those in the comparison group. Participation in the intervention group, however, did not lead to improvements in A1C. CONCLUSION: This study shows that implementing an integrated stepped care model within an interprofessional pediatric diabetes clinic can lead to the improvement of adolescents' overall QoL and DRQoL.

Towards a community-driven definition of community wellbeing: A qualitative study of residents.

BACKGROUND: Understanding what promotes or hinders a community's capacity to serve the priorities of its residents is essential for the alignment of citizen needs and governance. Participatory approaches that engage community residents on the topic of community wellbeing are useful methods for defining outcomes that reflect a community's goals and priorities. Using qualitative focus group methods, the aim of this study was to outline bottom-up definitions of community wellbeing from a diverse pool of community residents in Ontario, Canada. METHODS: Semi-structured, two-hour group interviews were conducted with adult (≥18 years) participants (N = 15) residing in four communities across Canada's largest province of Ontario. Participants were purposively selected from a pool of screening questionnaires to ensure diverse group compositions based on race, gender, age, and educational attainment. Interviews were thematically analysed using descriptive and interpretive methods to characterize resident conceptions of community wellbeing. RESULTS: Focus group participants were between 18 and 75 years of age and most had lived in their local community for 5 or more years. Four major themes emerged: (1) a sense of community belonging is cultivated through shared spaces, routines, support, and identities; (2) a community constitutes the amenities and social contexts that enable residents to thrive; (3) effective regional decision-making must be community-informed; and (4) the wellbeing of a community relies on equal opportunities for engagement and participation. CONCLUSIONS: Residents described their communities and their associated wellbeing as a combination of accessible amenities and opportunities to engage without marginalization. This study underscores the value of participatory approaches in community wellbeing research, where the viewpoint and life experience of residents is used to inform local decision-making and service delivery. Future research will capture more diverse perspectives towards community belonging, particularly from community newcomers, for the development of regionally appropriate indicators of community wellbeing.

A multi-center, randomized, 12-month, parallel-group, feasibility study to assess the acceptability and preliminary impact of family navigation plus usual care versus usual care on attrition in managing pediatric obesity: a study protocol.

BACKGROUND: Pediatric obesity management can be successful, but some families discontinue care prematurely (i.e., attrition), limiting treatment impact. Attrition is often a consequence of barriers and constraints that limit families' access to obesity management. Family Navigation (FN) can improve access, satisfaction with care, and treatment outcomes in diverse areas of healthcare. To help our team prepare for a future effectiveness trial, the objectives of our randomized feasibility study are to (i) explore children's and caregivers' acceptability of FN and (ii) examine attrition, measures of study rigor and conduct, and responses to FN + Usual Care vs Usual Care by collecting clinical, health services, and health economic data. METHODS: In our 2.5-year study, 108 6-17-year-olds with obesity and their caregivers will be randomized (1:1) to FN + Usual Care or Usual Care after they enroll in obesity management clinics in Calgary and Mississauga, Canada. Our Stakeholder Steering Committee and research team will use Experience-Based Co-Design to design and refine our FN intervention to reduce families' barriers to care, maximizing the intervention dose families receive. FN will be delivered by a navigator at each site who will use logistical and relational strategies to enhance access to care, supplementing obesity management. Usual Care will be offered similarly at both clinics, adhering to expert guidelines. At enrollment, families will complete a multidisciplinary assessment, then meet regularly with a multidisciplinary team of clinicians for obesity management. Over 12 months, both FN and Usual Care will be delivered virtually and/or in-person, pandemic permitting. Data will be collected at 0, 3, 6, and 12 months post-baseline. We will explore child and caregiver perceptions of FN acceptability as well as evaluate attrition, recruitment, enrolment, randomization, and protocol integrity against pre-set success thresholds. Data on clinical, health services, and health economic outcomes will be collected using established protocols. Qualitative data analysis will apply thematic analysis; quantitative data analysis will be descriptive. DISCUSSION: Our trial will assess the feasibility of FN to address attrition in managing pediatric obesity. Study data will inform a future effectiveness trial, which will be designed to test whether FN reduces attrition. TRIAL REGISTRATION: This trial was registered prospectively at ClinicalTrials.gov (# NCT05403658 ; first posted: June 3, 2022).

Incorporation of patient and family values and preferences for health-related outcomes in paediatric obesity management: A systematic review.

OBJECTIVE: A systematic review of value and preference studies conducted in children and their caregivers related to the estimated benefits and harms of interventions for managing paediatric obesity. METHODS: We searched Ovid Medline (1946-2022), Ovid Embase (1974-2022), EBSCO CINAHL (inception to 2022), Elsevier Scopus (inception to 2022), and ProQuest Dissertations & Theses (inception to 2022). Reports were eligible if they included: behavioural and psychological, pharmacological, or surgical interventions; participants between (or had a mean age within) 0-18 years old with overweight or obesity; systematic reviews, primary quantitative, qualitative, or mixed/multiple methods studies; and values and preferences as main study outcomes. At least two team members independently screened studies, abstracted data, and appraised study quality. RESULTS: Our search yielded 11 010 reports; eight met the inclusion criteria. One study directly assessed values and preferences based on hypothetical pharmacological treatment for hyperphagia in individuals with Prader-Willi Syndrome. Although not having reported on values and preferences using our a priori definitions, the remaining seven qualitative studies (n = 6 surgical; n = 1 pharmacological) explored general beliefs, attitudes, and perceptions about surgical and pharmacological interventions. No studies pertained to behavioural and psychological interventions. CONCLUSION: Future research is needed to elicit the values and preferences of children and caregivers using the best available estimates of the benefits and harms for pharmacological, surgical, and behavioural and psychological interventions.

Text message-based intervention, Keeping in Touch (KiT), to support youth as they transition to adult type 1 diabetes care: a protocol for a multisite randomised controlled superiority trial.

INTRODUCTION: Transition from paediatric to adult care can be challenging for youth living with type 1 diabetes (T1D), as many youth feel unprepared to transfer to adult care and are at high risk for deterioration of glycaemic management and acute complications. Existing strategies to improve transition experience and outcomes are limited by cost, scalability, generalisability and youth engagement. Text messaging is an acceptable, accessible and cost-effective way of engaging youth. Together with adolescents and emerging adults and paediatric and adult T1D providers, we co-designed a text message-based intervention, Keeping in Touch (KiT), to deliver tailored transition support. Our primary objective is to test the effectiveness of KiT on diabetes self-efficacy in a randomised controlled trial. METHODS AND ANALYSIS: We will randomise 183 adolescents with T1D aged 17-18 years within 4 months of their final paediatric diabetes visit to the intervention or usual care. KiT will deliver tailored T1D transition support via text messages over 12 months based on a transition readiness assessment. The primary outcome, self-efficacy for diabetes self-management, will be measured 12 months after enrolment. Secondary outcomes, measured at 6 and 12 months, include transition readiness, perceived T1D-related stigma, time between final paediatric and first adult diabetes visits, haemoglobin A1c, and other glycaemia measures (for continuous glucose monitor users), diabetes-related hospitalisations and emergency department visits and the cost of implementing the intervention. The analysis will be intention-to-treat comparing diabetes self-efficacy at 12 months between groups. A process evaluation will be conducted to identify elements of the intervention and individual-level factors influencing implementation and outcomes. ETHICS AND DISSEMINATION: The study protocol version 7 July 2022 and accompanying documents were approved by Clinical Trials Ontario (Project ID: 3986) and the McGill University Health Centre (MP-37-2023-8823). Study findings will be presented at scientific conferences and in peer-reviewed publications. TRIAL REGISTRATION NUMBER: NCT05434754.

Service Provider Perspectives on Exploring Social Determinants of Health Impacting Type 2 Diabetes Management for South Asian Adults in Peel Region, Canada.

OBJECTIVES: Individuals from South Asian communities are known to have a higher likelihood of developing type 2 diabetes (T2D), which is often attributed to individual lifestyle and behavioural factors. This focus on individual responsibility can position communities as complicit in their illness, compounding stigmatization and systemic discrimination. In this article, we explore the social determinants of health (SDOH) that influence health behaviours among South Asian adults with T2D from a service provider's perspective. METHODS: Using a qualitative descriptive design, we conducted semistructured interviews with 12 community, social and health-care service providers. We used thematic analysis and the analytical concept of intersectionality to explore how different social locations and SDOH impact T2D management for South Asian adults. RESULTS: Three themes were identified: 1) managing challenges with settlement process, labour policies and job market disparities take priority over T2D management; 2) poor working conditions and low socioeconomic status reduce access to health care and medication; and 3) there are social, economic and cultural barriers to implementing diet and exercise recommendations. CONCLUSIONS: Service providers identified social, economic and systemic factors as influencing the higher prevalence of T2D among South Asian individuals. They also identified their important roles in providing culturally appropriate supports to address SDOH and described advocacy for changes to policies and practices that reinforce systemic racism. The providers further suggested that more equitable employment policies and practices are needed to address the systemic factors that contribute to the higher risk of T2D among South Asian adults in the Peel Region.