Improving diagnosis and treatment of knee osteoarthritis in persons with type 2 diabetes: development of a complex intervention.

BACKGROUND: Symptomatic knee osteoarthritis (OA) commonly co-occurs in people with type 2 diabetes (T2DM) and increases the risk for diabetes complications, yet uptake of evidence-based treatment is low. We combined theory, stakeholder involvement and existing evidence to develop a multifaceted intervention to improve OA care in persons with T2DM. This was done in partnership with Arthritis Society Canada to leverage the existing infrastructure and provincial funding for community arthritis care. METHODS: Each step was informed by a User Advisory Panel of stakeholder representatives, including persons with lived experience. First, we identified the target groups and behaviours through consulting stakeholders and current literature. Second, we interviewed persons living with T2DM and knee OA (n = 18), health professionals (HPs) who treat people with T2DM (n = 18) and arthritis therapists (ATs, n = 18) to identify the determinants of seeking and engaging in OA care (patients), assessing and treating OA (HPs) and considering T2DM in OA treatment (ATs), using the Theoretical Domains Framework (TDF). We mapped the content to behavioural change techniques (BCTs) to identify the potential intervention components. Third, we conducted stakeholder meetings to ascertain the acceptability and feasibility of intervention components, including content and modes of delivery. Fourth, we selected intervention components informed by prior steps and constructed a programme theory to inform the implementation of the intervention and its evaluation. RESULTS: We identified the barriers and enablers to target behaviours across a number of TDF domains. All stakeholders identified insufficient access to resources to support OA care in people with T2DM. Core intervention components, incorporating a range of BCTs at the patient, HP and AT level, sought to identify persons with knee OA within T2DM care and refer to Arthritis Society Canada for delivery of evidence-based longitudinal OA management. Diverse stakeholder input throughout development allowed the co-creation of an intervention that appears feasible and acceptable to target users. CONCLUSIONS: We integrated theory, evidence and stakeholder involvement to develop a multifaceted intervention to increase the identification of knee OA in persons with T2DM within diabetes care and improve the uptake and engagement in evidence-based OA management. Our partnership with Arthritis Society Canada supports future spread, scalability and sustainability. We will formally assess the intervention feasibility in a randomized pilot trial.

Barriers and enablers to health care providers assessment and treatment of knee osteoarthritis in persons with type 2 diabetes mellitus: A qualitative study using the Theoretical Domains Framework.

Objectives: Symptomatic knee osteoarthritis (OA) commonly co-exists in persons with Type 2 diabetes (T2DM) and may impede diabetes self-management. Yet, OA is often underdiagnosed and undertreated due to competing health care demands. We sought to determine healthcare providers' (HCPs') perceptions of the barriers and enablers to assessing and treating knee OA in persons with T2DM. Design: We conducted 18 semi-structured telephone interviews with HCPs who manage persons with T2DM (family physicians, endocrinologists, diabetes educators). Interviews were analyzed deductively using Theoretical Domains Framework (TDF), a framework developed to comprehensively identify behavioural determinants. Within relevant domains, data were thematically analyzed to generate belief statements, and these were compared across the different HCP disciplines. Results: Six TDF domains influenced HCPs behaviour to assess and treat knee OA in persons with T2DM. For all HCPs, important barriers included not seeing assessment/treatment of joint pain as a priority for their patients (intention), and insufficient access to required resources such as physiotherapy to treat OA (environmental context and resources). Endocrinologists and diabetes educators perceived having insufficient knowledge and skills to identify and manage OA (knowledge, skills), did not consider it within their professional role to do so (professional role and identity), and perceived other physicians would not want to receive a referral for OA care (social influences). Conclusions: We identified barriers and enablers encountered by diabetes HCPs to assessing and treating knee OA in persons with T2DM involving multiple domains of the TDF. These will help inform development of a complex intervention to improve health outcomes.

Understanding the behavioural determinants of seeking and engaging in care for knee osteoarthritis in persons with type 2 diabetes mellitus: A qualitative study using the theoretical domains framework.

Objectives: Symptomatic knee osteoarthritis (OA) frequently co-occurs in individuals with type 2 diabetes mellitus (T2DM). In the context of T2DM, OA is often underdiagnosed and undertreated. To elucidate strategies to improve OA care in persons with T2DM, we assessed their perceptions of the barriers and enablers to seeking and engaging in OA care. Design: We conducted semi-structured interviews with 18 individuals with T2DM and symptomatic knee OA in Ontario, Canada. Transcripts were deductively coded using the Theoretical Domains Framework (TDF), an implementation science framework that incorporates theoretical domains of behaviour determinants, which can be linked to behaviour change techniques. Within each of the relevant domains, data were thematically analyzed to generate belief statements. Results: Seven of the TDF domains prominently influenced the behaviour to seek and engage in OA care. Participants described insufficient receipt of OA knowledge to fully engage in care (knowledge), feeling incapable of participating in physical activity due to joint pain (beliefs about capabilities), uncertainty about effectiveness of therapies (optimism) and lack of guidance from health care providers and insufficient access to community programs/supports (environmental context and resources). Key enablers were strong social support (social influences), sources of accountability (behavioural regulation) and experiencing benefit from treatment (reinforcement). Participants did not see concomitant T2DM as limiting the desire to seek OA care. Conclusions: Among individuals with symptomatic knee OA and T2DM, we identified behavioural determinants of seeking and engaging in OA care. These will be mapped to behavioural change techniques to inform development of a complex intervention.

Formulating Knee Osteoarthritis Management Plans Taking Type 2 Diabetes Into Account: Qualitative Study of Arthritis Therapists Using Theoretical Domains Framework.

OBJECTIVE: Delivering person-centered care in individuals with knee osteoarthritis (OA) necessitates consideration of other chronic conditions that frequently co-occur. We sought to understand the extent to which arthritis therapists consider type 2 diabetes mellitus (T2DM) when treating persons with knee OA and concomitant T2DM, and barriers to doing so. METHODS: We conducted 18 semistructured telephone interviews with arthritis therapists working within a provincially funded arthritis care program (Arthritis Society Canada) in Ontario, Canada. We first analyzed interviews deductively using the Theoretical Domains Framework (TDF) to comprehensively identify barriers and enablers to health behaviors. Then, within TDF domains, we inductively developed themes. RESULTS: We identified 5 TDF domains as prominently influencing the behavior of arthritis therapists considering concomitant T2DM when developing a knee OA management plan. These were as follows: therapists' perceived lack of specific knowledge around comorbidities including diabetes; the lack of breadth in skills in behavioral change techniques to help patients set and reach their goals, particularly when it came to physical activity; variable intention to factor a patient's comorbidity profile to influence their treatment recommendations; the perception of their professional role and identity as joint focused; and the environmental context with lack of formalized follow-up structure of the current Arthritis Society Canada program that limited sufficient patient monitoring and follow-up. CONCLUSION: Within the context of a Canadian arthritis program, we identified several barriers to arthritis therapists considering T2DM in their management plan for persons with knee OA and T2DM. These results can help inform strategies to improve person-centered OA care and overall health outcomes.

A randomized home-based childhood obesity prevention pilot intervention has favourable effects on parental body composition: preliminary evidence from the Guelph Family Health Study.

BACKGROUND: Home-based lifestyle behaviour interventions show promise for treating and preventing childhood obesity. According to family theories, engaging the entire family unit, including parents, to change their family behaviour and dynamics may be necessary to prevent the development of childhood obesity. However, little is known about how these interventions, which may change the family dynamics and weight-related behaviours of parents, affect weight outcomes in parents. Our objective was to examine the effect of a pilot home-based childhood obesity prevention intervention on measures of anthropometrics and body composition in Canadian parents. METHODS: Forty-four families with children aged 1.5-5 years were randomized to one of three groups: 4 home visits with a health educator, emails, and mailed incentives (4 HV); 2 home visits, emails, and mailed incentives (2 HV); or general health emails (control). Both the 2 HV and 4 HV intervention were conducted over a period of 6 months. Body composition and anthropometric outcomes were measured at baseline and at 6 months and 18 months from baseline. RESULTS: In parents with baseline body mass index (BMI) ≥ 25 kg/m2, the 2 HV group had significantly lower body mass and waist circumference at 6-month (CI = -5.85,-0.14 kg;-5.82,-0.30 respectively) and 18-month follow-up (CI = -7.57,-1.21 kg;-9.30,-2.50 cm respectively) when compared to control, and significantly lower BMI at 18-month follow-up when compared to control (CI = -2.59,-0.29 kg/m2). In parents with baseline BMI < 25 kg/m2, the 4 HV group had significantly lower percentage fat mass (CI = -3.94,-0.12%), while the 2 HV group had significantly lower body mass (CI = -2.56,-0.42 kg) and BMI (CI = -0.77,-0.08 kg/m2) at 6-month follow-up, both compared to control; these effects were not maintained at 18-month follow-up. CONCLUSIONS: This study provides support that a home-based childhood obesity prevention intervention may improve weight outcomes among parents. Future research should explore how home-based interventions influence family behaviour and dynamics to impact weight outcomes in children and their parents. TRIAL REGISTRATION: Prospectively registered August 2014, clinical trial identifier NCT02223234.

Guelph Family Health Study: pilot study of a home-based obesity prevention intervention.

OBJECTIVE: To examine the feasibility and preliminary impact of a home-based obesity prevention intervention among Canadian families. METHODS: Families with children 1.5-5 years of age were randomized to one of three groups: (1) four home visits (HV) with a health educator, emails, and mailed incentives (4HV; n = 17); (2) two HV, emails, and mailed incentives (2HV; n = 14); or (3) general health advice through emails (control; n = 13). Parents randomized to the 2HV and 4HV groups completed post-intervention satisfaction surveys. At baseline and post-intervention, parents reported frequency of family meals and their children's fruit, vegetable, and sugar-sweetened beverage (SSB) intake. We assessed the children's physical activity, sedentary behaviour, and sleep using accelerometers and their % fat mass using bioelectrical impedance analysis. Differences in outcomes at post-intervention, controlling for baseline, were examined using generalized estimating equations. RESULTS: Of the 44 families enrolled, 42 (96%) had 6-month outcome data. Satisfaction with the intervention was high; 80% were "very satisfied" and 20% were "satisfied." At post-intervention, children randomized to the 4HV and 2HV groups had significantly higher fruit intake and children randomized to the 2HV group had significantly lower percentage of fat mass, as compared to the control. No significant intervention effect was found for frequency of family meals, the children's vegetable or SSB intake, physical activity, sedentary behaviour, or sleep. CONCLUSIONS: Our results suggest that the delivery of a home-based intervention is feasible among Canadian families and may lead to improved diet and weight outcomes among children. A full-scale trial is needed to test the effectiveness of this home-based intervention. CLINICAL TRIALS REGISTRATION NUMBER: NCT02223234.

Single Nucleotide Polymorphisms in Taste Receptor Genes Are Associated with Snacking Patterns of Preschool-Aged Children in the Guelph Family Health Study: A Pilot Study.

Snacking is an integral component of eating habits in young children that is often overlooked in nutrition research. While snacking is a substantial source of calories in preschoolers' diets, there is limited knowledge about the factors that drive snacking patterns. The genetics of taste may help to better understand the snacking patterns of children. The rs1761667 single nucleotide polymorphism (SNP) in the CD36 gene has been linked to fat taste sensitivity, the rs35874116 SNP in the TAS1R2 gene has been related to sweet taste preference, and the rs713598 SNP in the TAS2R38 gene has been associated with aversion to bitter, green leafy vegetables. This study seeks to determine the cross-sectional associations between three taste receptor SNPs and snacking patterns among preschoolers in the Guelph Family Health Study. Preschoolers' snack quality, quantity, and frequency were assessed using three-day food records and saliva was collected for SNP genotyping (n = 47). Children with the TT genotype in TAS1R2 consumed snacks with significantly more calories from sugar, and these snacks were consumed mostly in the evening. Total energy density of snacks was highest in the CC and CG genotypes compared to the GG genotype in TAS2R38, and also greater in the AA genotype in CD36 compared to G allele carriers, however this difference was not individually attributable to energy from fat, carbohydrates, sugar, or protein. Genetic variation in taste receptors may influence snacking patterns of preschoolers.