A1.1 Continuum of Prevention to Treatment for Child Health_Dianne Knox
33
SickKids & Toronto Public Health Early Intervention Program The continuum of prevention to treatment for child health Dianne Knox, MSW RSW Catherine S. Birken MD, MSc, FRCPC Maplelee Cardona RN Alisa Bar-Dayan, RD Allison Jeffery, PTS, CRA STOMP Early Years
Objectives • Learn about the collaborative practices
between SickKids and Toronto Public Health through review of STOMP early years program
• Indentify complex factors involved in the treatment and prevention of obesity
• Learn how to strengthen future partnerships in obesity prevention and treatment
STOMP Early Years
Agenda • Ice breaker • Current evidence • Case Study: STOMP Early Years • Discussion exercise & moving forward • Questions
STOMP Early Years
STOMP Early Years
Ice Breaker Benefits and Barriers Exercise
Buzz- What are the benefits of developing collaborative models of care in the area of childhood obesity? What are the barriers?
What is the current evidence?
Obesity Interventions for Young Children in the Community
STOMP Early Years
Presenter
Presentation Notes
Few interventions in the literature in primary care 1. RCT Mups Systematic review MUPS 2. Tavares RCT in boston 3. Wen RCT home visiting nurses 4. Quarten 5 Next Steps
• Overweight or obese 3-7 year olds • 4 additional visits, 3 phone calls • Restructured primary healthcare chronic care model
Home based intervention: 2-5 year olds • Motivational coaching home visits, phone calls, text
messages – Family meals, adequate sleep, limit TV time, remove TV
The study involved 121 families with children aged 2 to 5 years who had a television (TV) in the room where he or she slept; 111 (92%) had 6-month outcome data (55 intervention and 56 control). The mean (SD) age of the children was 4.0 (1.1) years; 45%were overweight/obese. Fifty-two percent of the children were Hispanic, 34%were black, and 14% were white/other. Nearly 60% of the families had household incomes of $20 000 or less. INTERVENTIONS The 6-month intervention promoted 4 household routines, family meals, adequate sleep, limiting TV time, and removing the TV from the child’s bedroom, using (1) motivational coaching at home and by phone, (2) mailed educational materials, and (3) text messages. Control subjects were mailed materials focused on child development. MAIN OUTCOMES AND MEASURES Change in parent report of frequency of family meals (times/wk), child sleep duration (hours/d), child weekday and weekend day TV viewing (hours/d), and the presence of a TV in the room where the child slept from baseline to 6 months. A secondary outcome was change in age- and sex-adjusted body mass index (calculated as weight in kilograms divided by height in meters squared). RESULTS Compared with control subjects, intervention participants had increased sleep duration (0.75 hours/d; 95%CI, 0.06 to 1.44; P = .03), greater decreases in TV viewing on weekend days (−1.06 hours/d; 95%CI, −1.97 to −0.15; P = .02), and decreased body mass index (−0.40; 95%CI, −0.79 to 0.00; P = .05). No significant intervention effect was found for the presence of a TV in the room where the child slept or family meal frequency.
Intervention: 8 public health home nurse visits Breast is best No solids for me until 6 months I eat a variety of fruit and vegetables every day Only water in my cup I am part of an active family Results • BMI decreased by -0.38 (-0.68, -0.08); p=0.01
Presenter
Presentation Notes
Australian National Guidelines.31 32 The key intervention messages included (also see appendix): • Breast is best�• No solids for me until 6 months�• I eat a variety of fruit and vegetables every day • Only water in my cup�• I am part of an active family. Four community nurses were recruited and trained to ensure consistency of delivering the intervention. The nurse visited participating families in the intervention group eight times at home, once at 30-36 weeks’ gestation and seven times after the birth (at 1, 3, 5, 9, 12, 18 and 24 months). The timing of the visits corresponds to milestones in early childhood development. At each visit, the nurse spent about one to two hours with the mother and infant. The nurse not only taught the mother specific skills and knowledge in relation to healthy infant feeding practices and active play (the key messages of the programme) but also discussed any issues and concerns raised by the mother. A visit checklist with standard minimum information plus additional discussion points for each key area plus appropriate resources to support each key message was developed. Four key areas included infant feeding practices, child nutrition and active play, family physical activity and nutrition, and social support. After each visit, the nurses documented all aspects of their visits with the participating families and provided regular reports to the investigators on questions and issues arising.
• Link staff, funds data, locally and regionally • Create common research and learning networks • Develop the workforce • Improve existing programs and create new ones
with legislation • Develop a national strategy, and investment plan
STOMP Early Years
STOMP Early Years
Ecological Systems Theory ( Davison & Birch, 2001)
STOMP Early Years
• Partnership between SickKids and Toronto Public Health
• To promote healthy families • To prevent severe obesity,
heart disease and diabetes • Connecting Families
Program Overview • Program for families with children under 6 years • Promoting child mental health and wellness • Prevention of cardiometabolic disease in children identified with
increased weight • Building a stronger parent child relationship
Program Goals • Increase fun active play • Encourage healthy eating behaviours • Learn coping and problem solving strategies • Learn to feel good about yourself • Support families in using strategies at home
STOMP Early Years
STOMP Early Years
PHASE II: INTENSIVE EDUCATION (Month 1 & 2)
10 WEEKLY HEALTHY LIFESTYLES and
INCREDIBLE YEARS PARENTING SESSIONS
PHASE III: GROUP SUPPORT & CLINIC VISITS (Months 3 to 18)
6 HEALTHY LIFESTYLE CHECK INS, GROUP SUPPORT & CLINIC VISITS
PHASE IV: COMMUNITY LINKS & TRANSITION (Months 18 to 24)
3 COMBINED CLINIC & GROUP SUPPORT Visits
PHASE I: ASSESSMENT
INITIAL ASSESSMENT WITH STOMP TEAM IN CLINIC FIRST HOME VISIT with TORONTO PUBLIC HEALTH NURSE
Case Study • 3 year old girl BMI 25 kg/m2
• history of obstructive sleep apnea, asthma • referred by sleep clinic • lives with single mom (caring, attentive) & older
brother • Income from social assistance • community centre, library and pool close by
• Moms main concerns: sleep symptoms, weight and low physical activity
STOMP Early Years
Presenter
Presentation Notes
Family Background Nila (mother) Single parent 3 children living in a 3 bdrm apt in high risk neighbourhood of Toronto Nila is nurturing and attentive to all her children Family geographically located on main street beside a community center, walking distance to a mall, library and pool Nila has a hx of abuse and trauma and is estranged from the children’s father Sole income from social assistance Neema (youngest child) Typical preschooler Energetic and happy Meeting developmental milestones Gets along well with siblings and strong attachment to mom Initial entry to program On initial referral, Neema presented with BMI of 25.0 kg/m2, dx of asthma and query sleep apnea and low iron levels. Neema’s diet included a variety of foods from the Canada’s Food Guide but also high sugar beverages and fruit juice. The family commonly ate fattier meat and starchy foods. Vegetables were often a challenge to include and multivitamins were used to supplement. Meal time was usually at scheduled times with snacking happening sporadically. The family often ate meals together, usually dinner and with the TV on but with the volume down. Mom had a habit of getting up during the meals to attend to other responsibilities. Neema participated in unstructured activities such as day camp and often played at the park, but often would become winded with simple activities. Stressors at the time of referral: middle child anaemic hx of abuse (mom) single parent financial challenges Informal supports: friends within the building Formal supports: Rexdale CHC counselor and RD, NYGH obesity clinic Mom’s Primary Concerns Asthma Sleep Apnea Managing Neema’s weight Increasing Neema’s physical activity STOMP Interventions Medical: referrals generated for sleep clinic______& diagnostic workup Nutrition: general education and specific counseling related to limiting sugary beverages and fruit juice, increase fibre , high iron foods and lean protein Physical Activity: education regarding CSEP guidelines and active living, walking to nearby destinations, incorporating “move on the spot” activity. Recommendation of participating in structured activities. Provision of subsidy to finance activities and education regarding screen time recommendations Social Work: support regarding further funding for activities and linking to other agencies ie. Investing in Families Public Health Nurse: 7 home visits supported the implementation of written rules, routines charts ( meals and snacks, bed time) Visits X 2- meal time participation, physical activity family fun hour emphasize importance of modeling, social rewards ie. effective praise, and effective commands/ limit setting and follow through Stressors during STOMP participation: mom underwent surgery Neema’s abnormal cholesterol and kidney results death in the family court proceedings for child support Outcomes Medical: decreased BMI to 22.7 kg/m2 lowered cholesterol decrease asthma attacks sleep improvement Nutrition: drinking primarily water or diluted fruit juice switched to whole grains trying various vegetables eating leaner sources of protein and light dairy products no longer using multivitamins as child is now eating a wider variety of foods from the Canada's Food Guide family sits together during meal time with the TV off mom more aware of her behaviours at meal time Physical activity: Neema has participated in ballet, soccer& swimming lessons endurance has increased need for her asthma medication has decreased family spends time together at home dancing, walking to nearby destinations and going for family swims Social supports: active with Investing in Families (funds parks and recreation programs) transportation support via OW Family Functioning: children displaying more cooperative behaviour children participate during meal time prep and clean up mom and the children spend more quality time together mom delivering fewer commands as children are aware of their responsibilities
The STOMP Team
Tips for Raising Healthy Eaters • Consistent meal time schedule • Choose filling foods • Comfortable eating environment • Limit milk and sweet drinks • Caregivers decide menu items • Fill the house with healthy foods
The STOMP Team
The four food groups include: • Vegetables & Fruit • Grain Products • Milk & Alternatives • Meat & Alternatives
The balancing act: • Balance meals with 3-4 food groups • Balance snacks with 2-3 food groups
The STOMP Team
The Plate Method
Ensures Balanced Meal with 3-4 Food Groups
The STOMP Team
FIVE WAYS TO BE MORE ACTIVE BOOST THE FUN FACTOR ENCOURAGE MANY DIFFERENT ACTIVITIES FOR
BOTH BOYS AND GIRLS BE A ROLE MODEL MIX IT UP STAY ACTIVE IN ALL KINDS OF WEATHER
The STOMP Team
COMMUNITY CONNECTIONS
STOMP Early Years
Parenting
Ignore and Consequences
Limit Setting and Follow Through
Household Rules and Routines
Social Rewards and Incentives
Academic, Emotion and Social Coaching
Child directed Play
STOMP Early Years
Group Learning Methods Goal setting
Values exercises
Role Play/ Practice
Buzzes
Vignettes
Homework
• Neema and Jay Mertelly, their mother Nila and public health nurse, Maple Cardona get active with the hokey-pokey after dinner. (Deborah Baic /The Globe and Mail)
STOMP Home Visit
STOMP Early Years
Home Visiting
Home environment assessment
Health teaching
Incorporating IY strategies
Linking to community supports
The STOMP Team
Community Resources TPH NURSE REFERRALS SOCIAL WORK REFERRALS
Incredible Years Parenting Series (Chinese Language Series)
Centre for Information and Community Services
Rouge River Ontario Early Years Center
Chinese speaking RD- Scarborough Center for Healthy Communities
Let's Talk Series through IIF
Toronto Parks and Recreation
Welcome Policy
Rexdale Women's Center
Albion Library
North Kipling Community Center
Ontario Early Years Center
Parkway Forest Satellite Early Years Center
Support with Ontario Works worker Jennifer Ashleigh Children’s Charity Rotary Club Patient Amenities funds Big Brothers of Canada Peel CAS Healthy babies, health children & Peel Public Health OW ACSD Transhelp OSAP United Achievers SNAP and Erin Oaks Kids Ronald McDonald House Daycare (with CAS support) Point in Time Ontario Early Years Centre Archie Stouffer Elementary School Family health Team Children’s Aid Society
Outcomes ‘STOMP is like a family to me, they help me so much’
parent quote
• BMI decreased to 20 kg/m2 in 18 months • Cholesterol lower • Treated GERD, improved sleep symptoms • Increased water, whole grains, try vegetables • Stopped multivitamin and increased nutritious foods • Increased active family time together • Support through Investing in families, transportation
STOMP Early Years
Presenter
Presentation Notes
Outcomes Medical: decreased BMI to 22.7 kg/m2 lowered cholesterol decrease asthma attacks sleep improvement Nutrition: drinking primarily water or diluted fruit juice switched to whole grains trying various vegetables eating leaner sources of protein and light dairy products no longer using multivitamins as child is now eating a wider variety of foods from the Canada's Food Guide family sits together during meal time with the TV off mom more aware of her behaviours at meal time Physical activity: Neema has participated in ballet, soccer& swimming lessons endurance has increased need for her asthma medication has decreased family spends time together at home dancing, walking to nearby destinations and going for family swims Social supports: active with Investing in Families (funds parks and recreation programs) transportation support via OW Family Functioning: children displaying more cooperative behaviour children participate during meal time prep and clean up mom and the children spend more quality time together mom delivering fewer commands as children are aware of their responsibilities
STOMP Early Years
Program Outcomes (keep slide?)
BASELINE OUTCOME
BMI z score BMI z score n
6 mos 26.2 6.0 24.9 4.9 7
12 mos 26.1 5.9 25.8 5.1 5
18 mos 28.3 7.3 27.1 5.5 3
STOMP Early Years
2.00
3.00
4.00
5.00
6.00
7.00
8.00
9.00
0 6 12 18
Change in BMI Z-Score BM
I Z-S
core
Months Summary of weight-related outcomes: @ 6 mos -1.3 kg/m2, -1.1 z score (n = 7) @ 12 mos -0.3 , -0.8 z score (n = 5) @ 18 mos -1.2 , -1.8 z score (n = 3)
Discussion • Have participants brainstorm in small groups
what future collaborations between primary care and public health might look like in the area of childhood obesity
• Incorporate barriers that came from the ice breaker activity, how can we work through the barriers?
STOMP Early Years
Lessons Learned • Meet families where they are at
• Access to care • Readiness to participate
• Increasing awareness • Families • Practitioners • Community
• Flexibility in program structure and content • Address individual goals • Customized learning
