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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.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.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 less concerns on DRQoL domains than those in the comparison group. Participation in the intervention group, however, did not lead to improvements in A1C.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.

Background and objectives As hospital-based pediatric clinicians and researchers, we conducted engagement with representatives from public, private, and nonprofit organizations in the Peel Region of Ontario. Objectives were to build relationships and inform research, education, innovation, and programming to improve the health of local children, youth, and families (CYF). Method Relevant public, private, and nonprofit organizations were identified through an extensive environmental scan. Semistructured interviews and focus groups were conducted with front-line, managerial, and executive representatives. Analysis consisted of thematic analysis and quantitative content analysis. All participants were invited to a 1-day community networking event to discuss the engagement findings and brainstorm next steps. Results Final sample was n = 155 individuals from n = 61 organizations. The community networking event included n = 45 participants from n = 41 organizations. Participants identified the top three health issues facing families as: (a) mental health and wellbeing (63%); (b) socioeconomic insecurity (52%); (c) lack of physical activity (43%). Major themes included: holistic health and wellness; equity and sociocultural dimensions of health; cross-sector/organizational collaboration and integration; need for inclusive, action-oriented, and participatory approaches. Conclusions Insights from these engagement activities led to the development of a community-based participatory research (CBPR) approach to CYF health in Peel. In this article we posit CBPR and a population health approach can come together in research and care to prioritize equity, collaboration, and active participation in a community-wide approach to CYF health. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Background 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. 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 3 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 adolescent 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. This article is protected by copyright. All rights reserved.

To assess stakeholder ratings of health indicators and subgroup analyses in systematic reviews used to update the Canadian Clinical Practice Guideline for Managing Paediatric Obesity.Stakeholders (caregivers of children with obesity and Clinical Practice Guideline Steering Committee members) completed an online survey between April 2020 and March 2021. Participants rated importance of health indicators and subgroup analyses for behavioural and psychological, pharmacotherapeutic, and surgical interventions for managing paediatric obesity from not important to critically important using Grading, Recommendations, Assessment, Development and Evaluation criteria.No health indicators or subgroup analyses were rated not important by the 30 caregivers and 17 Steering Committee members. Across intervention types, stakeholders rated anxiety, depression, health-related quality of life, serious adverse events, plus age and weight status subgroups as critically important.Stakeholder ratings will inform data reporting and interpretation to update Canada's Clinical Practice Guideline for Managing Paediatric Obesity.

PurposeIn Canada, integrated care pilot projects are often implemented as a local reform strategy to improve the quality of patient care and system efficiencies. In the qualitative study reported here, the authors explored the experiences of healthcare professionals when first implementing integrated care pilot projects, bringing together physical and mental health services, in a community hospital setting.Design/methodology/approachEngaging a qualitative descriptive study design, semi-structured interviews were conducted with 24 healthcare professionals who discussed their experiences with implementing three integrated care pilot projects one year following project launch. The thematic analysis captured early implementation issues and was informed by an institutional logics framework.FindingsThree themes highlight disruptions to established logics reported by healthcare professionals during the early implementation phase: (1) integrated care practices increased workload and impacted clinical workflows; (2) integrating mental and physical health services altered patient and healthcare provider relationships; and (3) the introduction of integrated care practices disrupted healthcare team relations.Originality/valueStudy findings highlight the importance of considering existing logics in healthcare settings when planning integrated care initiatives. While integrated care pilot projects can contribute to organizational, team and individual practice changes, the priorities of healthcare stakeholders, relational work required and limited project resources can create significant implementation barriers.

Many patients with Type 2 Diabetes (T2D) have difficulty in controlling their disease despite wide-spread availability of high-quality guidelines, T2D education programs and primary care follow-up programs. Current diabetes education and treatment programs translate knowledge from bench to bedside well, but underperform on the 'last-mile' of converting that knowledge into action (KTA). Two innovations to the last-mile problem in management of patients with T2D are introduced. 1) Design of a platform for peer-to-peer groups where patients can solve KTA problems together in a structured and psychologically safe environment using all the elements of the Action Cycle phase of the KTA framework. The platform uses Self-Determination Theory as the behavior change theory. 2) A novel patient segmentation method to enable the formation of groups of patients who have similar behavioral characteristics and therefore who are more likely to find common cause in the fight against diabetes.

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.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.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.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.

Our study purpose was to determine the prevalence of metabolically healthy obesity (MHO) and examine factors associated with MHO in children with obesity. This cross-sectional study was a secondary, exploratory analysis of data that included 2-17 years old with a body mass index (BMI) ≥85th percentile from the CANadian Pediatric Weight management Registry. Children were classified as having MHO or metabolically unhealthy obesity (MUO) using consensus-based criteria. Those with MHO had normal triglycerides, high-density lipoprotein cholesterol, blood pressure, and fasting glucose. Logistic regression was used to examine factors associated with MHO, which included calculating odds ratios (ORs) and 95% confidence intervals (CIs). In total, 945 children were included (mean age: 12.3 years; 51% female). The prevalence of MHO was 31% (n = 297), with lower levels across increasing age categories (2-5 years [n = 18; 43%], 6-11 years [n = 127; 35%], 12-17 years [n = 152; 28%]). Children with MHO were younger, weighed less, and had lower BMI z-scores than their peers with MUO (all p

Summary Background Disease severity in paediatric obesity is usually defined using the body-mass index (BMI). Although informative at the population level, its usefulness on an individual level has limitations. The use of a clinical staging system—Edmonton Obesity Staging System for Pediatrics (EOSS-P)—in identifying health risk has been proposed. This study aimed to examine the association between BMI class and EOSS-P stage. Methods This cross-sectional study was done in children with obesity aged 5–17 years who enrolled in the Canadian Pediatric Weight Management Registry (CANPWR) between May 31, 2013, and Oct 27, 2017, involving ten multidisciplinary paediatric weight management clinics in Canada. We classified participants into WHO BMI classes (class I as 2–3 SD scores, class II as >3 SD scores, and class III as >4 SD scores above the WHO growth standard median), and applied the EOSS-P staging system (stages 0, 1, and 2/3) based on the clinical assessment of coexisting metabolic, mechanical, mental health, and social milieu issues. Clinical information was extracted from medical records and reported using standardised case report forms. Associations of BMI class with EOSS-P stage were examined in children with complete data. Findings Of the 847 children with complete data, 546 (64%) had severe obesity based on BMI class (ie, class II or III) and 678 (80%) were EOSS-P stage 2/3. Stage 2/3 obesity-related health issues were common; mental health concerns were most common (520 [61%] of 847 children), followed by metabolic (349 [41%] of 847 children), social milieu (179 [21%] of 847 children), and mechanical (86 [10%] of 847 children) health issues. Mental health issues (eg, anxiety and attention-deficit hyperactivity disorder) were equally distributed across BMI classes, metabolic health issues were slightly more common in higher BMI classes, and mechanical (eg, musculoskeletal issues and sleep apnoea) and social milieu (eg, bullying and low household income) issues increased with increasing BMI class. Of children with class I obesity, 206 (76%) of 270 had overall EOSS-P stage 2/3, compared with 195 (85%) of 229 with class III obesity. Interpretation Physical and mental health issues were highly prevalent among children with obesity irrespective of BMI class. Participants with class III obesity carried the greatest health risk across subcategories of the EOSS-P. As BMI class increased, a concomitant increased disease burden in mechanical and social milieu issues was observed, whereas metabolic and mental health risks were high across BMI classes. Funding Canadian Institutes of Health Research, Ontario Ministry of Health, McMaster University, and McMaster Children's Hospital.

Background: Clinical practice guidelines for pediatric weight management highlight the importance of family-based behavioral strategies to enhance health behaviors. Little is known, however, of how clinics implement these programs. The study objectives were to (1) describe how Canadian pediatric weight management clinics deliver care and (2) evaluate change in services over time. Methods: The CANadian Pediatric Weight management Registry (CANPWR) is a multisite prospective cohort study of participants enrolled in a Canadian pediatric weight management clinic. Clinical program characteristics (e.g., referral process, inclusion criteria, funding, program characteristics, patient interaction methods, and follow-up) were collected at the start and end of the CANPWR recruitment period (2015-2019). Results: Entrance into the nine clinics varied with limiting criteria based on geographic proximity, age, weight status, and presence of health conditions. The clinics varied in size (50-220 new patients/year). The planned length of intervention varied widely, from 10 weeks to open-ended (median 2 years). Behavior modification strategies were delivered with a mix of individual and group-based sessions and most were delivered in person, complemented by use of virtual care. Over time, more clinics saw patients under the age of 5 years and all clinics defined a program length. Conclusion: Although all clinics offered family-based behavioral weight management services, these varied considerably, especially in program entrance criteria, size of clinic, and the length of intervention. The influence of the variability in delivery of services on health outcomes will be addressed in future studies.

Social networks influence the health and well-being of children and families. This study aimed to identify and understand the social networks of caregivers of children participating in the KidFit Health and Wellness Clinic, a paediatric weight management program. An egocentric social network analysis was used. Caregivers with children enrolled in KidFit participated in semi-structured interviews by completing a personal network map and discussing the individuals in their social networks and their influence on them and their family. Twenty-two caregivers (90.9% mothers) completed the interview. Four structural patterns were identified within the networks: existence of a core, star-shaped network, well-connected network and existence of multiple clusters. Healthcare providers and family had the most influence within the caregivers' networks. With the exception of healthcare providers, individuals who communicated less frequently with caregivers tended to have less influence on caregivers. Internet resources, activity-related resources and social media were the top three services, resources or supports that caregivers reported accessing. It is important that practitioners working with children and families within paediatric settings recognize the unique sociocultural context of each family. Reconceptualising a care model that includes community and incorporates services, supports and resources beyond the clinic could enhance treatment.

OBJECTIVE To conduct a systematic review of the literature for strategies designed to reduce attrition in managing paediatric obesity. METHODS We searched Ovid Medline (1946 to May 6, 2020), Ovid Embase (1974 to May 6, 2020), EBSCO CINAHL (inception to May 6, 2020), Elsevier Scopus (inception to April 14, 2020), and ProQuest Dissertations & Theses (inception to April 14, 2020). Reports were eligible if they included any obesity management intervention, included 2 to 18 year olds with overweight or obesity (or if the mean age of participants fell within this age range), were in English, included experimental study designs, and had attrition reduction as a main outcome. Two team members screened studies, abstracted data, and appraised study quality. RESULTS Our search yielded 5,415 original reports; six met inclusion criteria. In three studies, orientation sessions (n = 2) and motivational interviewing (MI) (n = 1) were used as attrition-reduction strategies before treatment enrollment; in three others, text messaging (n = 2) and MI (n = 1) supplemented existing obesity management interventions. Attrition-reduction strategies led to decreased attrition in two studies, increased in one, and no difference in three. For the two strategies that reduced attrition, (a) pre-treatment orientation and (b) text messaging between children and intervention providers were beneficial. The quality of the six included studies varied (good [n = 4]; poor [n = 2]). CONCLUSION Some evidence suggests that attrition can be reduced. The heterogeneity of approaches applied and small number of studies included highlight the need for well-designed, experimental research to test the efficacy and effectiveness of strategies to reduce attrition in managing paediatric obesity.

Purpose of ReviewThis manuscript describes how person-reported outcomes (PROs) can be utilized in care for young people with diabetes in the context of motivation.Recent FindingsThe 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.SummaryUnderstanding 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.

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 β = -0.10; 95% CI [-0.15, -0.05], p = 0.0001), hours per week of organized physical activity (estimated β = -0.32; 95% CI [-0.53, -0.11], p = 0.0026), daily sugared drink intake (estimated β = 0.06; 95% CI [0.01, 0.10], p = 0.0136) and maternal BMI (estimated β = 0.03; 95% CI [0.02, 0.04], p

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. 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. 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. 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. 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.

Objective: To describe an approach using principles of experience-based codesign (EBCD) and quality improvement (QI) to integrate family experience into the development of a pediatric weight management program. Methods: Clinic development occurred in 3 plan, do, study, act (PDSA) cycles that were driven by family experience data. During these cycles, families were engaged in feedback sessions that informed program development. Staff reflected on feedback and designed and tested changes that would improve service delivery. Results: The first PDSA cycle resulted in the fundamental program parameters and a formalized patient engagement strategy. The second cycle focused on pilot programming, and feedback was used to develop the structured group program. During the third cycle, feedback sessions were embedded into the structured group programs. Program changes included focusing on health rather than weight-based outcomes, adjusting the timing of program offerings, increasing experiential learning opportunities, and providing more opportunities for peer support. Conclusions: Both EBCD and QI methodologies informed the process of family engagement and program development. This pragmatic approach might be useful for the development of other family-centered pediatric programs.

To incorporate the perspectives and experiences of family caregivers of children with obesity, the KidFit Health and Wellness Clinic, a paediatric weight management programme, embedded feedback opportunities into various stages of programme development. Caregivers were eligible to participate if their children had completed initial 4-week group-based pilot programming or were currently receiving treatment in 10 or 12 week group-based programming. Data were collected through feedback session discussions, audio-recorded, transcribed verbatim and analysed thematically. In total, 6 caregivers participated in the pilot group feedback session and 32 caregivers participated in the structured group feedback sessions. Caregivers reported that healthy lifestyle strategies first communicated by clinic staff to children during group sessions provided expert validation and reinforcement when discussing similar messages at home. Caregivers reported feeling isolated and blamed for causing their children's obesity and appreciated the supportive forum that group-based programming provided for sharing experiences. Since experiences of blame and isolation can burden caregivers of children with obesity, paediatric weight management programmes might consider including peer support opportunities and discussion forums for ongoing social support in addition to education about lifestyle change.

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. Electronic supplementary material The online version of this article (10.1186/s12887-018-1208-6) contains supplementary material, which is available to authorized users.

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.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.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.Participants were 247 children and adolescents (45.3% male, mean BMI z-score = 3.4 ± 1.0 kg/mDistinct 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.

Objective To evaluate the association between breastfeeding duration and early childhood cardiometabolic risk. Study design A cross-sectional study of 1539 healthy children, 3-6 years of age, recruited through The Applied Research Group for Kids! practice-based research network between October 2009 and August 2015. Adjusted multivariable linear regression was used to examine the association between breastfeeding duration and cardiometabolic risk z score and individual cardiometabolic risk factors of waist circumference, systolic blood pressure, glucose, high-density lipoprotein cholesterol, and triglycerides. Results The mean breastfeeding duration was 12.5 months (SD = 8.4). Breastfeeding duration was associated with lower cardiometabolic risk z score (beta = −0.03; 95% CI −0.05, −0.01). In analysis of cardiometabolic risk factors, each additional 3 months of breastfeeding was associated with a 0.13 cm (95% CI −0.20, −0.05) lower waist circumference and 0.16 mm Hg (95% CI −0.30, −0.02) lower systolic blood pressure. Compared with children who breastfed for 6-12 months, those who breastfed for 12-24 months had a lower systolic blood pressure of 1.07 mm Hg (95% CI −2.04, −0.10). There was no association between breastfeeding duration and cardiometabolic risk for those who breastfed beyond 24 months. Conclusions Breastfeeding duration is associated with lower cardiometabolic risk, although the magnitude of association is small. Causation cannot be inferred. Breastfeeding beyond 24 months may not have an added benefit for cardiometabolic health.