Kids In Control OF Food Dr Katherine Price Sheffield Children’s Hospital.

Kids In Control OF Food Dr Katherine Price

Sheffield Children’s Hospital

The KICk-OFF Journey

• Background

• Development

• Pilot

• KICk-OFF RCT

WHO DEALS WITH DIABETES?

Peter Hindmarsh

Patient

School

Health Care Professional

Clinic Setting

Hours spent with diabetes over 3 months

2160

480

12

0.25 - 0.50

Background

• DAFNE study group

• Good outcomes in diabetes control and quality of life from cross over study in adults

British Medical Journal 2002;325(7367):746.

• 2001 – Diabetes UK met with several UK paediatric centres

• Sheffield given task of taking forward paediatric DAFNE

Medical Research Council – A framework for development and evaluation of RCTs for complex interventions to improve health

( www.mrc.ac.uk April 2000, updated 2008)

4 phase approach

1. Theoretical “ Modelling” phase2. Development phase 3. Pilot evaluation4. Randomised controlled trial

Research question:What is the effect of an intensive, structured education course on glycaemic control and quality of life in children with Type 1 diabetes?

• DAFNE is based on model of therapeutic patient education developed in Germany ( Dusseldorf model)

• DAFNE trial in UK demonstrated benefit in 150 adults – improved blood sugar control, improved quality of life, less hypos

• Social learning theory – Bandura

Phase 1 – theoretical modelling

Social Learning Theory – A. Bandura 1977

People learn from one another via:

• observation of behaviour and attitudes

• imitation and adaptation

Requires :

• attention – affected by complexity, functional value

• retention – affected by imagery, organisation

• reproduction - physical capability, self observation

• motivation - reinforced by past and promised incentives

Phase 2 – development

Aim: to produce an education course for children with type 1 diabetes, that - was age appropriate - was acceptable to children and families

- used recognised educational techniques

Julie Knowles - Research nurse, Helen Waller - Psychologist

PDSN survey (Autumn 2002)Journal Of Diabetes Nursing 2005;9:332-339.

Focus groups (Jan. 2003) Child: Care, Health and Development 2005;31(3):283-289.

Lubeck, Germany (Jan. 2004)

How do we develop and implement educational interventions?

• Understand how children learn Educational Theories

• Understand how to teachLearning styles

• Develop a curriculum

How do you learn?

Principles of Adult Learning

• Adults are autonomous and self-directed

• Adults have a wealth of life experiences and knowledge

• Adults are goal orientated

• Adults are relevancy orientated

• Adults are practical

• Adults demand respect from instructors

The adult learner a neglected species. Malcolm Knowles 1994

How do children learn?

“Theories• Behaviourism

Learning from external stimuli. It can be conditioned by giving rewards and punishments

• Piaget – 4 stages of child development. Focused on maturation. Growing up does not mean knowing more but it changes how we think.

• Vygotsky – Learning is a social processLanguage development and learning through interaction with others of same age and older.

• IQ – Focused on the concept of a general intelligence

• Gardener – “multiple intelligences” allowing different learning styles

Muijs et al (2005). Effective Teaching

Working with teachers and educationalists

• Presentation

• Reading age

• Lesson planning

• Specific teaching skills

• Style of teaching (observation)

• Setting boundaries/learning environment

King Edward V11 Secondary School

Lesson planning

A step by step guide to the education session to allow replication by others and achievement of goals

Office For Standards in Education (OFSTED) • Is it clear what the purpose of the lesson is?• Has the lesson taken into account the learners needs?

5 day out patient course for 11-16 yr olds

• 8 per group

• Age banded 11-13 years and 14-16 years

• Modular structure,

• Involves parents and friends

• Variety of teaching styles – very practical and interactive

KICk-OFF course

Transition of care

Living with diabetes School and Diabetes

Hypoglycaemia Monitoring

Insulin management Sick day rules

What is diabetes? Food and diabetes

Modules from the Paediatric KICk-OFF Curriculum

Tuesday Learning objectivesIndividual insulin adjustment practiceContinue with carbohydrate and insulin ratiosFurther skills in counting grams of carbohydrateHypoglycaemia – signs and symptoms, treatment and preventionFeedback to carersContinue with school packs

Today’s programmeSession 1 9.00am-10.30amDiscussion about individual blood glucose levelsHypoglycaemiaBREAKSession 2 10.45am-12.15pmHypoglycaemiaCP/insulin ratioWork out CP’s for lunchPACKED LUNCHSession 3 1.00pm-2.15pmPractical session [cooking] on counting grams of carbohydrate BREAKSession 4 2.30pm-4.00pmPrepare food for parents to practice CHO estimation QuizParents invited to listen. Recap days objectivesPlan evening insulin dose

KICk-OFF curriculum – day 2

Educator Dietitian and nurse

Preparation Transport children to school cookery room. Set up the work stations with foods needed for recipes.

TIME

EDUCATORACTIVITY

STUDENTACTIVITY

MATERIALS

2pm Explain:-This session is a practical session to learn how to work out how much CHO is in the food you prepare.

Group to split into pairs and they are each given a recipe

Response:

Split into pairs but not the same pairs as the morning

Follow recipes

Tidy up after the food is prepared

Complete work sheet

4 recipes for fruit muffinsfruit scones jam and butterscalesPaper platesingredientsutensilsCalculatorsPensFlip chartsWorksheet for estimating CP’s in rice, pasta, potato, cereals.

Day 2, session 4. Counting grams of carbohydrate

TUESDAY

Session 4:-

Counting grams of carbohydrate

Practical session

Learning Objectives

Continue with carbohydrate and insulin ratios

Continuing with learning the skills for counting grams of carbohydrate

Materials

Scales Food ingredientsRecipesFlip chartPens Diaries Work sheets Calculators PlatesKitchen equipmentDigital scalesPots and pansBaking tinsWashing up materials(tea towels, cloths, washing up liquid)

Chocolate Chip Muffins

Ingredients150g/5oz self-raising flour150g/5oz margarine150g/5oz sugar2 eggs75g/3oz chocolate chips100g/3½oz drinking chocolate powder

Session 4 2.30pm-4.00pmPrepare food for parents to practice CHO estimation Quiz

Carbohydrate counting in snacks and recipes

Outcomes over 6 months Educational evaluation Process evaluation Interviews with psychologist

Biomedical – HbA1c, Hypos, BMI

Psychological – quality of life, self efficacy, family conflict etc

Results Good evaluation – some changes to programmeMore parent teaching

HbA1c – unchanged overallImproved in those with poor controlImproved in younger age group

QOL – improved Self efficacy, coping withdiabetes etc improved

Phase 3 –Pilot evaluation

December 2003 - 2004 :

6 courses – 48 young people, age 11-16 yrs from 3 centres

Hands on Learning …

Social Support…

Cooking and Counting Carbs …

Eating Out and Bowling Exercising in the Gym

Improve presentation :

Cell

energy

Phase 4 – randomised controlled trial

In 11-16 year olds on intensive insulin therapy : -

Does the KICk-OFF structured education course affect outcomes, measured over 2 years?

Primary outcome measures: • Biomedical – blood sugar control (HbA1c), hypoglycaemia• Psychological – quality of life, fear of hypoglycaemia, self efficacy

Secondary outcomes• Process evaluation, sustainability of education• Weight, diet • Is it cost effective ?• Website support

Educator training and support

How do we ensure uniformity of teaching in all centres?

Does the curriculum allow key learning points to be achieved?

Can there be flexibility within a curriculum?

How do we support the learning needs of educators?

5 day Educator Training course – Sheffield Hallam University

Quality assurance/ peer review

Trial Design

• Risk of “ contamination of control group in clinic trained to deliver the course – cluster randomisation

• The intervention will be delivered to groups rather than individuals

• Variation between centres –in HbA1c, staffing levels, ethnic & social mix of patients, current educational practise – stratification

Each recruit 16-32 N=560

n= 280 n= 280

15 Control 15 Intervention

30 centres

Centre stratification

KICk-OFF coursesUsual care

Follow up 6,12 & 24 months

KICk-OFF courses5 days 3 educators (2 researchstaff, 1 local) 8 participants 11-13 or 14-16 yrs

• 4 year project from Sept 08

• Martin Fox – project coordinator • Julie Knowles- lead educator

• Project group –Educationalists - Jerry Wellington, Grace Hoskins1

Health Economics – Alan Brennan, Katherine Stephens 1

Psychology – Chris Eiser 1

Clinical – Simon Heller, Jerry Wales1

Statistician – Jenny Freeman1

Website development and evaluation – Amy McPherson2

1 = University of Sheffield, 2 = University of Nottingham

Current priorities

• local R&D/ ethics approval and centre stratification

• recruitment of participants then centre randomisation

• 6 educator posts start Sept 09

• educational material – printing, purchase etc

• website – to support learning of those in KICk-OFF groups

www.kick-off.org.uk

Thank you : • Diabetes UK • Julie Knowles and all the research team • To all the centres participating • Children and families for their support