Kids In Control OF Food

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Kids In Control OF Food

• Dr Katherine Price
• Sheffield Childrens Hospital

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The KICk-OFF Journey

• Background
• Development
• Pilot
• KICk-OFF RCT

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WHO DEALS WITH DIABETES?
Hours spent with diabetes over 3
months 2160 480 12 0.25 - 0.50
Patient
School
Health Care Professional
Clinic Setting
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Background

• DAFNE study group
• Good outcomes in diabetes control and quality of
  life from cross over study in adults
• British Medical Journal 2002325(7367)746.
• 2001 Diabetes UK met with several UK paediatric
  centres
• Sheffield given task of taking forward paediatric
  DAFNE

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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?

• 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
• Theoretical Modelling phase
• Development phase
• Pilot evaluation
• Randomised controlled trial

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Phase 1 theoretical modelling

• 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

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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

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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 20059332-339.
• Focus groups (Jan. 2003)
• Child Care, Health and Development
  200531(3)283-289.
• Lubeck, Germany (Jan. 2004)

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How do we develop and implement educational
interventions?

• Understand how children learn
• Educational Theories
• Understand how to teach
• Learning styles
• Develop a curriculum

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How do you learn?
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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
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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 process
• Language 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

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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
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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?

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KICk-OFF course

• 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

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Modules from the Paediatric KICk-OFF Curriculum
What is diabetes? Food and
diabetes
Insulin management Sick day
rules
Hypoglycaemia
Monitoring
Living with diabetes School and
Diabetes
Transition of care
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KICk-OFF curriculum day 2
Tuesday Learning objectives Individual insulin adjustment practice Continue with carbohydrate and insulin ratios Further skills in counting grams of carbohydrate Hypoglycaemia signs and symptoms, treatment and prevention Feedback to carers Continue with school packs Todays programme Session 1 9.00am-10.30am Discussion about individual blood glucose levels Hypoglycaemia BREAK Session 2 10.45am-12.15pm Hypoglycaemia CP/insulin ratio Work out CPs for lunch PACKED LUNCH Session 3 1.00pm-2.15pm Practical session cooking on counting grams of carbohydrate BREAK Session 4 2.30pm-4.00pm Prepare food for parents to practice CHO estimation Quiz Parents invited to listen. Recap days objectives Plan evening insulin dose
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Educator Educator Dietitian and nurse Dietitian and nurse Dietitian and nurse
Preparation Preparation Transport children to school cookery room. Set up the work stations with foods needed for recipes. Transport children to school cookery room. Set up the work stations with foods needed for recipes. Transport children to school cookery room. Set up the work stations with foods needed for recipes.
TIME EDUCATOR ACTIVITY EDUCATOR ACTIVITY STUDENT ACTIVITY 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 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 muffins fruit scones jam and butter scales Paper plates ingredients utensils Calculators Pens Flip charts Worksheet for estimating CPs in rice, pasta, potato, cereals.
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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 ingredients Recipes Flip chart Pens Diaries Work sheets Calculators Plates Kitchen equipment Digital scales Pots and pans Baking tins Washing up materials (tea towels, cloths, washing up liquid)
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Carbohydrate counting in snacks and recipes
Chocolate Chip Muffins Ingredients150g/5oz
self-raising flour150g/5oz margarine150g/5oz
sugar2 eggs75g/3oz chocolate chips100g/3½oz
drinking chocolate powder
Session 4 2.30pm-4.00pm Prepare food for parents
to practice CHO estimation Quiz
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Phase 3 Pilot evaluation
December 2003 - 2004
6 courses 48 young people, age 11-16 yrs from 3
centres
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
programme More parent teaching
HbA1c unchanged overall Improved in those with
poor control Improved in younger age group QOL
improved Self efficacy, coping with diabetes etc
improved
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Hands on Learning
Social Support
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Cooking and Counting Carbs
Exercising in the Gym
Eating Out and Bowling
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Improve presentation
Cell
energy
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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

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Educator training and support
5 day Educator Training course Sheffield
Hallam University
Quality assurance/ peer review
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?
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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

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30 centres
KICk-OFF courses 5 days 3 educators (2
research staff, 1 local) 8 participants 11-13 or
14-16 yrs
Each recruit 16-32 N560
Centre stratification
n 280
n 280
15 Control
15 Intervention
KICk-OFF courses
Usual care
Follow up 6,12 24 months
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• 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

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• Current priorities
• local RD/ 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

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

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