Healthy Weights Interventions in Aboriginal Children and Youth

C. Towns, M. Cooke, L. Rysdale, and P. Wilk

Canadian Public Health Association May 26 2015

Martin Cooke School of Public Health and Health Systems Department of Sociology and Legal Studies University of Waterloo cooke@uwaterloo.ca www.healthyweightsconnection.ca

Co-Authors and acknowledgements

Lee Rysdale Northern Dietetic Internship Program Claire Towns Dietetic Intern, NODIP Piotr Wilk Schulich School of Medicine and Dentistry

Support provided by CIHR Institute for Aboriginal Peoples’ Health Operating Grant: Understanding Aboriginal Childhood obesity: Trajectories, Contexts and Determinants Public Health Agency of Canada Innovation Strategy: Achieving Healthier Weights in Canada’s Communities

Overweight and obesity among Aboriginal children Socio-ecological perspectives on the problem Research Questions Methods Results Considerations for future intervention

Organization

Willows, N. (2005). Overweight in First Nations Children: Prevalence, implications and Solutions. Journal of Aboriginal Health, 2 (1).

PHAC & CIHI (2011) Obesity in Canada: A joint report from the Public

Health Agency of Canada and the Canadian Institute for Health Information. http://www.phac-aspc.gc.ca/hp-ps/hl-mvs/oic-oac/assets/pdf/oic-oac-eng.pdf.

Evidence about overweight and obesity

PMK-reported obesity for children and youth 6 to 14 (%), 2006

0

5

10

15

20

25

30

First Nations(off-reserve)

Métis Inuit

MalesFemales

2006 Aboriginal Peoples Survey

Social structures

Community context Social cohesion

Built environment Social capital, Culture

Family context

Individual behaviours

Individual biology/genetics

Distal factors

Proximate factors

e.g. Willows, Hanley and Delormier, 2012. A socioecological framework to understand weight-related issues in Aboriginal children in Canada Appl Physiol Nutr Metab. Feb; 37 (1), 1–13.

Research questions What is the evidence regarding successful interventions to reduce overweight and obesity among Indigenous children and youth? What is the site of successful interventions? What are their program elements?

Towns, C. Cooke, M., Rysdale, L., & Wilk, P. 2014. Canadian Journal of Dietetic Practice and Research 75, 3: 125–131.

PICO Terms Search Strategy

Population Aboriginal; Inuit; Métis; First Nations; Native American; Indigenous; North American Indian; Children; Adoles*(cent) (cence); Child; Youth; Preschooler; Toddler: Teen*(s) (agers)

Interventions Prevent*(ive)(ative)(ion);Promotion; Importance; Program; Treatment; Service; Strateg*(y)(ies); Initiatives; Intervention; Action

Comparisons Successful; Effective

Outcomes Overweight; Obese; Healthy Weight

Databases PubMed, Medline, Web of Science, ERIC, PsyINFO, Google Scholar

Electronic search results screened for retrieval (Unique articles: n=75) Pubmed (n=35) Medline (n= 30) Web of Science (n= 17) ERIC (n=29) PyschINFO (n=15)

Reviewed Articles (n=18)

Articles included in review (n= 17) Articles reporting outcome evaluations (n=12) Articles reporting process or formative evaluation (n=5)

Articles excluded after screening title and abstract (n= 57) Out of scope: Focus on other populations, other outcomes or on clinical treatment (n=38) Lack of intervention described (n=16) Lack of evaluation (n=2) Focus of evaluation not on overweight/obesity component (n= 1)

Articles added by hand search (n=4) Published after 2012 search, found by re-search PubMed in June 2013 (n=1) Published pre-2000, presenting evaluation of interventions in reviewed articles (n=3)

Articles excluded after review (n=5) Not focused on intervention (n=2) Report baseline only (n=2) No evaluation results (1)

Evaluation of Studies

Effectiveness Impact Plausibility Fit Change in diets, physical activity, or obesity

Change in knowledge, attitudes or behaviour Change in environmental or policy supports

Participatory approach

Cultural content

Cameron et al. 2001. Health Promot. Pract. 2 (1): 35-42.

Strength of evaluation • Evaluation design • Outcome measures used and results reported

7 interventions 5 in First Nations (Canada) 2 rural/remote 3 in large southern communities 1 urban (US) 1 large multi-site (South Dakota, Arizona, New Mexico) Sites 2 home-based 1 strictly school 1 after school 3 school and community components

Results

Home based 1. Maternal (9 mos-3 years) home visit parenting supports and education re:

diets, screen time behaviour (16 weeks) 2. Local worker visits to families assist with diet and PA goal-setting, provision of

filtered or bottled water (1 year).

School and community-based 1. Classroom lessons on diet/PA, community activities (e.g. walking club),

training of community staff, school nutrition policy, walking paths. 2. Classroom activities, healthy lunch/breakfast program, weekly radio show,

cooking videos, school meal policy. 3. Classroom curriculum, training of teachers and staff, activity kits for families

School-based 1. After-school program (7 months), nutrition, after school dinners 2. Engagement of teachers and administrators, production of action plans re; diet

& PA)

Interventions

Evaluation designs 3 RCT (group or individual randomization) 1 other community as control 3 single-sample pre/post test Follow up ranged 6 months to 8 years Measures Diet: (24h recall, 7-day FFQ, menu analyses) PA/SB: (accelerometers, logs, 7-day recall) KAB: (questionnaires) Overweight, obesity: (ht, wt, skinfold, waist circumference,

bioelectrical impedance, DEXA) Fitness: walk/run tests

Results

Participatory approach: 4/7 Cultural content: 5/7 Knowledge, attitudes: 4/5 Environmental supports: 3/7 Impact • Physical activity: 0 of 6 • Diet: 4 of 7 • Fitness: 1 of 2 (walk-run test) • Obesity/adiposity: 1 of 7 (not sustained)

Results

There was no real evidence of sustained impact on BMI or adiposity. No evidence of effectiveness in increasing physical activity, some effectiveness improving diet. Some projects improved knowledge and attitudes.

Conclusions

Why are these results so disappointing? Similar results in other contexts (Waters et al. 2011) Duration? Power of contextual factors relative to program components?

1. Attention to urban, Métis and Inuit contexts 2. Are we focussing on the right outcomes? 3. Are we focussing at the right level?

Considerations for future interventions and evaluations