The KICk-OFF study (Kids In Control Of Food) Progress towards a structured education programme Julie Knowles/Dr Kath Price Sheffield Children’s NHS Trust

Diabetes UK and Department of Health 2005 Recommendations/guidelines Diabetes NSF 2001 NICE 2004 and 2004 Evidence based Clear aims and objectives To meet personal learning needs Trained educators Structured Quality assured and audited Diabetes UK and Department of Health 2005 DUK and DH highlighted a gap in the delivery of such education to children and adolescents and now provides quality standards for education programmes ………………….

DAFNE – Dose Adjustment for Normal Eating for Adults 5 day structured training programme 4-5 injections a day 4-5 blood tests a day Free diet Insulin dose to match carbohydrate intake Reduce HbA1c Improved QOL DH has highlighted one programme that meets the criteria for type 1 diabetes …………

Paediatric KICk-OFF course research project Phase 1 – 2002 -Development of a curriculum Funded by Sheffield Children’s Appeal Phase 2 – 2004 - Pilot courses, refinement of curriculum Grant from DUK Phase 3 - Multicentre Randomised Control Trial To be funded by DUK awaiting confirmation of start date

Development of the KICk-OFF curriculum PDNS survey (Autumn 2002) Focus groups (Jan. 2003 Comparing current education programmes with DAFNE ) Lubeck, Germany (Jan. 2004) School teachers

Working with school teachers DAFNE to KICk-OFF National schools curriculum “Intellectual development” - growth in pupils knowledge understanding and skill “ Social development” - growth in self esteem, self confidence, greater maturity 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?

Working with school teachers Style of teaching (observation) Lesson planning Specific teaching skills Presentation Setting boundaries/learning environment Reading age

Introduction to the course Monday Tuesday Wednesday Thursday Friday Introduction to the course What is diabetes? Group discusses blood sugar levels Hypoglycaemia Discuss overnight blood sugar levels. How to adjust insulin Discuss blood sugar levels Healthy eating/weight control Sweets, treats and snacks [Friends invited] Discuss overnight blood sugar levels. Friends recap what is diabetes Everyone discusses using Kick-Off in school Break Signs and symptoms, Insulin Types of food and CP’s CP booklet and diary Insulin/CHO relationship Hypoglycaemia and Kick-off treatment CP/insulin ratio Work out CP’s for packed lunch How to manage illness using KICkOFF guidelines Alcohol and social issues Poster display Exercise [theory] Managing hypos in and out of school Puberty awareness and control What happens next? Follow-up after the course Discuss school packs Recap weeks learning objectives Evaluation Lunch Packed lunch Lunch - buffet Insulin/CHO continued Correction dose Monitoring Practicing counting grams of CHO + practical Diabetes and long term health discussion Healthy lifestyle vs unhealthy Exercise Practical session. Parents will discuss follow-up care, discussion about the week and continued support Children do fun activity Millionaire game Recapping the days objectives Plan evening insulin dose. Personal interviews Practical session continued Quiz Prepare food for parents Recap objectives of the day Plan evening insulin dose Students to plan evening insulin dose Free session for guest speaker or other activity Continued Presentation of quiz winners Finish

Day 2, session 2. Counting grams of carbohydrate TUESDAY Session 2:- 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)

Group to split into pairs and they are each given a recipe Response: Educator Dietitian and nurse Preparation Transport children to school cookery room. Set up the work stations with foods needed for recipes. TIME EDUCATOR ACTIVITY STUDENT MATERIALS 11am 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 CP’s in rice, pasta, potato, cereals.

Pilot Study 2004 8 per course, 11-13 and 14-16 yr 2 research educators and 1 local educator 3 Paediatric centres Sheffield, Manchester and Derby Training the trainers course Sheffield Hallam University 3 days (2 theory, 1 practical)

EVALUATION Teaching, curriculum, course format : independent peer review interview daily feedback questionnaire Effectiveness: HbA1c pre course , 3 and 6 months hypoglycaemia rates BMI Psychological outcome at 0, 2 weeks, 3 and 6 months QoL Satisfaction with treatment family conflict self management responsibility self efficacy

Table 1. Mean HbA1c Values Over Time Baseline 3-months 6-months Mean (sd) 8.58 (1.80) 8.72 (1.98) 8.69 (1.98) More mild hypo’s No more moderate or severe hypo episodes No significant change BMI

QOL: Diabetes QOL: Generic Children F(3,81)=8.00,p=.0001*** Parents

Psychosocial Outcomes for child and parent Satisfaction with Treatment: Greater satisfaction with diabetes treatment after the course. Self-Efficacy: Children more confident managing their diabetes after the course. Family Conflict: no significant change (minimal before and after course). Parent-child Responsibility: more responsibility for managing diabetes after the course. Coping with Diabetes: more able to cope after the course.

Changes to the course: Venue Timings of difficult sessions- in the first 2 sessions More practical sessions Specific parent teaching – 1 day teaching course Improved school support Follow-up Interactive booklet More CHO/Ratio practice 5 day skills training programme for educators

Multi-centre cluster randomised controlled trial comparing intensive education with standard education in 11-16 year olds on intensive insulin therapy. Sponsored by DUK 36 UK paediatric diabetes clinics (576 total participants) 18 intervention/18 control – both using MDI 2 year follow-up Control group receives skills training course and KICk-OFF curriculum Outcomes measured at 0, 6, 12, 24 months:- HbA1c Psychological outcomes Hypoglycaemia episodes DKA BMI Diet related behaviours