Paula Brauer

Recommendations on screening for cervical cancer

cervical cancer were diagnosed in Canada, with about 350 deaths. The number of cases of diagnosed cervical cancer in creases among women aged 25 years and older, peaking during the fifth decade of life (Figure 1). The incidence of and mortality due to cervical cancer in Canada have decreased substantially in the past 50 years, and long-term survival rates after treatment are high. Lifetime incidence was 1.5% in 1972, and is now 0.7%; risk of death from cervical cancer is now 0.2%. Most advanced cervical cancer (and associated mortality) occurs among women who have never undergone screening or who have had a long interval between Papanicolaou (Pap) tests. Screening for cervival cancer using the Pap test detects precursor lesions, thereby allowing earlier and potentially less invasive treatment than is re quired for disease that causes symptoms. The benefits of such screening on the incidence of invasive disease and death due to cervical cancer have been consistently shown in cohort and case–control studies. It is likely that much of the change seen in the incidence of cervical cancer in Canada is due to screening, but early and frequent (often annual) cervical screening is unnecessary: other countries have achieved similar outcomes with less frequent testing and starting screening at older ages. The similar levels of success with different approaches highlights uncertainties regarding the best ages at which to start and stop screening, screening intervals and screening methods. Furthermore, the benefits of screening must be balanced against its potential harms, such as additional follow-up tests for abnormal results and unnecessary treatment (e.g., owing to false -positives and overdiagnosis). The likelihood of abnormal Pap test results is highest for young women, and decreases with increasing age. Because the prevalence of highgrade abnormalities declines steadily with age, al though the incidence of cancer is higher, the proportion of abnormal results that represent serious abnormalities is greater among older women. Women whose initial Pap test result is abnormal may be asked to undergo a repeat test or have a colposcopy. The colposcopist may then biopsy the cervix. If the biopsy shows cervical intra epithelial neoplasia, the colposcopist may then treat the cervix by excising the transformation zone using various methods. These procedures cause short-term pain, bleeding and discharge, and may cause early loss of future pregnancies or premature labour. It is likely that many of these procedures can be considered overtreatment, because fewer than one-third of even high-grade abnormalities progress to cancer. This guideline provides updated recommendations for screening for cervical cancer in Canada based on new information about the epidemiology and diagnosis of cervical cancer and a new systematic search of the literature. This guideline updates the recommendations of the Canadian Task Force on Preventive Health Care that were last revised in 1994. Recommendations are presented for the use of Pap tests for women with no symptoms of cervical cancer who are or who have been sexually active, regardless of sexual orientation. Separate recommendations are provided for screening in women in the following age categories: younger than 20 years, 20–24 years, 25–29 years, 30– 69 years and 70 years or older. Re com mend ations Recommendations on screening for cervical cancer

Recommendations on screening for type 2 diabetes in adults.

ans (6.8%) had either type 1 or type 2 diabetes, and an additional 480 000 (1.4%) were unaware that they were affected. The most recent Canadian data indicate that, from 1998/99 to 2008/09, the prevalence of diagnosed diabetes increased by 70% (Figure 1). The greatest relative increase in prevalence was seen in the age groups 35–39 and 40–44 years, in which the proportion doubled. In 2008/09, almost 50% of people with newly diagnosed diabetes were 45–64 years old (Figure 2). Substantial increases in prevalence are projected over the next decade. Because type 1 diabetes is much less common than type 2 diabetes and is generally symptomatic, we focused on type 2 diabetes in these guidelines. Laboratory values used to define the diagnosis of diabetes have become more inclusive over time (Appendix 1). In 2002, a new diagnostic category (now commonly known as prediabetes) was created to describe patients at very high risk of diabetes. More recently, glycated hemoglobin (herein referred to as A1C), which reflects an individual’s average plasma glucose level over the previous 2–3 months, has been accepted as an alternative diagnostic test for type 2 diabetes. Long-term consequences of type 2 diabetes include microvascular (retinopathy, nephropathy, neuropathy) and macrovascular (stroke, myocardial infarction) complications. An estimated 65%–80% of people with diabetes will die of a cardiovascular event, many without prior signs or symptoms of cardiovascular disease. Type 2 diabetes is a prevalent and costly chronic illness that demands lifestyle interventions, effective monitoring and pharmacologic management. Management of risk factors, including physical inactivity, blood pressure and blood lipid levels as well as blood glucose levels, is required to prevent long-term complications. Uncertainties remain about how best to prevent diabetes, the relative benefits of population screening and risk assessment, the ideal frequency of screening in high-risk populations and the potential harms of screening. This document updates the 2005 Canadian Task Force on Preventive Health Care recommendations on screening asymptomatic adults for type 2 diabetes. It does not apply to people with symptoms of diabetes or those who are at risk of type 1 diabetes.

Recommendations for prevention of weight gain and use of behavioural and pharmacologic interventions to manage overweight and obesity in adults in primary care

The prevalence of obesity in adults has increased worldwide and has almost doubled in Canada, from 14% in 1978/79[1][1] to 26% in 2009–2011,[2][2] with 2% of men and 5% of women having a body mass index (BMI) score greater than 40 (Appendix 1, available at [www.cmaj.ca/lookup/suppl/doi:10.1503/

Recommendations for growth monitoring, and prevention and management of overweight and obesity in children and youth in primary care

The prevalence of obesity in Canadian children has risen dramatically from the late 1970s, more than doubling among both boys and girls.1 Based on growth curves generated by the World Health Organization, the prevalence of overweight and obesity in Canadian children aged 2 to 17 years in 2004 was about 35%.1,2 More recent estimates from 2009 to 2011 based on measured weight and height for children aged 5 to 17 years suggest that 32% are overweight (20%) or obese (12%), with the prevalence of obesity almost twice as high in boys (15%) than in girls (8%)3 (Appendix 1, available at www.cmaj.ca/lookup/suppl /doi :10.1503/cmaj.141285/-/DC1). Studies suggest that excess weight in children often persists into adulthood.4–6 Childhood obesity is associated with an increased risk of cardiovascular disease and diabetes in adolescence7 and later in life.8,9 It is now recognized that obesity is a complex problem that will require action from multiple sectors and “systems thinking.”10 Within primary care, the chronic disease model has been proposed as a framework for managing obesity, supporting children and families to manage body weight over time.10 For childhood obesity, the complexity may include parents’ knowledge, parenting style and the family activity environment.11 Whereas options for management of childhood obesity include behavioural, pharmacologic and surgical approaches offered or referred by primary care,10 it is recognized that interventions must be familycentred and may involve services delivered by an interdisciplinary team.11 The 2006 Canadian Clinical Practice Guidelines on the Management and Prevention of Obesity in Adults and Children provided recommendations for the prevention and management of obesity in Canadians of all ages.12 The last task force guidance specifically on childhood obesity was in 1994; it focused on screening for and treatment of obesity in children, but did not address primary prevention.13 The current guideline provides recommendations for growth monitoring and prevention of overweight and obesity in healthy-weight children and adolescents aged 17 years and younger in primary care settings, and guidance for primary care practitioners on the effectiveness of overweight and obesity management in children and youth aged 2 to 17 years.

Use of electronic dietary assessment tools in primary care: an interdisciplinary perspective

BackgroundDietary assessment can be challenging for many reasons, including the wide variety of foods, eating patterns and nutrients to be considered. In team-based primary care practice, various disciplines may be involved in assessing diet. Electronic-based dietary assessment (e-DA) instruments available now through mobile apps or websites can potentially facilitate dietary assessment. Providers views of facilitators and barriers related to e-DA instruments and their recommendations for improvement can inform the further development of these tools. The objective of this study was to explore provider perspectives on e-DA tools in mobile apps and websites.MethodsThe exploratory sequential mixed methods design included interdisciplinary focus groups followed by a web-based survey sent to Family Health Teams throughout Ontario, Canada. Descriptive and bivariate analyses were completed. Focus group transcripts contributed to web-survey content, while interpretive themes added depth and context.Results11 focus groups with 50 providers revealed varying perspectives on the use of e-DA for: 1) improving patients’ eating habits; 2) improving the quality of dietary assessment; and, 3) integrating e-DA into the care process. In the web-survey 191 respondents from nine disciplines in 73 FHTs completed the survey. Dietitians reported greater use of e-DA than other providers (63% vs.19%; p = .000) respectively. There was strong interest among disciplines in the use of e-DA tools for the management of obesity, diabetes and heart disease, especially for patient self-monitoring. Barriers identified were: patients’ lack of comfort with using technology, misinterpretation of e-DA results by patients, time and education for providers to interpret results, and time for providers to offer counselling.Conclusionse-DA tools in mobile apps and websites may improve dietary counselling over time. Addressing the identified facilitators and barriers can potentially promote the uptake of e-DA into clinical practice.

Recommendations on screening for developmental delay

CMAJ 2016. DOI:10.1503 /cmaj.151437 Developmental delay in children may be transitory or sustained and is characterized by a significant delay (i.e., performance 1.5 standard deviations or more below age-expected norms) in one or more of the following domains: gross and fine motor skills, speech and language, social and personal skills, activities of daily living and cognition.1,2 Children with sustained developmental delay are at higher risk of learning difficulties, behavioural problems and functional impairments later in life.2,3 Many factors are associated with increased risk of developmental delay, including poor maternal health during pregnancy, birth complications, infections, genetic characteristics, exposure to toxins, trauma, maltreatment and possibly low socioeconomic status.1,3–7 There is considerable interest in the possibility that early identification and intervention may improve health outcomes among children with developmental delay.1,8,9 Population-based screening of all preschool children has been proposed to facilitate early identification and treatment. For example, the province of Ontario recommends developmental screening of all children at 18 months,10 and the American Academy of Pediatrics recommends developmental screening at 9, 18 and 30 months and autism screening at 24 and 30 months.11,12 The Canadian Task Force on Preventive Health Care assessed the evidence on the effectiveness of populationbased screening for developmental delay in primary care settings. To inform the resulting recommendations, the task force also assessed evidence on the accuracy of screening tools to identify undetected developmental delay and the effectiveness of behavioural interventions.

Defining Malnutrition Risk For Older Home Care Clients

PURPOSE The Resident Assessment Instrument-Home Care (RAI-HC) is widely used to assess needs of home care clients and includes five items used to screen for malnutrition. This study involved defining malnutrition risk and identifying other items within the RAI-HC that might improve malnutrition screening among adults aged 65 or older receiving home care. METHODS A literature review, three focus groups of community care access centre case managers (n=29), and five key informant interviews with registered dietitians were used to identify malnutrition risk factors and indicators. A nominal group (n=5) was used to rank RAI-HC malnutrition risk items. Data were charted and integrated to create the final list of potential risk factors. RESULTS Seven malnutrition indicators (dietary intake, appetite, dysphagia, nutrition support, end-stage disease, weight status, and fluid intake) and seven risk factors (health status, functional ability, self-reported poor health, mood status, social function, cognitive performance, and trade-offs) were considered important concepts in the construct of malnutrition for older home care clients. CONCLUSIONS These items identified through divergent methods form the basis for developing a screening-for-malnutrition-risk tool for home care.

Dietary education tools for South Asians with diabetes.

Purpose: South Asian immigrants to Canada are at high risk for developing diabetes, and culturally relevant diet counselling tools are needed. We examined perceived needs and preferences for diet counselling resources based on the newly revised Canadian Diabetes Association meal planning guide. Methods: Five focus groups of individuals fromdifferent regions of South Asia (n=53) discussed portion size estimating methods, cultural values and holidays, food group classifications, and common South Asian foods. A focus panel with dietitians (n=8) provided insight on current diabetes educationmethods and resources for teaching South Asian clients. Results: The dietitian panelmembers reported a need for resources targeted at differing client skill levels. They also noted preferences for individual counselling, and common barriers to education including finances, access, South Asian diets, and cultural views on health. Community focus groups reported larger portions but fewer dailymeals in Canada. Ingredients and...Purpose: South Asian immigrants to Canada are at high risk for developing diabetes, and culturally relevant diet counselling tools are needed. We examined perceived needs and preferences for diet counselling resources based on the newly revised Canadian Diabetes Association meal planning guide. Methods: Five focus groups of individuals fromdifferent regions of South Asia (n=53) discussed portion size estimating methods, cultural values and holidays, food group classifications, and common South Asian foods. A focus panel with dietitians (n=8) provided insight on current diabetes educationmethods and resources for teaching South Asian clients. Results: The dietitian panelmembers reported a need for resources targeted at differing client skill levels. They also noted preferences for individual counselling, and common barriers to education including finances, access, South Asian diets, and cultural views on health. Community focus groups reported larger portions but fewer dailymeals in Canada. Ingredients and...PURPOSE South Asian immigrants to Canada are at high risk for developing diabetes, and culturally relevant diet counselling tools are needed. We examined perceived needs and preferences for diet counselling resources based on the newly revised Canadian Diabetes Association meal planning guide. METHODS Five focus groups of individuals from different regions of South Asia (n=53) discussed portion size estimating methods, cultural values and holidays, food group classifications, and common South Asian foods. A focus panel with dietitians (n=8) provided insight on current diabetes education methods and resources for teaching South Asian clients. RESULTS The dietitian panel members reported a need for resources targeted at differing client skill levels. They also noted preferences for individual counselling, and common barriers to education including finances, access, South Asian diets, and cultural views on health. Community focus groups reported larger portions but fewer daily meals in Canada. Ingredients and portions were not measured. Fasting was an important value, and sweets were a crucial component of holidays. Resources in South Asian languages, inclusion of pictures, and separate legumes, sweets, and snacks food groups were preferred. CONCLUSIONS Findings can be used when developing new counselling tools for the South Asian community.

Interventions for prevention of childhood obesity in primary care: a qualitative study

BACKGROUND Preventing childhood obesity is a public health priority, and primary care is an important setting for early intervention. Authors of a recent national guideline have identified a need for effective primary care interventions for obesity prevention and that parent perspectives on interventions are notably absent from the literature. Our objective was to determine the perspectives of primary care clinicians and parents of children 2-5 years of age on the implementation of an obesity prevention intervention within team-based primary care to inform intervention implementation. METHODS We conducted focus groups with interprofessional primary care clinicians (n = 40) and interviews with parents (n = 26). Participants were asked about facilitators and barriers to, and recommendations for implementing a prevention program in primary care. Data were recorded and transcribed, and we used directed content analysis to identify major themes. RESULTS Barriers existed to addressing obesity-related behaviours in this age group and included a gap in well-child primary care between ages 18 months and 4-5 years, lack of time and sensitivity of the topic. Trust and existing relationships with primary care clinicians were facilitators to program implementation. Offering separate programs for parents and children, and addressing both general parenting topics and obesity-related behaviours were identified as desirable. INTERPRETATION Despite barriers to addressing obesity-related behaviours within well-child primary care, both clinicians and parents expressed interest in interventions in primary care settings. Next steps should include pilot studies to identify feasible strategies for intervention implementation.

Estimating benefits and harms of screening across subgroups: the Canadian Task Force on Preventive Health Care integrates the GRADE approach and overcomes minor challenges

OBJECTIVE This paper describes the integration of the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach into their clinical preventive guideline development process by the new Canadian Task Force on Preventive Health Care. STUDY DESIGN The GRADE approach focused the analytic framework and key questions on patient-important benefits and harms related to screening that incorporated detection, treatment, and follow-up. It also led to an explicit consideration of values and preferences and resource implications on the basis of the recommendations. RESULTS There are challenges, however, in incorporating the GRADE approach to clinical prevention, as the randomized controlled trials in this field have needed to be very large and of long duration, given the rare occurrence of primary outcome events in asymptomatic individuals. We provide examples of how we met these challenges in relation to developing clinical guidelines for screening for breast cancer, cervical cancer, diabetes, hypertension, and depression in primary care settings. CONCLUSION The focus on the patient-important outcomes was helpful in estimating effectiveness of screening approaches and providing explicit detailing of the basis of our recommendations across subgroups.