This study provides a comprehensive analysis of dietary trends in the United States from 2000 to 2018, examining the population's adherence to the Dietary Guidelines for Americans (DGAs) across diverse food groups. Utilizing National Health and Nutrition Examination Survey (NHANES) data and employing meta-regression analysis, the research evaluates the intake patterns of vegetables, fruits, grains, protein, dairy, fats and oils, and key nutrients. The findings reveal a consistent and widespread non-adherence to recommended DGA servings, challenging the effectiveness of dietary guidelines in influencing public behavior. Despite revisions in guidelines, the study demonstrates remarkable stability in the intake of both recommended and discouraged foods. Additionally, the study investigates trends in obesity prevalence and BMI, suggesting that the DGAs alone may not be the primary driver of the obesity epidemic. The discussion highlights the persistent disconnect between DGA recommendations and actual dietary behaviors, emphasizing the need for public health interventions. This study contributes valuable insights into the limitations of current dietary guidelines in shaping broader dietary patterns, calling for a more holistic approach to public health interventions.

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The day that I joined McMaster University and the Department of Health Research Methods, Evidence, and Impact as a Master student, I did not foresee the amazing journey I was embarking on or the impact of my academic achievements. I was continuously challenged to think critically and apply my ideas to real world problems. Seeing the opportunity to make a difference in clinical research and patient care inspired me to begin my PhD studies. Creating knowledge and applying it practically was a difficult task, however, the opportunities to share my research in a dynamic and complex field with the world fuelled my motivation. Completing a PhD has been an incredible privilege for which I will always be grateful. To my family – Mamma, Papa, Mark and Matthew – thank you for your undying and unconditional love, support, and encouragement. A pandemic forced us to come together, and having your support 24/7 (literally) made the journey more enjoyable. To my closest friends, thank you for being a part of my life and supporting my ambitions. We all recognized my ambitiousness would set me on a difficult path and completing a PhD was not my original plan. Thank you for inspiring me to take on the challenge and ensure my work was truly impactful. Thank you for encouraging mental strength, being understanding and willing to lend a hand, reminding me that I can achieve anything I set my mind to, and inspiring me to dare. To my supervisory committee members and independent study supervisor, thank you for your continued interest in my work and for always supporting my ambitions. I am grateful for your patience and belief that I would succeed in completing what I had sought to achieve. Thank you for the chance to work together, and for your constant support and mentorship throughout my PhD journey. To the faculty, staff and fellow students at the Department of Health Research Methods, Evidence, and Impact, and the McMaster Centre for Transfusion Research, thank you for providing the resources, friendship, and guidance I needed to achieve greatness. To the panel members of the ITP Emergency Management Guideline, thank you for believing in this project and making this work possible. I look forward to implementing the results of our efforts into clinical practice. To the ITP patient community, thank you for entrusting me with the task of improving patient care and supporting me along the way. You have enabled me to be a voice for change. To the rare disease community, I know the completion of my PhD journey will not be the end of our work together. To the funding agencies who allowed this project to be possible, the Canadian Institutes of Health Research and Platelet Disorder Support Association, thank you for supporting my PhD journey and the completion of this important work. To my doctoral supervisor, Dr. Donald Arnold, it has been an honour and privilege to have learned from you and received your guidance throughout my PhD journey. Since our initial meeting, when I hobbled into the McMaster Centre for Transfusion Research offices several minutes late, I felt that your kindness and honesty would be the perfect form of mentorship to push me towards success. Thank you for recognizing my ambition and reminding me to keep focused. I will continue to apply this lesson throughout my life and strive for ‘depth’. For many years, you have been my mentor who I reached out to for advice, support, honest feedback, and encouragement. Thank you for imparting your knowledge to me over my PhD journey and teaching me how to be an inspirational mentor who highlights the strengths of their students while simultaneously supporting their growth. Although I may have finally reached the destination in my PhD journey, I know that we will continue to collaborate for many years to come. / Developing clinical practice guidelines (CPGs) for rare diseases is methodologically challenging. As each disease has so few patients, published literature includes low-quality studies or studies that do not directly address the questions of interest. As a result, CPG panelists have limited evidence on which to base their recommendations. Historically, when no evidence was available, CPGs have relied on physician opinion. This does not align with the mandate of CPGs which transparently identifies, appraises, and relies on evidence. The challenges of developing CPGs for rare diseases are exemplified by immune thrombocytopenia (ITP), a rare autoimmune disease that affects approximately 1 in 8,000 people. It predominantly affects females and young adults, and is characterized by low blood platelets that increase the risk of bleeding. Bleeding emergencies in ITP patients are critical, life-threatening events that can cause life-long morbidity and associated health care costs. Treatment of ITP bleeding emergencies requires a rapid, coordinated approach that involves emergency department staff, hematologists, pharmacy, and the laboratory. However, there is no evidence-based CPG for the management of ITP bleeding emergencies. The objectives of my PhD thesis are (1) exploring the heterogeneity of ITP diagnosis using antiplatelet autoantibodies; (2) developing a standardized definition of ITP bleeding emergencies; (3) outlining the synthesis of existing evidence on the treatment of ITP bleeding emergencies through a systematic review; and (4) developing a novel methodology to address the lack of evidence in rare disease CPGs and applying it to develop a CPG for the management of ITP bleeding emergencies. / Thesis / Candidate in Philosophy / Guidelines for rare diseases can be hard to develop because of a lack of information. Doctors and researchers make decisions on rare disease management based on their experiences, which can be limited. Low blood platelets and emergency bleeding can be caused by a rare disease called immune thrombocytopenia (ITP). When emergency bleeds occur, patients need care from the Emergency Department immediately. The problem is that there is no standard way for doctors to treat these ITP bleeding emergencies. My PhD thesis project will fill an important gap for ITP emergency treatment. First, we will assess how ITP patients are diagnosed. Second, we will define an ITP bleeding emergency. Third, we will collect existing information about ITP bleeds. Fourth, we will overcome the challenge of not having enough information by collecting new data from patient records. The method we use to develop ITP guidelines can be used for other rare diseases.

Yes / Global initiatives that promote public health responses to dementia have resulted in numerous countries developing new national policies. Current policy guidelines in England, for example, recommend that people diagnosed with mild-to-moderate dementia receive information and psychosocial interventions to improve their ability to ‘live well’. However, it remains unclear to what extent these recommendations are being achieved. Methods: Self-reported information from 1537 people living with dementia and informant-reported information from 1277 carers of people living with dementia was used to quantify receipt of community-based dementia support services, including health and social care services provided by statutory or voluntary-sector organisations, in Britain from 2014 to 2016. Demographic factors associated with differences in receipt of support services were also investigated to identify particularly vulnerable groups of people living with dementia. Results: Both self- and informant reports suggested that approximately 50% of people living with dementia received support services for dementia. Receipt of support services was lower among people living with dementia who are older, female, and have fewer educational qualifications. Receipt of support services also differed according to diagnosis and carer status, but was unrelated to marital status. Conclusions: Limited receipt of dementia support services among people living with dementia in Britain provides a baseline to assess the efficacy of current policy guidelines regarding provision of information and support. Targeted efforts to facilitate receipt of support services among the particularly vulnerable groups identified in the current study could improve the efficacy of dementia support services both in Britain and internationally, and should inform policy development. / The IDEAL study’ was funded jointly by the Economic and Social Research Council (ESRC) and the National Institute for Health Research (NIHR) through grant ES/L001853/2. The IDEAL‐2 study’ is funded by Alzheimer's Society, grant number 348,AS‐PR2‐16‐001.

The Center for High Performance Learning Environments (CHPLE) at Virginia Tech aims to provide guidance on various issues associated with high performance learning environments, using information gained through the various studies undertaken at the College of Architecture and Urban Studies. One such study is presented in this thesis. Leadership in Energy and Environmental Design (LEED), an environmental rating system for buildings, introduced in 1998, is still in the process of development. The USGBC conducted research and introduced various LEED manuals for different building types. For each building type, in order to achieve environmental credits under LEED, evidence must be provided in terms of various documents. The process of collecting and submitting these documents is perceived to be difficult and this study tries to find the barriers to the documentation process as required during LEED certification. Currently, while documenting the credits under LEED, the design team must assume many important responsibilities. Hence this research sought participation from this group of professionals, who are proactive in promoting LEED and also have experience in school design. To understand the design professionals perception about LEED, a semi-structured interview method was adopted to obtain data for this study. Out of a total of 175 invitations, 15 agreed to participate. A questionnaire was developed and the participants were asked to respond. All interviews were recorded, providing the main source of data. IRB approval was obtained prior to the interviews and all the prescribed ethical concerns were addressed during the interviews. The responses to the questionnaire, were categorized as, 1.Barriers for documentation and2.Recommendations from participants for improving the LEED documentation process. The identified barriers were sequenced to understand the interrelationships between different barriers. The recommendations are interpretations and derivations of the participant recommendations. These recommendations could be adopted by the USGBC to improve the process of documentation in LEED. This study may also initiate other studies to help further understand the opinions of school authorities and other project members with respect to LEED documentation. / Master of Science

These guidelines provide an overview of the issues to be considered when undertaking or commissioning geophysical survey in archaeology. As every project diff ers in its requirements (e.g. from fi nding sites to creating detailed maps of individual structures) and variations in geological and environmental conditions lead to diff erent geophysical responses, there is no single ‘best’ survey technique or methodology. Th is guide, in its European approach, highlights the various questions to be asked before a survey is undertaken. It does not provide recipebook advice on how to do a geophysical survey or a tick list of which technique is suitable under what conditions. Experienced archaeological geophysicists should be consulted to address the questions that are being posed. Using geophysical techniques and methods inappropriately will lead to disappointment and may, ultimately, result in archaeologists not using them at all. “If all you have is a hammer (or magnetometer), driving a screw becomes impossible”. Especially in the American literature the term ‘remote sensing’ is oft en used to describe geophysical as well as air and space based exploration of underground features (e.g. Wiseman and El-Baz 2007). By contrast, and in line with European traditions, a clear distinction is made here between ground-based geophysical techniques and remote sensing techniques. Th is is based on the imaging principles underlying the respective technologies. Ground based systems usually collect one spatially registered data sample from each sensor location (e.g. a single reading for each magnetometer, or a single trace from each GPR antenna). Remote sensing techniques, by contrast, collect spatially resolved data from a whole area of investigation from each sensor location, using either the system’s optical aperture (e.g. photography) or a scanning device (e.g. laser sampling). These guidelines are based on the experience of the authors in archaeological geophysics and infl uenced by various published sources.

The high prevalence of back and neck pain results in enormous social, psychological, and economic burden. Most seeking help for back or neck pain consult general practitioners or chiropractors. Chiropractic is a regulated health profession (serving approximately 10 – 15% of the population) that has contributed to the health and well-being of North Americans for over a century. Despite available evidence for optimal management of back and neck pain, poor adherences to guidelines and wide variations in services have been noted. For instance, overuse and misuse of imaging services have been reported in the chiropractic literature. Inappropriate use of spine imaging has a number of potential adverse outcomes, including inefficient and potentially inappropriate invasive diagnosis and subsequent treatment, and unnecessary patient exposure to ionizing radiation. Although evidence-based diagnostic imaging guidelines for spinal disorders are available, chiropractors are divided on whether these guidelines apply to them. While guidelines can encourage practitioners to conform to best practices and lead to improvements in care, reviews have demonstrated that dissemination of guidelines alone is rarely sufficient to optimise care. Evidence regarding effective methods to promote the uptake of guidelines is still lacking. There is growing acceptance that problem analysis and development of interventions to change practice should be guided by relevant theories and tailored to the target audience. To date, very little knowledge translation research has addressed research-practice gaps in chiropractic. This thesis reports rigorous methods to: (1) assess practice and providers’ characteristics, (2) determine baseline rates and variations in spine x-ray ordering, (3) evaluate the impact of disseminating guidelines to optimise spine x-ray ordering, and (4) assess determinants of spine x-ray ordering and potential targets for change prior to the design of a tailored intervention. A mixed method using two disciplinary perspectives (epidemiology and psychology) was undertaken. A cross-sectional analysis of administrative claims data was carried out on a sample of chiropractors enlisted in a large American provider network. Despite available clinical practice guidelines, wide geographical variations in x-ray use persist. Higher x-ray ordering rates were associated with practice location (Midwest and South US census regions), setting (urban, suburban), chiropractic school attended, male provider, employment, and years in practice. The impact of web-based guideline dissemination was evaluated over a five year period using interrupted time series and demonstrated a stepwise relative reduction of 5.3% in the use of x-rays. Passive guidelines dissemination appeared to be a simple, cost effective strategy in this setting to improve but not optimise x-ray ordering rates. Focus groups using the theoretical domains framework were conducted among Canadian and US chiropractors to explore their beliefs about managing back pain without x-rays. Findings were used to develop a theory-based survey to identify theoretical constructs predicting spine x-ray ordering practice. Psychological theories and theoretical constructs explained a significant portion of the variance in both behavioural simulation and intention. Results from this thesis provide an empirically-supported, theoretical basis to design quality improvement strategies to increase guidelines adherence and promote behaviour change in chiropractic. Other researchers interested in improving uptake of evidenced-based information could use this method in their own setting to investigate determinants of behaviour among other professional groups. Future research may use knowledge gained to inform the development and evaluation of a theory-based tailored intervention to improve guideline adherence and reduce the use of spine x-rays among targeted providers.

This thesis describes the preparation of financial statements and the creation of internal guidelines for specific company. The theoretical part of the thesis describes the theory of the issue deals with basic procedures and accounting methods, and processing of accounts and creation of internal accounting directives in line with current legislation. Practical part demonstrates the theoretical knowledge to specific companies.