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This thesis examines the association between parental feeding and children's eating behaviour and adiposity. Past research is inconsistent, with some studies finding that higher parental control is associated with adverse effects in terms of unhealthy food choices, disordered intake regulation and obesity, and others indicating positive effects. Discrepancies may relate to variability in parental control measures, sample characteristics and research methods. Study 1 examined the factor structure of two existing measures of parental feeding in 190 parents of 3-5 year olds, and Study 2 added interview and diary data in a sub-sample of these parents. Several distinct dimensions of parental control emerged and a wide range of motivations underlying feeding practices was apparent. In Studies 3 and 4, control was assessed using an improved measure in a socio-economically diverse sample of 541 parents. Pressuring to eat and instrumental feeding were more common in lower socio-economic (SES) parents, while restriction was more frequent with higher SES. Child adiposity was unassociated with restriction or instrumental feeding but negatively associated with pressure to eat. This relationship could be partly explained by parents' putting more pressure on thinner children with less appetite for food, although other explanations also fit the data. Study 5 added to the longitudinal literature on parental control, finding a negative prospective association between pressure to eat and weight gain from 4 to 7 years. Study 6 assessed regulation of intake over a two-part meal in a sample of 4-5 year olds, and found some evidence for a negative association between regulation and parental monitoring. Study 7 showed that children with slower eating rates and lower meal intakes had parents who exerted more pressure to eat, but found negligible associations between parental feeding and eating without hunger. The importance of these findings for understanding how parents influence children's weight is discussed.

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Obesity has emerged as a worldwide problem over the last three decades, and is now regarded as an epidemic by the World Health Organization (WHO). This problem includes children and adolescents, and has even been shown to extend to infants under two years of age. Prior studies have shown that obesity in early life tracks through childhood to adulthood, with severe consequences for governments in terms of healthcare spending, as well as for the health of the overweight and obese individuals. This thesis therefore examines children's nutrition, and does so in the form of protein intake, since previous studies have found that a high protein intake during early infancy (up to 2 years of age) is strongly associated both with accelerated early growth and an increased risk of overweight and obesity during later childhood. The thesis has three main objectives: 1) to describe and evaluate changes in dietary patterns (with a particular emphasis on protein intake) in the early stages of life; 2) to examine the associations between dietary intakes (with a particular emphasis on protein intake) and weight status, from the complimentary feeding period through to later childhood and then (in one study) through to adolescence; and 3) to compare the mean protein intake of infants and older children through to adolescence with several different national and international reference values for protein.

The aims of this study were to examine parental perception of children's weight and eating and the relationships between parenting styles and food mles in the context of childhood obesity.

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Childhood obesity has reached epidemic proportions globally (Wang & Lobstein, 2006). Obesity has been linked with psychopathology in adolescents seeking treatment (Zametkin, Zoon, Klein & Munson, 2004). To avoid serious health consequences in adulthood, the high incidence of psychopathology in this population needs to be addressed. Exercise has the potential to improve both physical and psychological health simultaneously; however, there is a lack of research investigating the effects of exercise upon psychopathology in obese young people. Therefore, this thesis provides an examination of the effects of a supervised exercise therapy intervention upon psychopathology related outcomes in obese adolescents using a randomised controlled trial (RCT) method. The primary trial hypothesis was that exercise therapy would lead to improvements in participants' physical self-esteem and reductions in psychopathology. Two qualitative studies explored obese adolescents' experiences of participation in an exercise therapy intervention and a further study investigated their ratings of perceived exertion (RPE) during exercise. The population sample consisted of 81 obese (body mass index (BMI) > 2.5 SDS, adult equivalent BMI of > 30) adolescents aged between 11-16 years who had been referred to a children's hospital for evaluation of obesity or responded to a community advert. Participants were randomised to exercise therapy, an equal contact exercise-placebo intervention or usual care control. Intervention participants attended three one-to-one sessions per week, over eight-weeks and then completed a home programme for six-weeks. Participants were interviewed at the end of the eight-week intervention and again after the home programme. Outcomes included self-perceptions (self-esteem), depression, affect, physical activity and BMI. Repeated measures mixed analysis of covariance (controlling for baseline scores) revealed significant differences in physical self-worth, associated measures of self-esteem and physical activity over time in favour of the exercise therapy condition. There were no significant differences in BMI. Findings from the qualitative studies revealed that obese adolescents were happier than when they began the programme, expressed surprise at how much they were capable of achieving in terms of exercise and felt empowered to continue to exercise over the long-term. Some felt that the intervention was not long enough and many of the common barriers to exercise typically reported by other young people, such as time, were cited at interview. Obese adolescents reported RPE during exercise to be significantly greater for the lower limbs compared with aerobic exertion. This study is the first RCT to demonstrate that a brief supervised exercise therapy intervention has the potential to significantly improve psychopathology related outcomes and increase physical activity in obese adolescents, relative to usual care. Findings indicate that obese children can successfully perform short intermittent bouts of structured exercise, given the opportunity, and that physical activity can contribute to the enhancement of their psychological and social well-being. Results also suggest that obese adolescents find prolonged bouts of exercise fatiguing in the lower limbs particularly which underlines the critical need for future interventions aimed at treating obesity to be aware of the importance of assessing ratings of perceived exertion during exercise. It is hoped that this thesis will generate additional research interest and concern about the psychopathology of young people who are obese. In particular, raise awareness of the importance of assessing the efficacy of obesity treatments in relation to psychopathology outcomes in future trials. It is also hoped that the exercise therapy guidelines provided here would inform health practitioners in the delivery of exercise therapy and highlight the potential contribution exercise therapy could make to the treatment of childhood obesity in pragmatic environments such as the NHS.

Childhood obesity is a major public health concern. Recent data suggests although childhood obesity prevalence rates appear to be slowing, they are still unacceptably high (Health Survey for England, 2010). To establish a downward trend in childhood obesity rates, effective treatment options are vital. To date, multi-component treatment interventions (MCTIs) incorporating a physical activity, healthy eating and behavioural component and encouraging family involvement appear to be the most promising approach to treat childhood obesity. However, no firm conclusion can be made regarding the sustainability of treatment outcomes (i.e. behavioural & weight related outcomes) (Luutikhuis et al., 2009). This thesis contributed to the evidence base regarding the sustainability of treatment outcomes from MCTIs; considered stakeholder views in the intervention design process and provided an insight into treatment recipient's reasons for attrition from MCTIs. To critically examine the evidence base, Study 1 provided a systematic review of childhood obesity treatment interventions. Results revealed gaps in the evidence in terms of how best to maintain treatment outcomes. Furthermore the study highlighted a need to better consider stakeholder views in intervention design and to fully report treatment fidelity (TF). In Study 2, a qualitative inquiry explored stakeholder perspectives towards childhood obesity treatment and the maintenance of treatment outcomes. Results revealed incongruence between treatment recipients (i.e. parents & children) and treatment deliverers (i.e. health professionals). Treatment recipients suggested they required ongoing support to maintain treatment outcomes. Conversely, treatment deliverers suggested ongoing support is unrealistic and MCTIs should create autonomous individuals who feel confident in their ability to maintain treatment outcomes. Implications included the need to consider maintenance strategies that promote autonomous motivations and perceived competence for behavioural changes in participants with the aim of improving weight maintenance following MCTIs. In light of stakeholder views in Study 2, Study 3A detailed a pilot study to test the efficacy of a maintenance intervention underpinned by Self Determination Theory (Deci & Ryan, 1985; 2000) and that integrated Motivational Interviewing (Miller & Rollnick, 1991; 2002) and cognitive behavioural strategies to improve the sustainability of behavioural and weight related outcomes following a MCTI. A secondary aim of Study 3A was to evaluate TF. Findings supported the potential importance of autonomous motivation and perceived competence in enhancing the maintenance of behavioural and weight related changes. Furthermore this study highlighted a need to explore participants' reasons for attrition from MCTIs. Study 3B provided a qualitative exploration of parents and children's reasons for attrition from MCTIs. Findings underlined the complexity of attrition with several psychological and motivational reasons appearing as the driving source for attrition. Study implications included the need to consider individual families' needs within MCTIs, targeting parents and children's motivations for maintaining a healthy lifestyle and weight differently. The collective implications of the four studies included the need for stakeholders to be involved at all levels of design, implementation and evaluation of MCTIs, the need to assess and report all aspects of TF and the need for MCTIs to develop families' perceived competence and autonomous motivations for health behaviour changes in order to improve the sustainability of weight related outcomes.

Obesity prevalence has accelerated over the last two decades and is predicted to continue to rise, bringing with it increased morbidity and mortality as well as rising dramatically health care costs. Obesogenic environments are one of the explanations for the rising prevalence. Accordingly this thesis investigates the obesogenic environment factors, as well as obesogenic behaviour factors, associated with the increased prevalence of childhood obesity, using familiar geographical techniques in novel ways. These results were then applied to develop a targeted childhood obesity prevention policy for Leeds to reduce the risk of childhood obesity in different populations. In this ecological study body mass index in Leeds for children aged 3 to 13 years old was examined to measure variations in childhood obesity. Spatial microsimulation modelling was utilised to give synthetic individual estimates of obesogenic covariates (e. g. obesogenic environment variables such as socio-economic characteristics and perceived social capital; individuals' behavioural variables such as dietary variables and physical activity levels) at the micro level. Additionally two demographic indices based on the 2001 Census were employed. The relationship between childhood obesity and the obesogenic covariates were considered at the home and school level using a combination of spatial statistical techniques. Spatial microsimulation modelling was shown to be a robust method to estimate obesogenic covariates at the micro-level. In the design of a spatial microsimulation model using a deterministic re-weighting algorithm, the input variables must be strongly correlated with the output variables to be able to accurately simulate micro-area estimates. Also this thesis has highlighted that there is considerable advantage to analysing health data at a small scale, otherwise micro-level differences are simply "averaged" away and missed. As well as showing that individuals' behaviours are important in determining risk of childhood obesity, this study adds to the increasing evidence of the existence of "obesogenic environments": features of the local environment in Leeds may affect childhood obesity by changing health behaviours. There was significant variation in childhood obesity across Leeds, with "hot spots" in both deprived and affluent areas. Further, relationships between obesogenic covariates and childhood obesity were not uniform across Leeds, highlighting the need for tailored, multifaceted public health policies that are based on locally relevant evidence.

Introduction Obesity is the most common nutritional disorder in the world and is widely acknowledged as having become a global epidemic.(1) The prevalence of childhood obesity in the United Kingdom (UK) dramatically increased over a short number of years in the 1990s.(2-4) There are well-recognised health consequences of childhood obesity, both during childhood as well as those tracking into adulthood affecting health, psychological and economical welfare.(5;6) However, there is a surprising lack of well conducted published research into effective childhood obesity treatment strategies and few with relevance to the UK National Health Service (NHS).(5;7) This thesis describes (a) the Scottish Childhood Obesity Treatment Trial (SCOTT), a randomised controlled trial (RCT) that compared standard NHS dietetic management of childhood obesity with a novel intensive dietetic approach in Scottish primary school aged (5 – 11 years old) children and (b) reports a complementary qualitative study that explored the parents’ perceptions of the dietetic treatments their child received during the SCOTT project. The SCOTT project was conceived to be an easily reproducible treatment programme within the UK NHS system for primary school aged children. Methodology The SCOTT quantitative study was a single-blind RCT involving 134 obese children of primary school age (5 -11 years), 75 females and 59 males. Inclusion criteria were children with ‘simple’ obesity (body mass index (BMI)  98th centile on the UK 1990 charts) and families that perceived the child’s weight as a problem and were motivated to change. The intervention arm involved an evidence-based novel dietetic treatment over 6-months giving 5 hours of treatment and used client-centred behavioural change techniques to increase motivation for changing diet (using a modified traffic light diet), increasing physical activity and reducing sedentary behaviour. The control arm received 1.5 hours of ‘typical’ dietetic weight management delivered in a traditional (educational) manner. Outcomes recorded at baseline, six and 12 months were BMI standard deviation (SD) score, objectively measured physical activity and sedentary behaviour (using accelerometers) and possible adverse effects of treatment (height growth and quality of life). The primary outcome was change in BMI SD score at six months. The complementary qualitative study used in-depth interviews to explore the thoughts and feeling of parents of the children who had completed the dietetic intervention. All interviews took place after the SCOTT 12 month outcome measurements had been completed. Purposive sampling was used and out of the 79 eligible SCOTT parents 17 were interviewed. The interviews were taped and then transcribed by experienced secretaries. Analysis was carried out using the Framework methodology (8) and aided by Nvivo software. Key Results The novel treatment programme had no significant effect relative to the standard dietetic care on BMI SD score from baseline to six months (-0.10 vs -0.06; 95% CI -0.05 to 0.11) and 12 months (-0.07 vs -0.19; 95% CI -0.17 to 0.07). BMI SD score decreased significantly within both groups from baseline to six and 12 months. There were significant differences between the groups in favour of the novel treatment group for changes in total percentage of time spent in physical activity (95%CI 0.8 to 6.3) and light intensity physical activity (95%CI -4.8 to -0.5). In the qualitative study we found themes and concepts both on our original evaluation and emergent data on the parents’ thoughts and feelings on entering, continuing and leaving treatment. Those parents who had taken part in the behavioural change techniques applauded the process finding it child-friendly and talked of ‘forming a partnership’ with the child and dietitian. Developing a rapport with the dietitian was significant for the parents in their perception of a positive experience. Parents appeared to be characterised as being unaware of their child’s weight problem, in denial, or actively seeking treatment. Parents were consistently motivated to enter treatment due to perceived benefits to their child’s self esteem or quality of life, and weight outcomes were considered less important. During treatment parents expressed a lack of support for lifestyle changes outside the clinic, and noted that members of the extended family often undermined changes. Parents generally felt that treatment should have continued beyond six months, and that it had provided benefits to their child’s well-being, self-esteem, and quality of life, and this is what motivated many of them to remain engaged with treatment. Conclusions The modest magnitude of the benefits observed in the SCOTT study perhap suggest that interventions should be longer term and more intense. The results of the qualitative study suggested that longer term interventions would be acceptable to parents. The qualitative study was an informative addition to the SCOTT quantitative study as it allowed exploration of the subtle differences as perceived by the parents who took part in both arms of the study. It may help inform future treatments for childhood obesity by providing insights into the aspects of treatment and approaches applauded by parents. Future treatments may need to consider providing greater support to lifestyle changes within the extended family, and may need to focus more on psychosocial outcomes. This study highlighted skills and qualities required by dietitians and other health professionals to engage with families of obese children.