Class of 2010 Abstract / OBJECTIVES: To evaluate the product information and pivotal studies of injectable medications to determine if a specific size descriptor was included and if information was provided for dosing patients with extremes of body weight (body mass index < 18.5 or > 40 kg/m2). METHODS: This is a descriptive study of medications that received an approved new drug application (NDA) by the FDA between 1 January 2004 and 30 January 2009. Any information related to size descriptors, or dosing of patients with extremes of weight, was extracted and evaluated with a dosing usefulness score that ranged from a low of 0 to a high of 3. A score of 2 or greater was considered at least minimally adequate for dosing patients with extremes of weight. RESULTS: Of the 84 medications evaluated, some reference to weight descriptors was found for 23 (27%). None of the medications had information that generated a usefulness score of 2 or greater. CONCLUSIONS: The product information and pivotal studies involving newly approved medications is inadequate for dosing patients with extremes of weight and further research is needed. The FDA should mandate that product information contain the size descriptor and extremes of body weight relative to age and height that were used to develop dosing recommendations.

The aim of this research was to determine ethnic and cultural influences on body composition, lifestyle, and aspects of body image (perception, acceptability, and satisfaction) of younger (age 18-40 years) Australian and Japanese males, the latter including groups living in Australia and Japan. The sample sizes of the three groups were 68 Japanese living in Australia, 84 Japanese living in Japan, and 72 Australian Caucasian males respectively. The methodology included body composition assessments (by anthropometry and DXA), lifestyle and body image questionnaires, and dietary records. The study found significant p<0.05) ethnic differences in the %BF at given BMI levels and for Japanese the BMI values of 23.6kg/m2 and 28.6kg/m2 were found to be equivalent to 25 and 30 for Caucasians when used to classify individuals as "overweight" and "obese". Equations in common use for the calculation of body composition in Japanese males were evaluated using modern methods of body composition assessment and found to need considerable modification. New regression equations that represent BMI-%BF relationships for Japanese and Australians were proposed: Japanese: Log %BF = -1.330 + 1.896(log BMI), (R2 = 0.547, SEE = 0.09); Australians: Log %BF = -1.522 + 2.001(log BMI), (R2 = 0.544, SEE = 0.10). Equations were also developed to predict %BF for Japanese and Australian males from body composition assessments using anthropometry and DXA: Japanese: %BF = 0.376 + 0.402(abdominal) + 0.772(medial calf) + 0.217(age), (R2 = 0.786, SEE = 2.69); Australians: %BF = 2.184 + 0.392(medial calf) + 0.678(supraspinale) + 0.467(triceps), (R2 = 0.864, SEE = 2.37). Lifestyle factors were found to influence perceptions of body image. / Australian males participate in physical activity more frequently than their Japanese counterparts (Australians = 98.6% involved in vigorous activity at least once per week, Japanese living in Japan = 85.7%, Japanese living in Australia = 72.1%). Significant differences p<0.05) in energy contribution patterns were found between the Japanese group (Protein: 14.4%, Carbohydrate: 50.4%, Fat: 28.1%) and Japanese living in Australia (JA: Protein: 16.3%, Carbohydrate: 47.3%, Fat: 32.3%) and the Australians (Protein: 17.1%, Carbohydrate: 47.9%, Fat: 30.6%). This shows that the Japanese living in Australia have adopted a more westemised diet than those living in Japan. Body Image assessments were done on all study groups using the Somatomorphic Matrix (SM) computer program and questionnaires, including the Ben-Tovim Walker Body Attitudes Questionnaires, (BAQ) the Attention to the Body Shape Scale (ABS), and the Eating Attitudes Test (EAT). Japanese males tended to overestimate their weight and amount of body fat, while Australian Caucasian males underestimated these parameters. The Japanese groups had higher scores on the selfdisparagement subscale and lower scores on the strengths and the attractiveness subscales of the BAQ questionnaire than Australian males. Australian males also had higher scores on the EAT total score and the dieting subscale of the EAT questionnaire than Japanese males. When all groups of subjects selected their perceived body image from the SM program menu, these results had no relationship with measured body composition values, suggesting that further development of this program is needed for use in these populations.

This thesis explores race and gender differences in perceptions and behaviors regarding weight and obesity, along with the relative influence of individual and structural factors on the personal weight status of black and white adults. In addition, this study examines the extent to which black and white adults differ in their perceptions of discrimination attributed to their personal weight. Based on an analysis of data from a national poll conducted by ABC News and TIME magazine, results indicate that weight status perceptions of overweight black females were consistent, while incongruity was found in perceived and actual weight status among obese black women. On the other hand, a greater proportion of obese white women under-assessed their weight status compared to obese black women. However, regardless of race, men were more likely to under-assess their weight than women. There were no differences by race and gender in reports of having felt discriminated against because of personal weight status. Findings also revealed that black females and males face greater constraints than their white counterparts related to controlling weight and fighting obesity, including such factors as a lack of information on how to establish good eating habits, the need to monitor food content, and being able to afford the cost of purchasing healthy food. A discussion of these findings in relation to previous research is provided along with recommendations for further study.

In recent years, childhood obesity has increased to epidemic proportions across the United States (U.S.) in parallel with adult obesity, which often reflects poor dietary choices and bad nutritional habits. Nutrition literacy, which encompasses the constructs of nutrition knowledge and skills, is considered a basic tool for good dietary habits and health promotion undertakings; however, its more definitive relationship to adolescent children’s weight status is unknown. Most childrens’ weight status studies have focused solely on behavioral aspects of adolescent food intake, taking into consideration parental influence, peer pressure, and societal expectations. Studies evaluating the measurement of nutrition literacy with regard to adolescent weight status are non-existent. The primary purpose of this study was to examine the effects of parent and adolescent nutrition literacy expressed as nutrition knowledge and skills, with total household income and parent level of education, as predictors of weight status in adolescents that live in a Florida community. The secondary purpose of this study was to examine the implications for nutrition literacy levels within parent/adolescent dyads to identify public health initiatives aimed at adult and adolescent populations. Parent/adolescent dyads were screened against inclusion criteria and 110 dyads were chosen to participate. Following informed consent from the parent and assent from the adolescent, demographic data were collected and the parent/adolescent participants were asked to complete two study instruments: the Nutrition Literacy Survey (NLS) testing nutrition knowledge (Diamond, 2007) and the Newest Vital Sign (NVS) assessing nutrition skills (Weiss, Mays, Martz, Castro, DeWalt, Pignone, Mockbee, Hale, et al., 2005). The written instruments were administered to both parents and the adolescent child simultaneously, directly following the collection of adolescent height and weight. iv First, paired t-tests were used to compare means for the NLS and NVS survey in parentadolescent dyads. Next, bivariate correlation scores were computed between the two variables of parent/adolescent NLS and NVS scores. Higher total correct scores indicated higher levels of nutrition knowledge, whereas lower total correct scores indicated lower nutrition knowledge. Next, a correlation analysis using the Pearson r correlation coefficient was computed to determine if a relationship existed between nutrition knowledge and nutrition skills in parentadolescent dyads. Lastly, regression models for examining adolescent BMI were compared with the independent variables of the study. The first model used standard multiple regression analysis to determine the correlation between parent/adolescent level of nutrition knowledge and parent/adolescent level of nutrition skills to children’s weight status (BMI). The second model used logistic regression analysis to determine if a correlation between parent/adolescent level of nutrition knowledge, parent/adolescent level of nutrition skills, and demographic characteristics, to children’s BMI could be predicted. The third model used the same procedure for logistic regression with all IV data as categorical data rather than actual values. Gender was included in the final model, since it was of relevance to BMI for adolescent populations. The study results indicate that adolescent male participants had higher BMI (27 + 3.48) than females (24 + 2.90), t(108) = 4.83, (p = < .001). The results suggest that percentage underweight/normal weight for males (32.8%) and females (75.5%) and percentage overweight/obese for males (67.2%) and females (24.5%) differed comparatively between the two groups, with a larger percentage of adolescent males having greater BMI than female adolescents. The mean Nutrition Literacy Scale score (M=19) for parent (adult) study participants indicated low overall levels of general nutrition knowledge whereas the mean Nutrition Literacy v Scale score (M=21.7) for adolescent study participants demonstrated slightly greater aptitude for general nutrition knowledge than parental scores. The mean Newest Vital Sign score (M=4.1) for parents suggests adequate levels of nutrition skills. Likewise, the mean Newest Vital Sign score (M= 4.1) for adolescents suggests adequate levels of nutrition skills, similar to scores attained in the adult population. Spearman rho correlations yielded positive correlations between parents’ nutrition knowledge and adolescents’ nutrition knowledge, (rs = .224, p = .019), and parents’ nutrition knowledge and skills (rs = .596, p < .001). Positive correlations were also noted between adolescents’ nutrition knowledge and parents’ nutrition skills (rs = .257, p = .007) and adolescents’ nutrition knowledge and nutrition skills (rs = .260. p = .006). For the first model, a multiple regression was calculated to predict BMI from parent/adolescent nutrition knowledge and parent/adolescent nutrition skills. These variables did not statistically predict adolescent BMI, F(4,109) = .348, p < .845, R2 = .013. All four variables did not significantly add to the prediction, p < .05. In the second model, a logistic regression was computed to predict adolescent underweight/normal weight and overweight/obese from parent/adolescent nutrition knowledge and parent/adolescent nutrition skills, household income, and parent education level. These variables did not statistically predict adolescent weight status, (χ2 (6) =3.31, p = .769; -2 Log Likelihood 149.036; R2 .03; Hosmer and Lemeshow Goodness-of-Fit χ2 (8) = 12.36, p = .136). In the third model, a logistic regression was calculated to predict adolescent underweight/normal weight and overweight/obese from parent/adolescent nutrition knowledge and parent/adolescent nutrition skills, household income, and parent education level, and adolescent gender. These variables did not statistically predict adolescent weight status, (χ2 (11) vi = 14.506, p = .206; -2 Log Likelihood 137.841; R2 .124; Hosmer and Lemeshow Goodness-ofFit χ2 (8) = 10.864, p = .210. Analysis of regression coefficients indicates none of the variables demonstrated significance. The results of the study suggest that parents and adolescents may have similar amounts of nutrition literacy when examining the constructs of nutrition knowledge and skills; however, BMI is not solely dependent on these skill sets. Gender may play an important role in the prediction of BMI in adolescents. Examination of the factors that influence parents and children’s weight status are important elements in shaping families adoption of sound dietary habits and improving health outcomes

Similarities and differences between obesity and addiction are a prominent topic of ongoing research. We conducted an activation likelihood estimation meta-analysis on 87 studies in order to map the functional magnetic resonance imaging (fMRI) response to reward in participants with obesity, substance addiction and non-substance (or behavioural) addiction, and to identify commonalities and differences between them. Our study confirms the existence of alterations during reward processing in obesity, non-substance addiction and substance addiction. Specifically, participants with obesity or with addictions differed from controls in several brain regions including prefrontal areas, subcortical structures and sensory areas. Additionally, participants with obesity and substance addictions exhibited similar blood-oxygen-level-dependent fMRI hyperactivity in the amygdala and striatum when processing either general rewarding stimuli or the problematic stimuli (food and drug-related stimuli, respectively). We propose that these similarities may be associated with an enhanced focus on reward – especially with regard to food or drug-related stimuli – in obesity and substance addiction. Ultimately, this enhancement of reward processes may facilitate the presence of compulsive-like behaviour in some individuals or under some specific circumstances. We hope that increasing knowledge about the neurobehavioural correlates of obesity and addictions will lead to practical strategies that target the high prevalence of these central public health challenges.

The Three-Factor-Eating-Questionnaire (TFEQ) is an established instrument to assess eating behaviour. Analysis of the TFEQ-factor structure was based on selected, convenient and clinical samples so far. Aims of this study were (I) to analyse the factor structure of the German version of the TFEQ and (II)—based on the refined factor structure—to examine the association between eating behaviour and the body mass index (BMI) in a general population sample of 3,144 middle-aged and older participants (40–79 years) of the ongoing population based cohort study of the Leipzig Research Center for Civilization Diseases (LIFE Health Study). The factor structure was examined in a split-half analysis with both explorative and confirmatory factor analysis. Associations between TFEQ-scores and BMI values were tested with multiple regression analyses controlled for age, gender, and education. We found a three factor solution for the TFEQ with an ‘uncontrolled eating’, a ‘cognitive restraint’ and an ‘emotional eating’ domain including 29 of the original 51 TFEQ-items. Scores of the ‘uncontrolled eating domain’ showed the strongest correlation with BMI values (partial r = 0.26). Subjects with scores above the median in both ‘uncontrolled eating’ and ‘emotional eating’ showed the highest BMI values (mean = 29.41 kg/m²), subjects with scores below the median in all three domains showed the lowest BMI values (mean = 25.68 kg/m²; F = 72.074, p<0.001). Our findings suggest that the TFEQ is suitable to identify subjects with specific patterns of eating behaviour that are associated with higher BMI values.

The Three-Factor-Eating-Questionnaire (TFEQ) is an established instrument to assess eating behaviour. Analysis of the TFEQ-factor structure was based on selected, convenient and clinical samples so far. Aims of this study were (I) to analyse the factor structure of the German version of the TFEQ and (II)—based on the refined factor structure—to examine the association between eating behaviour and the body mass index (BMI) in a general population sample of 3,144 middle-aged and older participants (40–79 years) of the ongoing population based cohort study of the Leipzig Research Center for Civilization Diseases (LIFE Health Study). The factor structure was examined in a split-half analysis with both explorative and confirmatory factor analysis. Associations between TFEQ-scores and BMI values were tested with multiple regression analyses controlled for age, gender, and education. We found a three factor solution for the TFEQ with an ‘uncontrolled eating’, a ‘cognitive restraint’ and an ‘emotional eating’ domain including 29 of the original 51 TFEQ-items. Scores of the ‘uncontrolled eating domain’ showed the strongest correlation with BMI values (partial r = 0.26). Subjects with scores above the median in both ‘uncontrolled eating’ and ‘emotional eating’ showed the highest BMI values (mean = 29.41 kg/m²), subjects with scores below the median in all three domains showed the lowest BMI values (mean = 25.68 kg/m²; F = 72.074, p<0.001). Our findings suggest that the TFEQ is suitable to identify subjects with specific patterns of eating behaviour that are associated with higher BMI values.

Similarities and differences between obesity and addiction are a prominent topic of ongoing research. We conducted an activation likelihood estimation meta-analysis on 87 studies in order to map the functional magnetic resonance imaging (fMRI) response to reward in participants with obesity, substance addiction and non-substance (or behavioural) addiction, and to identify commonalities and differences between them. Our study confirms the existence of alterations during reward processing in obesity, non-substance addiction and substance addiction. Specifically, participants with obesity or with addictions differed from controls in several brain regions including prefrontal areas, subcortical structures and sensory areas. Additionally, participants with obesity and substance addictions exhibited similar blood-oxygen-level-dependent fMRI hyperactivity in the amygdala and striatum when processing either general rewarding stimuli or the problematic stimuli (food and drug-related stimuli, respectively). We propose that these similarities may be associated with an enhanced focus on reward – especially with regard to food or drug-related stimuli – in obesity and substance addiction. Ultimately, this enhancement of reward processes may facilitate the presence of compulsive-like behaviour in some individuals or under some specific circumstances. We hope that increasing knowledge about the neurobehavioural correlates of obesity and addictions will lead to practical strategies that target the high prevalence of these central public health challenges.

The primary objective of the work presented in this thesis was to identify trends in maternal body mass index (BMI) over time, the demographic predictors of those women most at risk of being obese in pregnancy, health inequalities, and the impact of maternal obesity on maternity services. A mixed methodology utilised quantitative and qualitative research to address these objectives. Data were collated from 34 maternity units across England, including 619,323 deliveries between 1989 and 2007 inclusive. Analysis identified an increasing incidence of maternal obesity over time, regional differences in incidence, and significant inequalities with women residing in the highest levels of deprivation, and Black ethnic group. A systematic review was carried out including 49 studies investigating obesity and pregnancy outcomes with acute maternity resource implications. The meta-analysis found significantly increased odds of a number of outcomes, and concluded that maternal obesity had a considerable impact on maternity resources, and contributed towards a poorer prognosis for the mother and the baby during delivery and in the immediate post-partum period. Qualitative interviews and focus groups with 30 HCPs across eight NHS Trusts in the North East of England were carried out to identify barriers in implementing maternal obesity services, and to gain HCPs perspectives on what they felt was required in order to address maternal obesity effectively. The study identified the themes of ‘Service Development’, ‘Psychosocial Issues and Maternal Obesity Services’, ‘Information, Evidence, and Training’, and ‘Where to go From Here?’. Overall this programme of research has identified that maternal obesity is increasing over time and is significantly associated with health inequalities. The increase in maternal obesity has an impact on acute services, and HCPs feel that a holistic approach is required through partnership work in order to address maternal obesity effectively. This programme of research has primarily contributed to the knowledge of maternal obesity with the provision of the first national level statistics for trends in maternal obesity. The research has also provided a holistic view of the impact of obesity in pregnancy on maternity services, including the impact on resources and the issues relating to addressing the maternal obesity in clinical practice. The research has also identified aspects of service that need to be improved, and knowledge gaps in how to move services forward to effective address maternal obesity. The contribution of this research to the knowledge base is emphasised in the journal pre-publications, dissemination through UK and European, and international conference presentations, being an invited speaker at a number of conferences in the UK, and I received the 2007 Association for the Study of Obesity (ASO) Student Researcher Award for producing exemplary work in the study of obesity.

ABSTRACT The Implications of Chronic Stress on Obesity: Allostatic Load on Body Mass Index (BMI) Classification in the United States, NHANES 2005-2006 INTRODUCTION: In this modern environment, our world is reflecting an exponential increase in not only population, but in body size. Obesity is an overwhelming public health concern among the United States population. Research has shown there is a positive correlation between adiposity and stress. Allostatic load (AL) has been presented to be a consistent measure of chronic stress damage on the body. Yet, there is few studies exemplifying the presence AL on classification of body mass index (BMI). AIM: The aim of this study is to find a relationship between allostatic load (AL) and body mass index (BMI) classification in the United States adult population on a large national scale. This complex interaction can predetermine who among the US population will be at greater risk for excess adiposity following this psychoneuroendocrinology. METHODS: A representative sample size of n=3826 was gathered using NHANES data (2005-2006). Criteria for sample included all United States adults that had numerical values for 10 biomarkers chosen to represent chronic stress damage (allostatic load) along with individual body mass index (BMI). Allostatic load (low, high) and BMI classification (underweight to class III obese) were further categorized on severity and computed in SPSS to find significance between gradients of each variable (α=.05). Cross-sectional analysis and logistical regression (multivariate) were used to further decipher an association between allostatic load and BMI category. RESULTS: A strong positive correlation between allostatic load risk and BMI category was found (p<.001). Also among the variables in the study, significance was found within the strata of age, gender, race, smoking status and poverty income ratio (PIR). Findings show a strong statistically significant relationship between allostatic load and BMI. DISCUSSION: It is imperative to decipher the directional relationship between stress and obesity to provide effective treatment. Understanding the pathology of how stress affects adiposity could open the door for many clinical and public health interventions to eradicate a very preventable outcome. By addressing the effect of chronic stress, a new avenue of prevention can be developed to combat the growing obesity rates in the United States.