Objective: To assess the reliability of the Kids' Activity and Nutrition Questionnaire (KAN-Q) as part of a tiered process for developing Supplemental Nutrition Assistance Program-Education tools. Methods: The KAN-Q was administered at 2 time points to assess internal consistency using standardized values of Cronbach alpha and test-retest reliability using the intraclass correlation coefficient for continuous variables, Cohen's kappa (k) statistic for categorical variables, and the weighted k statistic for ordinal data. Results: Data were collected from 119 fourth graders. Cronbach a was adequate for behavior (.71) and knowledge (.72) scales and nutrition behavior (.78) and nutrition knowledge (.75) subscales. Test-retest reliability was generally acceptable, with intraclass correlation coefficients from 0.40 to 0.75 and k coefficients showing fair to substantial agreement (0.30 to 0.72). Conclusions and Implications: The KAN-Q is a practical and reliable questionnaire for school-based administration that aligns directly with Supplemental Nutrition Assistance Program-Education evaluation priorities.

Rising rates of obesity among children have become one of the most pressing issues in modern public health. Childhood obesity threatens both the mental and physical well-being of children. Attempts to halt the rise in obesity take many forms, but one of them is the recent implementation of a programme of measurement of primary children at reception and in year 6, with results being fed back to parents. This National Child Measurement Programme (NCMP) is controversial and has been criticised in some quarters as unethical, in being a form of screening programme with no clear or effective interventions available for those detected as having a problem. Study aims and objectives The main aim of the study was to explore the relationship between weight status and children’s mental wellbeing, especially in the context of the NCMP. Within this overall aim, key specific objectives of the study were: i) to investigate the association between weight status of 10-11 year old school children and their mental well-being; ii) to assess the impact on the mental wellbeing of children, of participating in the NCMP; and iii) to collect information about parents’/guardians’ and children’s reaction to the NCMP, with particular interest in identifying whether parents/guardians and their children found the feedback useful in moving towards the adoption of a healthy lifestyle. Methods The study was undertaken in primary schools in the catchment area of Gateshead Primary Care Trust (PCT). The overall study used a mixed methods study design. The study involved administering a questionnaire prior to NCMP measurement to a total sample of 264 children, sampled using a proportionate stratified random sampling technique. One-to-one semi-structured interviews were also conducted post measurement with 21 children purposively sub-sampled from the larger group, and with 16 parents/guardians. Results Prior to measurement, most children misclassified their weight status. About 1 in 10 children who were of ideal weight perceived themselves as overweight. Over three quarters of overweight children perceived themselves to be of ideal weight. There was no significant relationship between any of the indicators of mental wellbeing and actual weight status of children. However, there was very strong evidence for a Preface xxv significant relationship between perceived weight status and mental wellbeing among children. Seven major themes emerged from the post measurement interview data, but perhaps the most intriguing was the cycle of emotional reaction of families to the NCMP and weight feedback. Discussion The reactions of parents/guardians whose children are indicated to have weight problems follow a sequence of behaviours ranging from shock, disgust with the programme, through denial and self-blame to acceptance, worry and help seeking. Reasons for these responses relate in many cases to the way the weight problem is portrayed to the parents. While health authorities are keen to portray this problem as a medical one, parents/guardians see it as social one. The roots of overeating and lack of exercise are seen as lying in the complex social and cultural milieu in which this sample of people live. Consequently, associating this problem in feedback letters with dangerous diseases like cancer, and advising parents to visit GPs to resolve child weight issues, seems inappropriate to the recipients and causes controversy and anger. Conclusion The NCMP’s routine feedback could potentially induce families into the state of readiness to change lifestyle behaviours; however, given the reactions described in this study, it seems critical to avoid placing blame on individuals but rather to acknowledge the influence of the environment surrounding families and to provide non-medical support aimed at bringing families on board to support interventions for combating child weight problems.

The purpose of this study was to uncover the experience of health care providers (HCPs) as they work with fathers of children who are overweight and obese in the outpatient setting. Interpretative phenomenological analysis was used for data collection and analysis in this study. Seven HCPs were interviewed about their experiences. Two major themes emerged from the experiences of these HCPs: "dad in the backseat," and "paternal resistance." The theme of "dad in the backseat" captured to the HCPs' perception of parental roles and related stereotypes with respect to fathers' lack of presence in the health-care setting, family roles that relegate fathers to the backseat in dealing with this issue, and the tendency of fathers to take a passive role and defer to mothers in the management of their child's weight. "Paternal resistance" reflected the perceived tendency of the father to resist the acceptance of their child's weight as a problem, and to resist change and even undermine family efforts to make healthier choices. Health care providers' experiences of fathers as having a minimal role in the management of their child's overweight and obesity may lead them to neglect fathers as agents of change in this important issue.

To properly evaluate initiatives targeting children's fruit and vegetable (FV) consumption, we need feasible and valid dietary assessment methods that are time, cost, and resource effective. The objectives of this study were to test the feasibility and validity of two methods, digital imaging (DI) and aggregate plate waste (APW), for assessing children's FV consumption. UVM dietary assessment team graduate students prepared and distributed FV snacks in two pre-school classrooms over 30 consecutive school days. Feasibility of APW was tested by recording the frequency and weight of waste sorting errors by pre-school children and performing paired t-tests comparing uncorrected and corrected FV waste. Feasibility was tested for DI by determining the total number of individual FV snacks from which FV consumption could be estimated using the digital images. Validity was tested for DI using paired t-tests to compare FV consumption as assessed by DI against actual consumption as assessed by weighed plate waste (WPW). A total of 159 cluster APW weights were recorded during the 20 days of APW collection, with an overall mean difference of 0.57 grams (p=0.440) between uncorrected and corrected FV waste. Researchers were able to capture 100-percent usable digital images, effectively displaying 214 individual FV snack servings over the 10-day DI study period. Percent agreement between the two digital image coders was 99.1-percent. DI estimations for individual FV item and cumulative consumption were strongly correlated with WPW (all above r=0.97). Overall FV consumption as estimated by DI differed from WPW by less than one gram, and DI estimations for individual FV items differed from WPW by no more than two grams. Paired t-tests revealed no significant difference between DI estimations of clementine (p=0.954) and peapod (p=0.806) consumption and WPW measurements. However, paired t-tests indicated statistically significant differences between DI and WPW measurements for overall (p=0.001), grape (p=0.031), carrot (p=0.008), and pepper (p=0.027) consumption. Both methods were feasible for assessing mean FV consumption. DI estimations for individual FV items and cumulative consumption were strongly correlated with WPW, suggesting that despite statistical significance between DI and WPW measurements in some cases, the DI method is still precise for mean FV consumption evaluation. APW may be especially advantageous for rapid and efficient evaluation of behavior change in response to interventions targeting children's FV consumption. Due to ease of administration and instantaneous results, the APW method reduces the need for trained research staff to be present, drastically increasing accessibility to group-level dietary assessment.

The obesity epidemic is a major public health concern, where the prevalence rates amongst the American children population have more than doubled since the 1980s. Among overweight children, the risk of becoming an overweight or obese adult is 70% higher than children of normal weight, and obese children are more likely to remain obese into adulthood and face a number of morbidities associated with it, including lower quality of life and increased financial burden. In this research, we examined the relationship between household food security and obesity among children and adolescents between the ages of 2-18 years old. We used data from the NHANES 2005-2006 (n= 3,432). Amongst the children aged 2-18 years, 31.21% were determined to be obese or at-risk for obesity. Children aged 2-18 years were 1.27 times more likely to be obese or at-risk when living in a food insecure household after adjusting for race/ethnicity. Adolescents aged 12-18 years were 1.47 times more likely to be obese or at-risk when living in a food insecure household. No significant association was found for young children aged 2-11 years. After adjusting for race/ethnicity and poverty level status, however, the association between food insecurity and obesity was not significant for either age group. Further investigation of other potential confounders could explain the association for both young children and adolescents. There are other factors, like social and societal, that influence the trends of obesity. Future programming could work to ameliorate the conditions of food insecurity and other infrastructure factors.

Thesis advisor: Susan Kelly-Weeder / Background: Addressing childhood obesity requires a multidisciplinary approach. School based BMI screening and referral provided an opportunity for school nurses (SNs) and pediatric primary care physicians to collaborate. Understanding the capacity to collaborate, as well as the barriers and benefits, help to support interprofessional care. Purpose: The purpose of this investigation was to determine SNs’ and pediatric physicians’ attitudes toward collaboration as well as the presence of successful collaboration proposed in the Four Dimension of Collaboration Model (FDCM). Methods & Sample: An exploratory, cross-sectional mixed methods study of SNs’ and pediatric physicians’ attitudes and practices regarding collaboration was conducted using a combination of web-based and mailed survey instruments utilizing both open and closed-ended questions. One hundred and fourteen school nurses and sixty-three pediatric physicians completed the study. Results: While SNs and physicians both reported high scores on the Jefferson Scale of Attitudes toward MD-RN Collaboration (JSAC) indicating a positive attitudes toward physician – nurse collaboration; SNs scores were significantly higher than physician scores (55.05 + 3.30 v 52.42 + 5.74, p = .001). A regression model identified that physician’s age, community location, and having a moderate percentage of obese patients within their practices were associated with positive (age) and negative (community and moderate percent obese patients) effects on attitude toward collaboration. Providers’ responses indicated deficits throughout the FDCM. Dimension indicator, “mutual acquaintanceship” indicated that 37% physicians did not know any SNs. Similarly, 24% SNs reported that they did not “trust” local physicians to listen to their concerns. Qualitative analysis indicated the myriad of challenges faced by both providers. Benefits and barriers were similar for SNs and physicians; however, their experiences suggested a lack of mutual knowledge. Conclusions: Collaboration around childhood obesity is a unique struggle due to its multifaceted nature. School nurses and physicians showed positive attitudes toward collaboration; however, their capacity to act was limited. School nurses and pediatric physicians recognized the value of interprofessional collaboration recommending improvements to the current system. / Thesis (PhD) — Boston College, 2017. / Submitted to: Boston College. Connell School of Nursing. / Discipline: Nursing.

A obesidade infantil vem aumentando progressivamente e está associada a várias complicações na infância e na idade adulta. Apresenta etiologia multifatorial, sendo o resultado de complexas interações entre fatores genéticos, dietéticos e ambientais. O presente estudo investiga um dos fatores ambientais, a influência familiar, e utiliza um novo instrumento para especificar como o comportamento dos pais influencia o excesso de peso de seus filhos durante a infância. O Questionário de Alimentação da Criança (QAC) avalia as crenças, atitudes e práticas dos pais em relação à alimentação de seus filhos e a relação destes componentes com a tendência ao desenvolvimento obesidade infantil. A versão original deste instrumento apresenta 31 questões e avalia 07 fatores: Percepção de responsabilidade, Percepção do peso dos pais, Percepção do peso da criança, Preocupação com o peso da criança, Restrição, Pressão para comer e Monitoramento. Portanto, o objetivo deste estudo foi investigar as atitudes, crenças e práticas das mães em relação à alimentação e propensão à obesidade em crianças que são atendidas pelo Sistema Único de Saúde (SUS) da cidade de Ribeirão Preto - SP. Os participantes foram 300 pais e filhos, sendo 150 mães e 150 crianças, aleatoriamente selecionadas, com idade entre 2 a 11 anos e de ambos os sexos. O QAC foi aplicado às mães e a avaliação antropométrica foi realizada através da aferição de peso corporal e estatura das mães e filhos, de acordo com as instruções recomendadas pelo Ministério da Saúde. Realizou-se a descrição dos dados por meio de frequências e percentuais e o teste de correlação de Kendall entre as variáveis em estudo. Os níveis de significância estatísticaestabelecido foi p<0,05. A avaliação do estado nutricional foi realizada através do IMC, segundo os critérios de classificação recomendados pela OrganizaçãoMundial da Saúde (OMS).Os resultados mostraram que parte das crianças e das mães apresentou excesso de peso. Em relação ao QAC, no fator Percepção de responsabilidade as mães consideram-se, na maior parte do tempo, responsáveis pela alimentação dos filhos. Para o fator Percepção do peso dos pais e percepção do peso da criança, estas relatam peso normal desde a infância até atualmente. Para o fator Preocupação com o peso da criança as mães consideram-se preocupadas. Para o fator Restrição, as mães concordam com a prática de restringir que sua criança coma determinados alimentos. No fator Pressão para comer, as mães concordam em relação à pressão para que sua criança coma determinada quantidade ou tipo de alimento. No fator Monitoramento, as mães relatam que sempre devem monitorar o que sua criança come. Além disso, verificou-se correlação positiva entre as variáveis IMC dos filhos e dos pais; IMC dos filhos e os fatores Percepção de responsabilidade, Percepção do peso da criança, Preocupação com o peso da criança, Restrição e Monitoramento; e negativa entre IMC dos filhos e Pressão para comer. Desta forma, é possível sugerir que as crenças, atitudes e práticas dos pais durante a alimentação dos filhos estão associadas com o excesso de peso na infância. / Childhood obesity has been increasing steadily and is associated with various complications in childhood and adulthood. Presents several causes and is the result of complex interactions between genetic, dietary and environmental. This study investigates one of the environmental factors, family influence, and uses a new tool to specify how parents\' behavior influences the overweight of their children during infancy. The Child Feeding Questionnaire (CFQ) assesses parents beliefs, attitudes and practices about childs feeding and relationship of these components with the trend of childhood obesity. The original version of this questionnaire has 31 questions and it evaluates 7 factors: Perceived Responsibility, Perceived Parent Weight, Perceived Child Weight, Concern about Child Weight, Restriction, Pressure to Eat and Monitoring. Therefore, the aim of this study was to investigate the attitudes, beliefs and practices of the parents about childs feeding and obesity proneness on children who are served by the Unified Health System in the city of Ribeirão Preto-SP. The participants were 300 parents and children (150 mothers and 150 children). The children were randomly chosen, with the age ranging from 2 to 11 years and of both sexes. The CFQ was applied on mothers and the anthropometric measurements were recorded by measurement of mothers and childrens body weight and height, according to the instructions recommended by the Ministry of Health. For the data analysis, a descriptive statistics (percentages and frequencies), the Kendall correlation test, when applicable, was used. The levels of statistical significance were set at p<0.05. The assessment of nutritional status used the Body Mass Index (BMI) according to the classification criteria recommended by the World Health Organization (WHO). The results showed that most children and mothers were overweight. In relation to the QAC, for the Perceived Responsibility Factor, mothers considered themselves, the responsible ones for feeding their child most of the time. As for Perceived Parent Weight Factor, they reported to have had normal weight from childhood up to the present moment. The Perceived Child Weight Factor, parents also affirmed that their children always had normal weight from their childhood up to the present moment. On Concern about Child Weight Factor, the mothers are considered to be worried. About the Restriction Factor, mothers agree with the practice to restrict the ingestion of some type of food to their children. For the Pressure to Eat Factor, mothers agree about the pressure to regulate the quantity of determined type of food consumed by their children. On Monitoring Factor, mothers reported that, they always should monitor what their child eats. Moreover, there was a positive correlation between children and parents BMI variables, as well as childrens BMI and the factors Perceived Responsibility; Perceived Child Weight; Concern about Child Weight, Restriction and Monitoring, and negative correlation between childrens BMI and Pressure to Eat. It can be concluded that the parental attitudes, beliefs and practices about childs feeding are positively associated with overweight in childhood.

Thesis advisor: Mary E. Walsh / Childhood obesity is a pervasive health issue in the United States. Research has demonstrated that various correlates are associated with the onset and maintenance of overweight status, including physical health conditions, psychological well-being, interpersonal relationships, family functioning, and educational attainment. Policymakers and educators have agreed that elementary and secondary schools are crucial settings for the promotion of healthy development and ameliorating obesity. Therefore, comprehensive school-based interventions that collaborate with community agencies are being implemented to improve the achievement and well-being of at-risk students. The present study focused on City Connects, an optimized student support intervention grounded in relational developmental systems theory that functions in predominantly high-poverty urban locations. City Connects recognizes students as possessing unique constellations of protective and risk factors (i.e., strengths and needs), and an integral aspect of the intervention is that it connects students to tailored services to enhance strengths and address needs. The endeavor of the present study was to examine K-5 students that City Connects identified as manifesting with overweight issues via a holistic, collaborative assessment process, and how these students differed from peers not designated as overweight. Findings indicated statistically significant differences across the groups, in terms of demographic characteristics, overall level of perceived risk, strengths and needs recognized, school-related academic and thriving outcomes, and the influence of specific psychosocial and familial strengths and needs on those school outcomes. Specifically, students presenting with overweight concerns were more likely to be from lower socioeconomic backgrounds; have a high association with special education service needs; represent a more intensive overall risk level; manifest a diverse array of strengths and needs across academic, social-emotional/behavioral, family, and health/medical domains; and mostly exhibit poorer school performance. The effects of certain strengths and needs moderated school performance differences in several instances. Implications for theory, policy, and practice are discussed, with recommendations for future research. / Thesis (PhD) — Boston College, 2016. / Submitted to: Boston College. Lynch School of Education. / Discipline: Counseling, Developmental and Educational Psychology.

Childhood is a critical time point in determining adult health. Healthy habits that are formed during childhood can not only prevent medical conditions and illnesses in adulthood, but also allow a child to learn, grow, and become a healthy adult. The importance of healthy childhood habits has been discussed in U.S. Health Department of Health and Human Services' Healthy People 2020 initiative and numerous scientific studies regarding the importance of promoting child health and physical activity at an early age to ensure that these habits continue into adulthood. The purpose of this retrospective, qualitative study is to analyze the effectiveness of CYCLE Kids, a school-based bicycling and nutrition curriculum, in promoting physical activity and healthy behaviors in children. The CYCLE Kids program is implemented as eight physical education classes for students in the fourth and fifth grade. It was evaluated using self-reported pre- and post- curriculum assessments to determine if students showed measurable behavioral changes or knowledge gains. The assessments also contained open-ended questions to further understand the students' point of view on what they were learning and what they enjoyed most. For the evaluation, the assessment questions were divided into bicycle skills and safety, bicycling frequency and physical activity, and nutrition and physical fitness. The study sample included 1,575 children ages 8-12 years (mean 10.2 years) from public schools in Cambridge and Somerville, Massachusetts. The demographics of the students were 30% Caucasian, 16% Latino, 19% African American, 10% Asian, and 2% American Indian or Alaskan Native. Teachers and police officers involved in the implementation of the CYCLE Kids program were also surveyed to ascertain perceptions of the strengths and weaknesses of the curriculum, and to discern the perceived benefits of participating in the program. A total of 15 teachers responded to the survey (60%) from partner schools in eight states across the United States where the CYCLE Kids curriculum is being taught. Results from the student assessments indicate that students showed the most knowledge gain in bicycle and safety skills, with a 39% increase in the proportion of students who reported knowing how to use hand signals when riding a bicycle by program completion. This trend remained prominent in students' post-assessment open-ended responses where bicycle skills and safety made up more than three-quarters (78%) of the responses to the two most important things learned in the program. Bicycling frequency and physical activity showed moderate increases; an increase by 4% (from 76% at baseline to 80% after the unit) in the proportion of students who own a bicycle at home, an increase by 7% (from 39% to 46%) in the proportion of student who rode their bikes weekly, and an increase by 10% increase (from 68% to 78%) in the proportion of students who were exercising and playing sports more often. In the nutrition and physical fitness category, children showed only minor improvement with the greatest gains in this category for knowing how to take their heart rate and wanting to learn more about healthy eating. Teachers perceived that the CYCLE Kids program increased a student's self-confidence, helped students overcome fears, and got students excited about riding a bicycle. Additionally, all but one teacher who participated in the survey reported perceived behavioral changes in their students. Teachers also noted several implementation obstacles to the curriculum delivery including not having enough classroom time to fully teach the lessons, the difficulty of doing textbook lessons in the gymnasium, and the logistics of moving the bicycles from storage to riding areas. Overall, the student and teacher feedback indicated that the CYCLE Kids program increases bicycle knowledge and safety skills in addition to increasing self-confidence of participants. Teaching children to safely and properly ride a bike develops a life skill that they can carry far into the future. However, it is unclear if participation in the CYCLE Kids program prompts students to be more physically active. A long-term study analyzing students' behaviors and physical activity levels several years after program participating in the program is warranted. Ongoing work will revise several of the CYCLE Kids curriculum components and address implementation logistics uncovered by this evaluation.

Childhood obesity and its sequelae are a major public health problem in both the USA and globally. This review will focus on a systems medicine approach to obesity. Systems medicine is an integrative approach utilizing the vast amount of data garnered from “omics” technology and integrating these data with conventional pathophysiology as well as diverse environmental factors such as diet, exercise, community dynamics and the intestinal microbiome. Omics technology includes genomics, epigenomics, metagenomics, metabolomics and proteomics. In addition to unraveling etiology, the goals of a systems medicine approach are to provide actionable and evidenced-based clinical approaches. In the case of childhood obesity, an additional goal is characterizing measureable risk factors/biomarkers for obesity at the earliest possible age and devising age-appropriate optimal intervention strategies. It is also important to establish the age at which interventions could be critical. As discussed below, it is possible that some of the pathophysiological and epigenetic changes resulting from childhood obesity could become more irreversible the longer the obesity remains untreated.