published_or_final_version / Community Medicine / Master / Master of Public Health

Class of 2005 Abstract / Objectives: To describe the physical activity and nutrition status of pharmacy students and determine the level of knowledge that these students have related to prevention of obesity. Methods: This was a descriptive study of the physical activity and nutrition status of pharmacy students and their knowledge related to the prevention of obesity. Data were collected from all the students using a paper and pencil questionnaire (a copy is provided in the Appendix). Students were asked to answer questions related to causes of obesity, definition of obesity using BMI, and physical activity relating to BMI. They were also asked to compare physical activity to drug therapy and define the recommended exercise guidelines by the Institute of Medicine. Students were asked to match physical activities with the intensity of the activity from light to vigorous. Students were also asked to list the fruits, vegetables, unsaturated fats, sweetened drinks, fried foods, and whole-grain foods consumed the day prior. Students listed the frequency of moderate and vigorous activities they participated in the week prior. Students chose the benefits of physical activity most important to them and were asked to rank the importance of physical activity, diet and obesity prevention to their health. Demographic data were collected on age, gender, ethnicity, height and weight. Results: Scores were derived for all questions and mean scores for the three classes were compared using student’s t-test for all groups. Mean scores and student’s t-test were also used to compare responses between genders. Implications: Overall, pharmacy students are lacking education in preventing obesity. By educating pharmacists about healthy eating and physical activity they, in turn, can educate the public on preventing obesity.

Childhood obesity is an extensive problem in the United States and North Dakota (CDC, 2014). Significant health consequences are linked to obesity, including type two diabetes, hypertension, hyperlipidemia, cardiovascular disease, cancers, and psychological disorders (Pandita et al., 2016; Xu & Mishra, 2018). Obesity comorbidities, previously presented in later adulthood, now emerge in younger populations (Pandita et al., 2016). Unfortunately, treatment of obesity is not effective, and therefore, prevention must be the primary focus (Daniels et al., 2015; Pandita et al., 2016). Diet and eating behaviors have a significant impact on weight, and children develop taste preferences and lifelong eating behaviors within the first few years of life (Birch & Anzman, 2010; Daniels et al., 2015; IOM, 2011). Therefore, targeting interventions on feeding and nutrition in infancy may foster healthy habits for life and play a role in the prevention of obesity. Responsive feeding interventions hold promise in supporting healthy growth. Ellyn Satter’s Division of Responsibility promotes the responsive feeding relationship between parent and child. The purpose of the practice improvement project was to address childhood obesity prevention through the development of an educational curriculum on feeding and nutrition. The parent-focused education correlated with each well child visit (WCV) between the ages of two weeks and three years. A multidisciplinary team of representatives from pediatrics, behavioral health, and patient education was consulted to develop the education. Ten providers at Midwestern primary care clinics reviewed the educational curriculum and provided feedback on the content and methods to deliver the education to parents. Most providers found the content to be accurate (n = 7; 70%) and comprehensive (n = 8; 80%). Three providers suggested expanding on topics such as breastfeeding and mixing formula. Providers unanimously agreed that the curriculum is relevant and understandable. A formal literacy evaluation resulted in grade-level readability scores between the 6th and 8th-grade levels. Almost all providers (n = 9) believed the curriculum would be valuable for use in practice. The preferred delivery method chosen was one on one provider to parent education. The project clinic plans to pilot the curriculum with parents attending infant and toddler WCVs.

Obesity is a complex and increasingly prevalent health disorder that is associated with a wide range of medical, social, and psychological difficulties. People are more likely to be obese if they consume an energy dense diet but do not engage in physical activity. Research has indicated that interventions, when implemented during childhood, have long-term outcomes that are superior to interventions implemented in adulthood. This research piloted a behaviourally based intervention programme, with parents as the agents of change, to promote a lifestyle change for inactive children. The programme focussed on increasing physical play (lifestyle activity) and on decreasing sedentary behaviour (an obesity promoting behaviour) during children's after school leisure time. The intervention was investigated using three case studies. Although no conclusive evidence was gained regarding the effectiveness of the pilot programme there was some evidence that children participating reduced their amount of sedentary behaviour and increased the amount of time they spent in physical play. There was also evidence that parents were able to administer the programme and that they found it useful. The results from the present study suggest that the development and application of parent administered behavioural programmes, in the form of packaged interventions to prevent child obesity, warrant further investigation both in terms of the benefits and costeffectiveness it could offer parents and practitioners alike.

Understanding the determinants of behaviour in children is crucial to curb the current population obesity trends. Children's behaviour develops within the home, making it a target for obesity prevention efforts. Previous research has identified a network of parental factors that are thought to influence children's health-related behaviour including weight, health-related knowledge and behaviour, parenting styles and practices, to name but a few. This complexity makes it important to use theory or models to guide research and to determine the relative importance of factors within the home environment to improve the effectiveness of future obesity prevention interventions. Embedded in psychological theory and nutrition education principles is the concept that knowledge is required for behaviour change. This thesis provides much-needed support for the theoretical foundation that nutrition knowledge is a determinant of dietary intake behaviour. The measurement of knowledge and the collection and interpretation of intake data are often cited as limitations to research & issues this thesis aimed to address. Modifications were made to an existing measure of nutrition knowledge, and a validation exercise conducted within a heterogeneous Australian community setting provided a valid and reliable assessment tool to measure knowledge. Single nutrient or food group analysis omits the synergistic nature of whole diet. A key component of this thesis was the modification of the United States Department of Agriculture's Healthy Eating Index to be consistent with Australian dietary guidelines and its application to the interpretation of dietary intake. An exploratory study, using the validated knowledge tool and modified diet quality index, revealed that some of the basic nutrition guidelines, such as eat more vegetables and less fatty foods, are reaching the community, but detailed knowledge of the nutrient content of foods, diet-disease relationships and making healthier food choices is poor. Indeed, knowledge was shown to be a significant independent predictor of dietary intake and diet quality. Knowledge was shown to be a stronger predictor of overall diet quality than of any single nutrient or food group. The second aim of this thesis was to disentangle the relative importance of family environmental factors in the context of obesity resistance in children. A 12-month longitudinal study involved 154 South Australian families with primary school-aged children, and used structural equation modelling and previous research to present a model of obesity resistance. The proposed model showed an acceptable fit (NFI=0.458; CFI=0.741; RMSEA=0.045). Parents' BMI (β=0.34*) and knowledge (β=-0.21*) had the strongest direct associations with children's obesity risk. Parents' intake and expenditure behaviours were indirectly associated with children's behaviours through the creation of the home environment. The physical activity environment was associated with children's sedentary (β=-0.44*) and activity habits (β=0.29*). The food environment was associated with fruit and vegetable intake (β=0.47*). General parenting styles (β=0.63*) and child feeding practices (β=-0.74*) were associated with the family environment. Parents' knowledge also had a direct influence on their parenting practices & parenting style (β=0.25*) and feeding practices (β=-0.50*). The proposed model provided a comprehensive insight into the potential avenues for intervention within the complex network of factors that make up the family home environment.

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Obesity results from a complex interaction between diet, physical activity, and the environment. The purposes of this study were to identify behaviors associated with resilience to childhood obesity, and to compare the sensitivity of the Figure Rating Scales (FRS) in reflecting Body Mass Index (BMI). Fifty health professionals in nutrition and 35 low-income, parent-and-child pairs completed the study. Children aged 6-11, perceived as “normal-weight” by their parents, were recruited. Five children had a measured BMI above the 85th percentile. Using a picture-sort method, each participant responded to a series of questions about 13 childhood obesity-related messages. Results included comparison between health professionals, parents, and children about 1) familiarity toward each message, 2) frequency in following the recommendation, 3) perception of ease for others to follow, and 4) perception of effectiveness to help prevent childhood obesity. Health professionals and parents had similar familiarity regarding all 13 messages. However, in terms of practicality, health professionals and parents differed significantly in eight messages that they reported “always taught/followed,” seven messages that they “sometimes taught/followed,” and two messages that they “seldom or never taught/followed.” In most messages, children’s observation about what the family followed differed from what parents reported following. In terms of ease for others to follow “Watch portion sizes” and “Tell children to eat all of the meal before getting dessert,” health professionals and parental perception differed significantly. In terms of effectiveness in childhood obesity prevention, health professionals and parents agreed on 12 of 13 messages. Health professionals did not find message “Tell children to eat all of the meal before getting dessert” to be effective in preventing childhood obesity, whereas parents did. FRS and measured BMI were significantly correlated among health professionals (r=0.75), parents (r=0.72), and children (r=0.53 for children ages 8-11, r=0.64 when a mother selected a silhouette for her child). For different subgroups, parent-and-child silhouette selection was closely correlated (r= 0.84). However, correlation between child’s BMI percentile and silhouette was nonsignificant in most subgroups (r= 0.47). In conclusion, FRS was effective among adults and older children (aged ≥8) in reflecting BMI but not among younger children (aged 6-7).

ABSTRACT Research suggests that it is important to establish regular physical activity and healthy eating patterns during the early years (0-5 years). Engaging in healthy behaviours during this stage of life supports growth and development and lays the foundation for a lifetime of health and wellbeing. Despite these benefits, research indicates that children in Canada are not meeting the daily recommended physical activity guidelines for early years. Moreover, their diets are lacking in fruits and vegetables and are high in processed foods. As many early years children spend a large part of their day in childcare centres, educators can have a large influence on their physical activity and healthy eating behaviours. In the Canadian Prairie Provinces many childcare centres are located in rural communities. Previous research suggests that rural educators are influenced by unique factors associated with geographic local (e.g., access to resources to promote physical activity and year round access to variety of healthy foods) when attempting to provide healthy opportunities for children. In order to address the specific factors identified by rural educators and support healthier behaviours among rural early year’s children, a multilevel physical activity and healthy eating intervention (Healthy Start) was developed using McLeroy’s ecological model and a population health approach. Healthy Start was pilot tested in three rural childcare centres. Purpose: The primary purpose of this dissertation study was to evaluate Healthy Start, a multilevel community-based physical activity and healthy eating intervention, in rural childcare centres throughout Saskatchewan. In order to achieve this primary purpose, the specific dissertation objectives were addressed as follows. Paper 1: a) Determine if over the course of the intervention, Healthy Start contributed to increases in physical activity levels and improvements in motor skill development among early years children aged 3 to 5 years; b) Determine if Healthy Start supported educators in providing children with more opportunities for physical activity; c) Describe educators’ experiences and perceptions of Healthy Start and its influence on physical activity within the childcare centre environment. Paper 2: a) Assess to what extent, Healthy Start contributed to healthier eating behaviours among early years children aged 3 to 5 years over the course of the intervention; b) Determine if Healthy Start supported childcare staff (educators and cooks) in providing children with more opportunities for healthy eating; c) Describe educators ‘experiences and perceptions of Healthy Start and its influence on healthy eating within the childcare centre environment. Paper 3: To pilot a pulse crop intervention study in one of the intervention childcare centres in order to: a) Increase knowledge and awareness about the nutritional value and health benefits of pulse crops among childcare staff (educators and cooks); b) Support childcare staff in providing children with more opportunities for pulse crop consumption; c) Expand the variety of healthy foods consumed by early years children by incorporating locally grown pulse crops into the childcare centre meals. Methods: A population health controlled intervention study using a wait-list control design (48 weeks delayed-intervention) was used to evaluate the impact of the intervention. Mixed methods were employed to determine the intervention’s influence on children and educator behaviours and on the childcare centre environment. Results: Overall, increases in children’s physical activity levels and improvements in healthy eating behaviours were observed in the intervention group. Moreover, educators felt the intervention was effective in supporting them to increase physical activity and healthy eating opportunities provided to rural early years children. Lastly, improvements to childcare centre environments were made to promote healthy behaviours among the children. Conclusion: Collectively, the pilot study provided insight into the complexities and feasibility of promoting physical activity and healthy eating among early years children in childcare centres, particularly in rural communities. This was an innovative intervention which addressed critical factors at multiple levels contributing to the development of healthy behaviours among rural early years children. The lessons learned in this dissertation study can be used to improve the Healthy Start intervention so its implementation can be effectively expanded to childcare centres within and outside of Saskatchewan. Additionally, the findings can contribute to the limited body of literature on implementing and evaluating interventions aimed at increasing both physical activity and healthy eating in Canadian childcare centres. In turn, supporting the healthy development of early years children in the province and beyond.

Introduction and Rationale: Childhood obesity is a public health epidemic in the United States. Prevention of childhood obesity is an important health concern, but there is a lack of prevention efforts focused on infancy (Birch, Anzman-Frasca, & Paul, 2012). Many health behaviors are learned in the very early childhood years (Dattilo et al., 2012), so infancy is an opportune time to begin obesity prevention efforts (Grote, Theurich, & Koletko, 2012; Paul et al., 2011). There are very few resources available to educate mothers and caregivers of infants on protective infant feeding practices to reduce obesity risk. Purpose and Objective: The purpose of this DNP project is to develop educational material about infant feeding practices as a significant modifiable risk factor for the development of childhood obesity. The educational material is directed towards pregnant women and caregivers of infants less than 12 months of age. The objective is to educate parents and caregivers about infant feeding practices and the importance of preventing excessive weight gain during the first year of life for the prevention of childhood obesity. Methods: The Information-Motivation-Behavior (IMB) Model of Health Behavior serves as a framework for the content of the educational material. The Toolkit for Making Written Material Clear and Effective serves as a guide for the design of the educational material. Results: A systematic assessment of the educational material was conducted using the Patient Education Materials Assessment Tool (PEMAT), a validated evaluation tool. The educational material was revised based on the PEMAT score. The PEMAT score was calculated for the revised handout and the handout is presented as an educational tool for the prevention of childhood obesity. Conclusions: This DNP Project demonstrated childhood obesity as a current significant health problem and identified infant feeding practices as a significant modifiable risk factor for the development of childhood obesity. Due to a lack of obesity prevention efforts focused on infancy, educational material was created using the IMB model of health behavior and the Toolkit for Making Written Material Clear and Effective. The final PEMAT evaluation yielded educational material that will likely have a positive health influence on the pediatric population.