Background and Significance: Severe childhood obesity, the fastest growing subcategory of childhood obesity, affects 4-6% of youth. Children from racial/ethnic minority groups and low income households are disproportionately affected. Severe obesity increases risk for metabolic syndrome, cardiovascular disease, non-alcoholic fatty liver disease, musculoskeletal problems, poor health-related quality of life, bullying, low self-worth, absenteeism, and adult obesity. One method of addressing childhood obesity is through school-based interventions. School nurses may be well-suited to lead obesity interventions because of their healthcare expertise, long-term relationships with students and families, and availability to students without financial burden. Purpose: The overarching aim of this mixed methods dissertation was to evaluate the implementation and efficacy of the Healthy Options and Physical Activity Program, a school nurse-led intervention for children with severe obesity attending New York City schools. This evaluation focused on the 2012/2013 school year, the first full year of program implementation. Methods: Aims 1 and 2 were conducted to prepare for the Healthy Options and Physical Activity Program evaluation. Aim 1 included conduct of a systematic review and meta-analysis of existing literature to examine the role and impact of nurses in school-based obesity interventions. Aim 2 studied application of 3 propensity score methods to the observational Healthy Options and Physical Activity Program data set to determine which best removed significant differences in 11 potential confounders between the 1,054 kindergarten through fifth grade children who participated in the program in 2012/2013 and the 19,464 children who were eligible but did not participate. Aims 3-6 comprised the Healthy Options and Physical Activity Program evaluation. Aims 3, 4, and 5, utilized a retrospective cohort design to examine program implementation and its one year impact on body mass index percentile, school absences, and walk-in school nurse visits. Analytic methods included descriptive statistics, Wilcoxon signed rank tests, McNemar’s test, and logistic regression. Aim 6 qualitatively explored perceived barriers to and facilitators of implementing the Healthy Options and Physical Activity Program from the perspective of school nurses, using individual semi-structured interviews. Interview data were analyzed using content analysis. Results/findings: Of 11 studies eligible for systematic review, 8 met inclusion for meta-analysis. Pooled findings suggest that school nurse led interventions decreased BMI percentile by -0.41 (95%CI: -0.60, -0.21; I2=0, Cochrane Q=2.0). The comparison of propensity score methods demonstrated that only propensity score matching removed all significant differences between children who received the Healthy Options and Physical Activity Program and children who were eligible for but did not receive the program. The program evaluation demonstrated that the program had limited reach (5% of eligible children) and low intensity (median 1 session/year, parent attendance at 3.2% of sessions). Factors associated with selection for program enrollment included attending a school with low school nurse workload (OR 2.4, 95%CI 2.0-2.8), low school poverty (OR 1.6, 95%CI 1.3-1.9), and lack of chronic illness comorbidity (OR 0.5, 95%CI 0.5-0.6). After propensity score matching, program participants failed to decrease body measures, school absences, or school nurse visits at 1 year. Themes of interviews with 19 school nurses suggest that nurses encountered barriers to program implementation: parental and administrative resistance, heavy workload, and obesogenic environments. Despite barriers, nurses implemented the program to the best of their ability using creativity and teamwork. Conclusion: As implemented, the Healthy Options and Physical Activity Program was not effective in reducing body mass index percentile, absences or school nurse visits in youth with severe obesity. Barriers such as limited time and lack of parental and administrative support prevented nurses from fully implementing the program. However, school nurses with their clinical knowledge base, cost-free accessibility to children and families, and long-term relationship with students may be able to successfully employ other school-based obesity interventions. Therefore future research should use rigorous methods to develop and test school-based interventions implemented by school nurses, with a focus on intervention feasibility and sustainability. Implications for the Profession: This dissertation has implications for nursing practice, health policy, and nursing science. Findings of this mixed methods evaluation suggests that nurses may not have the resources necessary to implement intensive school-based obesity interventions. Nurses who are planning to implement such an intervention may want to carefully consider program intensity and feasibility. In addition, careful attention to increasing parent buy-in and ensuring administrator support are key. In addition, policy that supports adequate school nurse staffing can support appropriate nursing workload and may allow nurses time to implement health promotion programs and obesity interventions. During the qualitative portion of this dissertation, nurses reported the obesogenic environment as a barrier to healthful living that impacted the program’s effectiveness; obesogenic environmental factors (e.g., unhealthy school meals) will need to be addressed via legislation. Lastly, nurse scientists can work to increase the literature surrounding school-based obesity interventions, particularly with randomized controlled trials of interventions and qualitative work with nurses, parents, school administrators, and children. In addition, school-based obesity interventions must be developed and tested that consider the challenges faced by vulnerable children such as children living and attending school in high poverty neighborhoods.

It is currently estimated that over one-third of children aged 6-11 years in the United States are overweight or obese with some of the highest rates documented in Southern Appalachia. Primary care providers are uniquely positioned to intervene, however, lack of time as well as training and confidence in using behavioral techniques have been cited as barriers. Recommended strategies include use of a multidisciplinary team approach, family-centered communication, behavioral strategies, and care delivery following the chronic care model, including enhancement of parent self-management. The purpose of this study was to develop and evaluate a parent-mediated approach utilizing physician’s brief motivational interviewing and parent group sessions to treat child overweight and obesity in the primary care setting in Southern Appalachia. The current study enrolled 67 children (5-11 years) with BMI≥85th percentile and a parent/primary caregiver from four primary care practices in Southern Appalachia. The two participating Pediatric practices and two Family Medicine practices were randomized to intervention or usual care control groups. Providers in the intervention group were trained to deliver two individual visits, using brief motivational interviewing and following the AAP 15-minutes obesity prevention protocol, and four group visits using the NIH We Can! Curriculum with parents over an 8-10 week period. Trained study staff also completed four phone calls using brief motivational interviewing with parents following each group visit. Child weight and height and parent surveys were collected for both intervention and control groups at baseline, three, and six months. Additionally, parents in the intervention group completed We Can! surveys at baseline and following the fourth group session. An analysis of covariance (ANCOVA) was performed to test for the effect of treatment on zBMI at three and six months post-intervention. We Can! survey results were analyzed using paired t-tests. Data on 53 (82%) and 46 (69%) of participants was available at 3 and 6 months, respectively. While the point estimate of the treatment effect was in the expected direction, the effect of treatment assignment did not have a statistically significant effect on the zBMI at either three or six months. However, significant (p This study provides preliminary data on the use of a combination of individual and group visits with parents to treat overweight and obesity in children in primary care.

Övervikt bland yngre barn är ett nationellt och globalt ökande hälsoproblem. Distriktssköterskor som arbetar inom barnhälsovården har en viktig uppgift, både i att arbeta hälsofrämjande och förebyggande med barns övervikt. Syftet med denna studie var att belysa distriktssköterskors erfarenheter av vad som påverkar deras arbete med överviktiga barn inom barnhälsovården. Data analyserades genom kvalitativ innehållsanalys, med en induktiv ansats, beskriven av Graneheim och Lundman. Åtta intervjuer med svenska distriktssköterskor, aktiva inom barnhälsovård, genomfördes. Ur resultatet framkom fem kategorier: arbetet förenklas med användbara verktyg, betydelsen av distriktssköterskornas interna och externa resurser, vikten av stöd från kollegor och andra professioner, samtalet som arbetsmetod, och föräldrars engagemang en förutsättning för ett bra arbete. Slutsatserna blev att ett tätare samarbete behövs mellan professioner, liksom ett större ansvarstagande från verksamheten. Distriktssköterskors erfarenhet underlättade möjligheterna till ett naturligt samtal med föräldrarna, och sågs som en viktig tillgång. Fortsatt forskning inom området behövs, möjligen baserad på föräldrars synvinkel, för att lättare förstå föräldrarna och kunna utveckla det viktiga arbetet med överviktiga barn. / Overweight among young children is a national and global increasing health problem. District nurses working in child health care has an important role, both in health promotion and prevention of children’s overweight. The aim of this study was to illustrate district nurses’ experiences of what influences their work with overweight children in child health care. The data was analysed by qualitative content analysis, with an inductive approach, described by Graneheim and Lundman. Eight interviews with Swedish district nurses active in child health care were conducted. From the result revealed five categories: the work is simplified with useful instruments, the significance of the district nurses’ intern and extern resources, the importance of support from colleagues and other professions, the conversation as working method, and parental involvement a prerequisite for a good work. The conclusions were that a closer cooperation is needed between professions, as well as greater accountability from the organization. District nurses’ experience facilitated the possibilities of a natural conversation with the parents, and was seen as an important asset. Continued research in this area is needed, possibly based on the parents’ point of view, to better understand the parents and develop the important work with overweight children.

The purpose of this study was to examine maternal and infant factors associated with body mass index (e.g., maternal weight gain, infant birth weight, infant feeding methods, and motor coordination) among obese pre-adolescents and adolescents aged 8-18 years enrolled in the Pediatric OverWeight Education and Research (POWER) program operated by Riley Hospital for Children in Indianapolis, IN, between October 2008 and September 2011. POWER, a three-phase, 12-month multi-disciplinary program to reduce childhood obesity funded by Indiana University Health, enrolls obese children (Body Mass Index [BMI] greater than the 95th percentile for age and gender) through referrals from pediatricians throughout Indiana. Prior to the child’s initial visit, each family completes a comprehensive background and family history profile, approved by the Indiana University-Purdue University (IUPUI) Institutional Review Board, that includes questions related to the obese child’s motor skill development, infant feeding methods, maternal prenatal weight gain, and infant birth weight. Data related to these four categories collected during Phase 1 (12 weeks) was examined using date from 253 pre-adolescents (8-12 years of age), and 285 adolescents (13-18 years of age), to determine their impact on the subjects’ BMI. No relationship between a mother’s prenatal weight gain and the child’s BMI was seen. There was a significant correlation between infant birth weight and BMI in the pre-adolescent group. Breastfed subjects entered the POWER program at a lower BMI than non-breast fed subjects and had consistently lower BMIs throughout the program compared to the non-breastfed subjects. Differences in physical activity were observed between adolescents and pre-adolescents. Paired analysis indicated the POWER program was associated with a significant reduction in BMI overall, and among both age groups throughout Phase 1 of the program. Adolescents were especially successful in reducing their BMI compared to preadolescents. Further research is needed to identify the association of maternal and infant factors and BMI among obese children. / Department of Family and Consumer Sciences

Thesis (M.S.) -- Mississippi State University. Department of Food Science, Nutrition, and Health Promotion. / Title from title screen. Includes bibliographical references.

Thesis (Ph. D.)--University of California, San Diego, and San Diego State University, 2005. / Vita. Includes bibliographical references.

Thesis (M. S.)--University of North Carolina at Greensboro, 2006. / Title from PDF title page screen. Advisor: Charlsena Stone ; submitted to the School of Health and Human Performance. Includes bibliographical references (p. 79-88).

Thesis (M.Soc.Sc. Psychology)--University of Waikato, 2006. / Includes bibliographical references (leaves 75-80) Also available via the World Wide Web.

Thesis (MTech (Biomedical Technology))--Cape Peninsula University of Technology, 2008 / Epidemiological reports have shown that South Africa, whilst a developing country, irs overweight and obesity prevalence rates in children is fast approaching those seen in the developed world. This country's population is unique in that it is made up of different ethnic groups with different socia-economic status, partly due to the past and present political environments in the country. South Africa, in particular, is faced with a rapid increasing childhood obesity of 10% among children under the age of two and 5-20% among those less than six years of age. The prevalence of obesity is increasing in children of all ages and represents the complex integration of genetic, behavioural and environmental influences. The Ectonucleotide Pyrophosphatase Phosphodiesterase 1 (ENPP1) gene is located on chromosome 6q22-q23; a locus linked to obesity and diabetes, spans 83 kb of genomic DNA and contains 25 exons. Studies in humans have shown a correlation between overexpression of ENPP1 and insulin resistance, obesity, and type 2 diabetes. ENPP1 has been implicated in up to 20% of Caucasian and 50% of Black communities suffering from obesity. The overall objective of the proposed study is to assess whether ENPP1 polymorphisms contribute to childhood obesity/overweight, and their association with components of metabolic syndrome in a South African Coloured population. Subjects for this study were identified through a screening program that aimed to determine the prevalence of obesity in learners between the ages of 8 - 18 years from the Western Cape Province, South Africa. The first phase of the project was to clearly differentiate between obese subjects and controls. The cut-off points for obesity established by Cole and co-workers in 2000, and adopted by the International Obesity Task Force (IOTF), were used to classify the obese subjects.

The aim of the study was to determine the Body Mass Index with regards to overweight and obesity of Black African children between the ages of six and nine years who were enrolled in three rural public schools within Mpumalanga Province, South Africa. The researcher used a quantitative descriptive research design. Each child’s weight and height was measured and their BMI and BMI percentile for gender and age calculated. According to the BMI percentile calculations for gender and age for the sample which consisted of 902 children, three percent were defined as being underweight, 79 percent as being normal weight, 11 percent as being overweight, and seven percent as being obese. In the sample there were also 21.3 percent children who were at risk of becoming overweight (3.5 percent) and obese (17.8 percent). Without intervention these at risk learners may in their adolescent and adult years be adversely affected by the physiological and psychosocial consequences related to their condition. Suggestion is made to utilise a Forum through which various stakeholders can pool their expertise and resources to develop a programme of intervention with the aim to prevent escalation of overweight and obesity, as well as reversing the current prevalence as identified within the research population.