Background: While the obesity epidemic is impacting children, survivors of childhood brain tumors (SCBT) are particularly vulnerable to obesity-driven cardiometabolic comorbidities. SCBT have excess body fat (adiposity) with similar body mass measures when compared to matched non-cancer controls. The effect of the built environment on the risk of obesity has received relatively limited attention in survivors. Aim & Methods: The aim of this project was to determine the impact of the built environment on body mass index (BMI) percentile, body fat percentage (BF%), waist-to-hip ratio (WHR), and waist-to-height-ratio (WHtR) in SCBT and non-cancer controls. The data for this secondary analysis were derived from participants in the Canadian Study of Determinants of Endometabolic Health in Children (CanDECIDE), a prospective cohort study based at McMaster Children’s Hospital, a tertiary pediatric academic center in Hamilton, Ontario, Canada. The Neighborhood Environment Walkability Scale (NEWS) was used to assess the built environment. Multivariable regression analyses were used to define the predictors of the association. Results: The built environment was not associated with BMI percentile in SCBT and non-cancer controls including residential density (B 0.276, p value 0.436), land use mix diversity (B -0.286, p value 0.301), land use mix access (B 0.004, p value 0.993), street connectivity (B 0.297, p value 0.431), walking/cycling facilities (B 0.185, p value 0.540), neighborhood aesthetics (B 0.270, p value 0.513), safety from traffic (B -0.368, p value 0.418), and safety from crime (B -0.074, p value 0.907). The built environment was also not associated with adiposity measures (BF%: residential density B 0.031, p value 0.851, land use mix diversity B -0.082, p value 0.513, land use mix access B -0.036, p value 0.861, street connectivity B 0.309, p value 0.055, walking/cycling facilities B 0.109, p 0.439, neighborhood aesthetics B 0.127, p value 0.503, safety from traffic B -0.047, p value 0.825, and safety from crime B -0.154, p value 0.601; WHR: residential density B -0.042, p value 0.362, land use mix diversity B 0.043, p value 0.131, land use mix access B -0.028, p value 0.558, street connectivity B -0.044, p value 0.252, walking/cycling facilities B 0.026, p value 0.476, neighborhood aesthetics B 0.062, p value 0.137, safety from traffic B -0.048, p value 0.336, and safety from crime B -0.083, p value 0.239; WHtR: residential density B 0.011, p value 0.865, land use mix diversity B 0.033, p value 0.462, land use mix access B -0.032, p value 0.662, street connectivity B 0.021, p value 0.720, walking/cycling facilities B 0.042, p value 0.493, neighborhood aesthetics B 0.018, p value 0.790, safety from traffic B -0.020, p value 0.789, and safety from crime B -0.086, p value 0.392). Conclusion: The results of this study suggest that the built environment has less of an impact than brain tumors and their treatments on driving body mass and fat mass changes in SCBT. The use of lifestyle interventions may need to be combined with pharmacotherapies in the treatment of obesity in SCBT. / Thesis / Master of Science (MSc) / Childhood obesity is a global epidemic. Survivors of childhood brain tumors (SCBT) are a subpopulation of childhood cancer survivors who exhibit numerous comorbidities including obesity. SCBT have increased amounts of adipose tissue compared to non-cancer controls at similar body mass. While tumor and treatment related drivers of obesity exist in this population, the impact of environmental factors on obesity and the fat mass are not well understood. In this cross-sectional study, we aimed to determine the association between the built environment and body mass in SCBT and non-cancer controls. There was no association between the built environment and body mass measures in survivors. This study suggests the disproportionate importance of the biological mechanisms including the original tumors and their treatments on body mass in SCBT. Interventions to mitigate obesity and cardiometabolic risk in survivors need to focus on addressing tumor and treatment impacts.

Background: While the obesity epidemic is impacting children, survivors of childhood brain tumors (SCBT) are particularly vulnerable to obesity-driven cardiometabolic comorbidities. SCBT have excess body fat (adiposity) with similar body mass measures when compared to matched non-cancer controls. The effect of the built environment on the risk of obesity has received relatively limited attention in survivors. Aim & Methods: The aim of this project was to determine the impact of the built environment on body mass index (BMI) percentile, body fat percentage (BF%), waist-to-hip ratio (WHR), and waist-to-height-ratio (WHtR) in SCBT and non-cancer controls. The data for this secondary analysis were derived from participants in the Canadian Study of Determinants of Endometabolic Health in Children (CanDECIDE), a prospective cohort study based at McMaster Children’s Hospital, a tertiary pediatric academic center in Hamilton, Ontario, Canada. The Neighborhood Environment Walkability Scale (NEWS) was used to assess the built environment. Multivariable regression analyses were used to define the predictors of the association. Results: The built environment was not associated with BMI percentile in SCBT and non-cancer controls including residential density (B 0.276, p value 0.436), land use mix diversity (B -0.286, p value 0.301), land use mix access (B 0.004, p value 0.993), street connectivity (B 0.297, p value 0.431), walking/cycling facilities (B 0.185, p value 0.540), neighborhood aesthetics (B 0.270, p value 0.513), safety from traffic (B -0.368, p value 0.418), and safety from crime (B -0.074, p value 0.907). The built environment was also not associated with adiposity measures (BF%: residential density B 0.031, p value 0.851, land use mix diversity B -0.082, p value 0.513, land use mix access B -0.036, p value 0.861, street connectivity B 0.309, p value 0.055, walking/cycling facilities B 0.109, p 0.439, neighborhood aesthetics B 0.127, p value 0.503, safety from traffic B -0.047, p value 0.825, and safety from crime B -0.154, p value 0.601; WHR: residential density B -0.042, p value 0.362, land use mix diversity B 0.043, p value 0.131, land use mix access B -0.028, p value 0.558, street connectivity B -0.044, p value 0.252, walking/cycling facilities B 0.026, p value 0.476, neighborhood aesthetics B 0.062, p value 0.137, safety from traffic B -0.048, p value 0.336, and safety from crime B -0.083, p value 0.239; WHtR: residential density B 0.011, p value 0.865, land use mix diversity B 0.033, p value 0.462, land use mix access B -0.032, p value 0.662, street connectivity B 0.021, p value 0.720, walking/cycling facilities B 0.042, p value 0.493, neighborhood aesthetics B 0.018, p value 0.790, safety from traffic B -0.020, p value 0.789, and safety from crime B -0.086, p value 0.392). Conclusion: The results of this study suggest that the built environment has less of an impact than brain tumors and their treatments on driving body mass and fat mass changes in SCBT. The use of lifestyle interventions may need to be combined with pharmacotherapies in the treatment of obesity in SCBT. / Thesis / Master of Science (MSc) / Childhood obesity is a global epidemic. Survivors of childhood brain tumors (SCBT) are a subpopulation of childhood cancer survivors who exhibit numerous comorbidities including obesity. SCBT have increased amounts of adipose tissue compared to non-cancer controls at similar body mass. While tumor and treatment related drivers of obesity exist in this population, the impact of environmental factors on obesity and the fat mass are not well understood. In this cross-sectional study, we aimed to determine the association between the built environment and body mass in SCBT and non-cancer controls. There was no association between the built environment and body mass measures in survivors. This study suggests the disproportionate importance of the biological mechanisms including the original tumors and their treatments on body mass in SCBT. Interventions to mitigate obesity and cardiometabolic risk in survivors need to focus on addressing tumor and treatment impacts.

Pediatric obesity has become a major health care concern over the last several decades. This condition can lead to detrimental life-long physical and mental comorbidities. Pediatric primary care providers have a unique opportunity to both prevent and treat pediatric obesity in their clinics. However, discussing this topic with families can be uncomfortable and time consuming. Time efficient resources to educate and increase confidence are needed to improve the management of pediatric obesity. This quality improvement project integrated the Healthy Care for Healthy Kids by the National Institute for Children's Healthcare Quality (2014) into the electronic medical record at a pediatric primary care office in rural East Tennessee. This toolkit included handouts, management algorithms, and provider education for pediatric obesity. After an 8-week implementation period, improvements in lab draws and evaluation of a family's readiness to change were noted. Overall, providers reported the toolkit was helpful and improved patient interaction. Currently, the clinic is still utilizing the integrated resources and handouts.

Most surgeries and many medical procedures commonly make use of some form of anesthesia to maximize patient comfort and safety. However, all are associated with risks. Obesity and related health care problems are relatively common in anesthesia and also have a negative effect on morbidity and mortality. Trends in pediatric obesity show increases in both the prevalence and risks for the development of other disease. Using the 1997 through 2009 Kids’ Inpatient Database (KID), this study will assess diagnostic codes to identify complications related to anesthesia in the obese pediatric population. Information gained from this study may serve to advance research and the development of anesthetic techniques to improve both safety and overall health for this population.

OBJECTIVES: To estimate the incidence and risk of childhood overweight and obesity according to socioeconomic status in Peruvian and Vietnamese school-aged children. METHODS: Longitudinal data from the Young Lives study were analyzed. Exposure was wealth index in tertiles. Outcome was overweight and obesity. Cumulative incidence per 100 children-years, relative risks (RR), and 95 % confidence intervals (95 % CI) were calculated. A hierarchical approach, including child- and family-related variables, was followed to construct multivariable models. RESULTS: The cumulative incidence of overweight and obesity was 4.8 (95 % CI 4.1-5.5) and 1.7 (95 % CI 1.3-2.2) in the younger and older Peruvian cohort, respectively; and in Vietnam 1.5 (95 % CI 1.2-1.8) and 0.3 (95 % CI 0.2-0.5), respectively. The incidence of overweight and obesity was higher at the top wealth index tertile in all samples. In the older cohorts, comparing highest versus bottom wealth index tertile, RR of overweight and obesity was four to nine times higher: 4.25 in Peru (95 % CI 2.21-8.18) and 9.11 in Vietnam (95 % CI 1.07-77.42). CONCLUSIONS: The results provide important information for childhood obesity prevention in countries moving ahead with economic, epidemiological and nutritional transitions. / Revisión por pares

abstract: Pediatric obesity is a public health concern due to its elevated prevalence rates and its relation to concurrent and long-term physical and psychosocial consequences. Pediatric obesity has been found to be associated with problem behaviors, albeit with inconsistent findings. The mechanism of this relation is unclear. It is possible that they have a shared etiology. Self-regulation and parenting practices are two factors that have been implicated in the development of problem behaviors and are garnering evidence for their relation with pediatric obesity. The goal of the present study was to examine whether self-regulation (SREC), positive behavior support (PBSEC), and coercive limit-setting (CLSEC) in early childhood are shared etiological factors of pediatric obesity and problem behaviors. Using multinomial logistic regression the likelihood of belonging to four outcome groups (Comorbid, Problem behavior only, Overweight only, and Typically developing) at age 10 based on these factors was assessed. Analyses controlled for intervention group assignment, child gender, child African-American or Bi-racial, child Hispanic, cumulative risk, child body size impression at age 2, and parent body size impression at baseline. In the models examining SREC alone, for every 1 standard deviation increase in SREC, there was a reliable reduction in the odds of the child belonging to the comorbid and problem behavior only groups at age 10, compared to the typically developing group (OR = 0.386, 95% CI [0.237, 0.628], OR = 0.281, 95% CI [0.157, 0.503], respectively). This relation was maintained when SREC was in the same model as PBSEC and CLSEC. PBSEC and CLSEC alone did not impact the likelihood of belonging to any of the outcome groups. A significant interaction was found between SREC and CLSEC, such that at high levels of both SREC and CLSEC the odds of a child belonging to the overweight only group at age 10 increased, compared to the typically developing group. Results highlight CLSEC as a parenting practice that may place a highly regulated child at risk for becoming overweight. Overall, the findings suggest that problem behaviors and pediatric obesity do not have a shared etiology. / Dissertation/Thesis / Doctoral Dissertation Psychology 2016

abstract: Background. Effects of lifestyle interventions on early biomarkers of oxidative stress and CVD risk in youth with prediabetes are unknown. Objective. To evaluate the effects of a lifestyle intervention to prevent type 2 diabetes among obese prediabetic Latino adolescents on oxidized lipoproteins. Design: In a quasi-experimental design, 35 adolescents (51.4% male, age 15.5(1.0) y, body mass index (BMI) percentile 98.5(1.2), and glucose 2 hours after an oral glucose tolerance test-OGTT 141.2(12.2) mg/dL) participated in a 12-week intervention that included weekly exercise (three 60 min-sessions) and nutrition education (one 60 min-session). Outcomes measured at baseline and post-intervention were: fasting oxidized LDL and oxidized HDL (oxLDL and oxHDL) as oxidative stress variables; dietary intake of fresh fruit and vegetable (F&V) and fitness (VO2max) as behavioral variables; weight, BMI, body fat, and waist circumference as anthropometric variables; fasting glucose and insulin, 2hour glucose and insulin after an OGTT, insulin resistance (HOMA-IR), and lipid panel (triglycerides, total cholesterol, VLDL-c, LDL-c, HDL-c, and Non-HDL) as cardiometabolic variables. Results. Comparing baseline to post-intervention, significant decreases in oxLDL concentration were shown (51.0(14.0) and 48.7(12.8) U/L, p=0.022); however, the intervention did not decrease oxHDL (395.2(94.6) and 416.1(98.4) ng/mL, p=0.944). F&V dietary intake (116.4(97.0) and 165.8(91.0) g/d, p=0.025) and VO2max (29.7(5.0) and 31.6(4.7) ml*kg-1*min-1, p<0.001) significantly increased. Within-subjects correlations between changes in F&V intake and oxidized lipoproteins, adjusted for VO2max changes, were non-significant (R=-0.15, p=0.52 for oxLDL; R=0.22, p=0.25 for oxHDL). Anthropometric variables were significantly reduced (weight -1.3% p=0.042; BMI -2.2% and BMI percentile -0.4%, p=0.001; body fat -6.6% and waist circumference -1.8%, p=0.025). Cardiometabolic variables significantly improved, including reductions in glucose 2hour (-19.3% p<0.001), fasting insulin (-12.9% p=0.008), insulin 2hour (-53.5% p<0.001), and HOMA-IR (-12.5% p=0.015), with 23 participants (66%) that reverted toward a normal glucose tolerance status. Most lipid panel significantly changed (triglycerides -10.2% p=0.032; total cholesterol -5.4% p=0.002; VLDL-c -10.4% p=0.029; HDL-c -3.2% p=0.022; and Non-HDL -5.5% p=0.0007). Conclusion. The intervention resulted in differential effects on oxidized lipoproteins and significant improvements in behavioral, anthropometric and cardiometabolic variables, reducing the high metabolic risk of obese prediabetic kids. / Dissertation/Thesis / Doctoral Dissertation Exercise and Nutritional Sciences 2017

Pediatric obesity is a major public health epidemic with serious physical and psychological consequences. Difficulty engaging families in treatment is a significant obstacle in addressing pediatric obesity, especially among underserved populations. Motivational interviewing (MI) is a collaborative, person-centered communication style that has been shown to reduce attrition, increase attendance, and improve patient treatment adherence; however, little is known about the process of MI and how it improves treatment engagement. This study examined clinician and parent language in a pre-treatment MI session that increased initial engagement in a parent- focused pediatric obesity intervention (N= 81). Results showed that increased parent change talk, and preparatory language in particular, was positively related to the likelihood of initial attendance at baseline. Additionally, certain types of MI consistent clinician strategies were positively associated with parent change talk. Complex positive reflections were correlated with preparatory language and overall change talk, suggesting this might be a particularly important MI skill. Findings have implications for better understanding the process of MI and mechanisms through which MI can improve treatment engagement.

Bakgrund:De senaste årens ökning av barnfetma leder till frågeställningen hur man som sjuksköterska kan arbeta preventionsanpassat tillsammans med obesa barn och dess familjer. Detta gäller både primär, sekundär och tertiärt arbete. Syfte: Syftet med denna litteraturstudie är att beskriva sjuksköterskors preventionsarbete med obesa barn och deras familjer. Även artiklarnas datainsamlingsmetod beskrivs. Metod:En beskrivande litteraturstudie. Databaser som användes var Cinahl samt PubMed. Artiklarna som var 12 till antalet var publicerade mellan åren 2007-2017 och låg till grund för resultatet. Huvudresultat:Sjuksköterskor upplevde att preventionsarbete är viktigt då fetma är ett stort hälsoproblem i världen. I många fall upplevdes bristen på tid, då arbetet skulle kunna utvecklas ännu mer. Ofta användes motiverande samtal för att stärka det positiva och utgöra en grund för respekt och måna om barnets autonomi. Mätinstrument som var vanligt förekommande var BMI. Vikten av av föräldrarengagemang betonas i flertalet artiklar, eftersom resultaten då blir bättre med barnens viktnedgång. Sjuksköterskorna upplever att föräldrarna behöver stöttning och vägledning av med hjälp av dem för att kunna vara ett bra support till barnen. Slutsats: Sjuksköterskor behöver mer stöd i att utveckla preventionsarbetet för att minska barnfetma. Detta kan annars bli problem senare i livet och leda till följdsjukdomar i vuxen ålder. / Background: The increase in childhood obesity in recent years leads to the question of how a nurse can work on preventions adapted to obese children and their families. This applies to both primary, secondary and tertiary work Aim: The purpose of this literature study is to describe the nurse's prevention work with obese children and their families. The article's data collection method is also described. Method: A descriptive literature study. Databases used were Cinahl and PubMed. The articles that were 12 to the number published between 2007-2017 and resulted in the result. Main result: Nurses felt that prevention work is important as obesity is a major health problem in the world. In many cases, the lack of time was felt, as the work could develop even more. Often motivational conversations were used to strengthen the positive and provide a basis for respect and mood about the child's autonomy. Measuring instruments that were common were BMI. The importance of parental involvement is emphasized in most articles, as the results then improve with the weight loss of children. Instead, parents need support and guidance from nurses to be a good support for the children. Conclusion: Nurses need more support in developing prevention efforts to reduce childhood obesity. This may otherwise be a problem later in life and lead to adulthood in adulthood.

Many family-based treatments for pediatric obesity teach specific parenting practices related to weight management. Although youth in these programs show increases in positive health behaviors and reductions in the extent to which they are overweight, most remain overweight after treatment. A recent trend is to create tailored programs for subgroups of families. We examine the possibility of tailoring based on family context, highlighting 3 aspects of family context that have been studied in relation to pediatric obesity: parenting style, family stress, and family emotional climate. We argue that family context may moderate treatment outcomes by altering the effectiveness of health-related parenting practices and discuss the implications of this argument for designing and evaluating tailored programs.