The aim of this thesis was to determine the synergistic effect of milk and exercise to: promote fat loss while maintaining protein balance and muscle; improve cardiovascular fitness and strength; and to evaluate the short-term adaptations of the inflammatory system and metabolic risk factors in overweight adolescents (boys ages 11-15 years, girls ages 9 to 13 years). A 7-day dietary intervention with 1-h intense exercise was used with randomization to milk (MILK: n=26, 8 male, 18 female) or carbohydrate beverage (CONT; n=29, 12 male, 17 female) post exercise. Both groups received a diet based on their resting energy expenditure. To determine whole body protein balance (WBPB), participants consumed 15N-glycine. Subjects performed a maximal cycling test to determine changes in power and 1-repetition maximum testing to determine changes in strength. Blood was taken to evaluate glucose and insulin; tumour necrosis factor-alpha (TNF-α), interleukin-6 and c-reactive protein ; and blood pressure was measured pre and post intervention. Although body weights did not change, the MILK group maintained more muscle (-0.2 ± 0.6 vs. -0.7 ± 0.8 kg, p<0.01) and had a greater loss in body fat (-0.4 ± 1 vs. 0.5 ± 1.0 %, p<0.006). The changes in body composition were supported by a greater WBPB after training in the MILK group (1.64 ± 1.1 vs. 0.84 ± 0.6, p<0.001). Power increased only in the MILK group with an increase of 0.13 watts/kg (p<0.05) with an increase in V02max that approached significance (p=0.06). Improvements in strength and the blood risk factors were not different between the groups. There was a greater decline in mean arterial pressure in the MILK group (-3 ± 6 mmHg vs. 2 ± 7 mmHg, p< 0.04). The exercise intervention led to an increase in TNF-α in both groups (0.3 ± 0.7 pg/ml vs. 0.5 ± 0.7 pg/ml, p<0.001). These data support the consumption of milk after exercise in the early stages of pediatric obesity treatment. / Thesis / Doctor of Philosophy (PhD) / The aim of this thesis was to determine if milk and exercise work together to: promote body fat loss while maintaining protein balance and muscle in overweight adolescents; increase fitness and strength; and assess changes in inflammatory markers and disease risk factors. A 7-day diet with 1-hour exercise sessions was performed with milk or a carbohydrate drink. Protein balance was measured by a urine marker. Pre and post the following measures were used: cycling test for power; weight lifting test for strength; blood for disease markers; and blood pressure. After the week, the milk group were in a more positive protein balance, maintained more muscle, had a greater loss in body fat, greater increase in power and lower blood pressure compared to the carbohydrate group. Some of the inflammatory markers increased in both groups. Exercise combined with the nutrients from milk can have a positive effect on adolescent health.

Obesity is a growing concern in North America and current research suggests that for addressing childhood obesity, family-based behavioural interventions targeting children are the treatment of choice. Due to the lack of clinics that offer face to face treatment, the Internet may serve as a viable method for the delivery of such interventions. Three studies are presented in order to explore the viability of the internet as a treatment modality for delivering family-based interventions for children who are overweight. The first study attempted to deliver a family-based behavioural intervention via the internet - the Healthy Eating and Active Living Throughout Youth (HEALTHY) - for children aged 8 to 14 (M = 10.5). The initial goal was to evaluate the effectiveness of the internet as a treatment modality for childhood obesity. A total of 20 families consisting of 25 child-parent dyads consented to the intervention. However, adherence and attrition were significant issues throughout the 3-month intervention and only two child-parent dyads (8%) completed the 3-month intervention. Therefore the goals of this study changed to become primarily exploratory, with the aims of identifying factors related to treatment adherence and attrition. For the second study, the parents of the 20 families who consented to the HEALTHY intervention were invited to participate in a telephone interview around their impressions of the study, barriers to participation, and their needs in seeking services for their children. Sixteen families (80%) provided consent and thematic analyses were conducted. Four categories of themes emerged from the data and included: 'Knowledge and Education', 'Social Supports', 'Tools for Success', and 'Program Goals'. These categories, and the themes embedded within each category are presented and discussed. For the third study a systematic review of exclusively web-based studies for paediatric obesity was conducted. Five health and social sciences databases were search between 1995 and March 2012 (including an initial and updated search). A total of 2432 bibliographic records were identified (following de-duplication) and were subjected to title and abstract screening, and a further 120 records were subject to full-text screening. Two reviewers independently assessed the eligibility of each bibliographic record at these multiple levels and conflicts were resolved by third party. Three records were included in the review, and a further three records were identified as noteworthy in that they reported on one larger web-based study with a minimal face-to-face component (i.e., 4 sessions over 2 years). Data regarding attrition, adherence, and body composition changes were extracted by two independent reviewers. Attrition rates from the included studies ranged from 43% to 85%. The noteworthy study reported 18% overall attrition at six months (following randomization: 18% from the intervention group) and 34% overall attrition at two years (following randomization: 36% from the intervention group). Adherence measures were varied, but suggested low adherence to study components. Body composition changes were marginal in the short-term, but then lost in the longer-term. Implications for research and practice will be discussed. The contributions of this thesis include examining whether family-based interventions for pediatric obesity delivered over the internet are feasible. This question will be answered by exploring baseline characteristics that are related to treatment adherence and attrition, investigating barriers that interfere with adherence and contribute to attrition, and reviewing other research conducted in the field. Following from this thesis, and other relevant research, implications and recommendations for future research and clinical practice will be discussed

Obesity is a growing concern in North America and current research suggests that for addressing childhood obesity, family-based behavioural interventions targeting children are the treatment of choice. Due to the lack of clinics that offer face to face treatment, the Internet may serve as a viable method for the delivery of such interventions. Three studies are presented in order to explore the viability of the internet as a treatment modality for delivering family-based interventions for children who are overweight. The first study attempted to deliver a family-based behavioural intervention via the internet - the Healthy Eating and Active Living Throughout Youth (HEALTHY) - for children aged 8 to 14 (M = 10.5). The initial goal was to evaluate the effectiveness of the internet as a treatment modality for childhood obesity. A total of 20 families consisting of 25 child-parent dyads consented to the intervention. However, adherence and attrition were significant issues throughout the 3-month intervention and only two child-parent dyads (8%) completed the 3-month intervention. Therefore the goals of this study changed to become primarily exploratory, with the aims of identifying factors related to treatment adherence and attrition. For the second study, the parents of the 20 families who consented to the HEALTHY intervention were invited to participate in a telephone interview around their impressions of the study, barriers to participation, and their needs in seeking services for their children. Sixteen families (80%) provided consent and thematic analyses were conducted. Four categories of themes emerged from the data and included: 'Knowledge and Education', 'Social Supports', 'Tools for Success', and 'Program Goals'. These categories, and the themes embedded within each category are presented and discussed. For the third study a systematic review of exclusively web-based studies for paediatric obesity was conducted. Five health and social sciences databases were search between 1995 and March 2012 (including an initial and updated search). A total of 2432 bibliographic records were identified (following de-duplication) and were subjected to title and abstract screening, and a further 120 records were subject to full-text screening. Two reviewers independently assessed the eligibility of each bibliographic record at these multiple levels and conflicts were resolved by third party. Three records were included in the review, and a further three records were identified as noteworthy in that they reported on one larger web-based study with a minimal face-to-face component (i.e., 4 sessions over 2 years). Data regarding attrition, adherence, and body composition changes were extracted by two independent reviewers. Attrition rates from the included studies ranged from 43% to 85%. The noteworthy study reported 18% overall attrition at six months (following randomization: 18% from the intervention group) and 34% overall attrition at two years (following randomization: 36% from the intervention group). Adherence measures were varied, but suggested low adherence to study components. Body composition changes were marginal in the short-term, but then lost in the longer-term. Implications for research and practice will be discussed. The contributions of this thesis include examining whether family-based interventions for pediatric obesity delivered over the internet are feasible. This question will be answered by exploring baseline characteristics that are related to treatment adherence and attrition, investigating barriers that interfere with adherence and contribute to attrition, and reviewing other research conducted in the field. Following from this thesis, and other relevant research, implications and recommendations for future research and clinical practice will be discussed

Introduction: Pediatric obesity prevention and management is a high priority for pediatric providers. Pediatric providers use evidence-based clinical guidelines to integrate the best current recommendations into practice. The contention of this inquiry is that while practice guidelines and obesity programs address the "who, what, when, where, and why" of pediatric obesity interventions, the guidelines fail to address the "how" of the process that bolsters adherence and attacks the high attrition rates of obesity management. Objective: The objective of this practice inquiry is to evaluate Prevention and Treatment for Pediatric Obesity: An Endocrine Society Clinical Practice Guideline Based on Expert Opinion using the Appraisal for Guidelines and Research and Evaluation (AGREE II) instrument and to investigate techniques to improve adherence to the lifestyle changes recommended in the guideline, by synthesizing the current research for using motivational interviewing with obese pediatric patients, and propose a plan for translating the intervention to measurable outcomes. Methods: Prevention and Treatment of Pediatric Obesity: An Endocrine Society Clinical Practice Guideline Based on Expert Opinion was evaluated using the AGREE II instrument. The current recommendations are detailed based on the findings of a review of the literature. Using the RE-AIM framework, recommendations are made to determine the translation potential for the use of motivational interviewing to improve adherence to lifestyle recommendations, thus improving the current clinical practice guideline. Results: Review of the Endocrine Society's CPG using the AGREE II instrument yielded an overall guideline quality rating of 6/7. The guideline is recommended for use with modifications to improve applicability. Integration of MI to the practice guideline and the use of the RE-AIM framework to improve uptake of the intervention is proposed to address the weaknesses in applicability revealed in the guideline evaluation. Conclusion: The CPG reviewed in this PI provides quality recommendations for the treatment and prevention of pediatric obesity. By integrating MI techniques and using the RE-AIM framework, pediatric providers may be able to bolster adherence to the guideline recommendations and ultimately improve clinical outcomes and impede the rising pediatric obesity rates. Future research should include evaluation of MI interventions in the pediatric clinical setting.

Obesity is a growing concern in North America and current research suggests that for addressing childhood obesity, family-based behavioural interventions targeting children are the treatment of choice. Due to the lack of clinics that offer face to face treatment, the Internet may serve as a viable method for the delivery of such interventions. Three studies are presented in order to explore the viability of the internet as a treatment modality for delivering family-based interventions for children who are overweight. The first study attempted to deliver a family-based behavioural intervention via the internet - the Healthy Eating and Active Living Throughout Youth (HEALTHY) - for children aged 8 to 14 (M = 10.5). The initial goal was to evaluate the effectiveness of the internet as a treatment modality for childhood obesity. A total of 20 families consisting of 25 child-parent dyads consented to the intervention. However, adherence and attrition were significant issues throughout the 3-month intervention and only two child-parent dyads (8%) completed the 3-month intervention. Therefore the goals of this study changed to become primarily exploratory, with the aims of identifying factors related to treatment adherence and attrition. For the second study, the parents of the 20 families who consented to the HEALTHY intervention were invited to participate in a telephone interview around their impressions of the study, barriers to participation, and their needs in seeking services for their children. Sixteen families (80%) provided consent and thematic analyses were conducted. Four categories of themes emerged from the data and included: 'Knowledge and Education', 'Social Supports', 'Tools for Success', and 'Program Goals'. These categories, and the themes embedded within each category are presented and discussed. For the third study a systematic review of exclusively web-based studies for paediatric obesity was conducted. Five health and social sciences databases were search between 1995 and March 2012 (including an initial and updated search). A total of 2432 bibliographic records were identified (following de-duplication) and were subjected to title and abstract screening, and a further 120 records were subject to full-text screening. Two reviewers independently assessed the eligibility of each bibliographic record at these multiple levels and conflicts were resolved by third party. Three records were included in the review, and a further three records were identified as noteworthy in that they reported on one larger web-based study with a minimal face-to-face component (i.e., 4 sessions over 2 years). Data regarding attrition, adherence, and body composition changes were extracted by two independent reviewers. Attrition rates from the included studies ranged from 43% to 85%. The noteworthy study reported 18% overall attrition at six months (following randomization: 18% from the intervention group) and 34% overall attrition at two years (following randomization: 36% from the intervention group). Adherence measures were varied, but suggested low adherence to study components. Body composition changes were marginal in the short-term, but then lost in the longer-term. Implications for research and practice will be discussed. The contributions of this thesis include examining whether family-based interventions for pediatric obesity delivered over the internet are feasible. This question will be answered by exploring baseline characteristics that are related to treatment adherence and attrition, investigating barriers that interfere with adherence and contribute to attrition, and reviewing other research conducted in the field. Following from this thesis, and other relevant research, implications and recommendations for future research and clinical practice will be discussed

Class of 2008 Abstract / Objectives: This was a retrospective chart review and survey of pediatric residents. This study aimed to examine standards for aminoglycosides in obese pediatrics; increase awareness of drug monitoring in obese populations; and reduce medication errors. Methods: 101 patients aged three to seventeen that received aminoglycoside treatment were included. Subjects were divided into three groups based on weight and height percentiles as defined by growth charts. Collecting retrospective data provided measured concentrations of aminoglycosides in order to evaluate pharmacokinetics. Data collected included: dose and frequency; time dose was given; length of infusion; two measured concentrations (peak and trough); and time concentration was measured. ANOVA allowed comparisons between aminoglycoside volumes of distribution to weight (based on specific weight groups). Tukey’s post hoc analysis further tested the significance of the pair-wise comparisons (p<0.05). Secondly, a questionnaire was administered to 26 pediatric medical residents at University Medical Center to assess current treatment protocols and attitudes towards medication dosing in obese pediatric patients. Results: The volume of distribution was not significantly different between normal weight and overweight patients (p=0.927); normal weight and obese patients (p=0.174); or overweight and obese patients (p=0.211). Most (81.8%) study participants have some difficulty finding references on dosing in overweight and obese patients. Conclusions: The positive correlation between volume of distribution and total body weight was not statistically significant. Pediatric residents agree that there is a lack of resources regarding obese pediatric medication dosing. Further research is warranted to ensure the reliability and validity of aminoglycoside dosing in obese children.

Despite a worsening obesity epidemic and despite the American Medical Association (AMA) declaring Obesity a disease (2013), few assessment tools exist that assist practitioners who are charged with identifying risk for development of OW/OB in children. The Center for Health Statistics (2017) reported a 40% rate in obesity in the adult population and 18.5% in children in the U.S. Successful weight loss maintenance after 1 to 2 years of non-invasive treatment is less than 1%, indicating obesity is nearly incurable, making prevention imperative. Assessing risk for OW/OB in children has proven difficult given the lack of validated tools. The purposes of this study were to evaluate the predictive validity and estimate the reliability of the Electronic Kids Dietary Index (E-KINDEX) to measure risk for development of overweight and obesity OW/OB in children aged 10 to 18. In addition, the relationship between quality of life perceptions and OW/OB in children was assessed. Methods. E-KINDEX, a 30-item questionnaire encompassing three dietary domains of food quality, dietary behaviors (attitudes), and dietary habits (Lazarou et al., 2011), was administered to 50 child participants who, with their parents’ consent, agreed to participate. The children also completed the quality of life questionnaire. The range for E-KINDEX scores was 1 (worst) to 87 (best) for assessment of the obesogenic environment that encompasses the immediate environment of the individual, factors that influence food quality, choices, and behaviors. Predictive validity was evaluated using multiple regression, factor analysis, and receiver operating curve statistics in SPSS; reliability was analyzed using Cronbach’s alpha. Pearson product-moment correlations were used to measure strength of relationships among OW/OB, E-KINDEX scores, and quality of life perceptions in the sample. Results. E-KINDEX overall score was significantly correlated with OW/OB (r = -340, n = 50, p = .008), as was Dietary Behaviors (r = -.593, n = 50, p = Discussion. Predictive validity of E-KINDEX subscales and overall were supported through achievement of aims of the study. Correlations between both E-KINDEX scores and child weights were significant and reliability supported by Cronbach’s alpha. Limitations included small sample size of 50 and accuracy of children self-report data in the presence of parents. Parental weight did not correlate with E-KINDEX, but should be studied further relative to the Obesogenic Environment. Physical activity was high in both OW/OB and lean groups. Validated Physical Activity tools are needed. Implications. Although refinement and further study are needed, E-KINDEX is a useful tool for clinicians to identify children at risk for the chronic disease of OW/OB before it develops, perhaps before risk factors become difficult to modify.

Background: Pediatric obesity is a serious health issue, with an exceedingly high prevalence, having both short and long-term consequences. The Family Lifestyle Program (FLP) provides treatment services to families struggling with pediatric overweight and obesity living in the Winnipeg Health Region. Purpose: To determine whether caregivers’ nutrition knowledge and/or their attitudes about nutrition change as a result of attending the family group education sessions of the FLP. Methods: In this quantitative exploratory research, 17 caregivers (68% female) attended at least four out of five family group education sessions and completed a self-administered survey over three time periods of the program intervention, spanning approximately eight weeks from Time 1 to Time 3. Results: Caregiver nutrition knowledge did not change. Significant changes in three of the four attitude measures across three time periods were observed, related to caregiver attitudes toward their child’s and their own eating habits, program specific nutrition content (label reading and meal planning), and the perceived effort in providing foods to family and in role modelling of healthy behaviours to family members. Conclusions: The family group education sessions assisted the caregivers apply nutrition knowledge through participation in the program intervention, to improve their confidence with following healthy eating principles and role modelling these behaviours to their family members.

Background: Pediatric obesity is a serious health issue, with an exceedingly high prevalence, having both short and long-term consequences. The Family Lifestyle Program (FLP) provides treatment services to families struggling with pediatric overweight and obesity living in the Winnipeg Health Region. Purpose: To determine whether caregivers’ nutrition knowledge and/or their attitudes about nutrition change as a result of attending the family group education sessions of the FLP. Methods: In this quantitative exploratory research, 17 caregivers (68% female) attended at least four out of five family group education sessions and completed a self-administered survey over three time periods of the program intervention, spanning approximately eight weeks from Time 1 to Time 3. Results: Caregiver nutrition knowledge did not change. Significant changes in three of the four attitude measures across three time periods were observed, related to caregiver attitudes toward their child’s and their own eating habits, program specific nutrition content (label reading and meal planning), and the perceived effort in providing foods to family and in role modelling of healthy behaviours to family members. Conclusions: The family group education sessions assisted the caregivers apply nutrition knowledge through participation in the program intervention, to improve their confidence with following healthy eating principles and role modelling these behaviours to their family members.

Obesity is a substantial public health concern. One subgroup that has shown a large increase in prevalence of obesity is adolescents (12 - 19 years) (CDC, 2014; Altman & Wilfley, 2014; Odgen et al., 2010; Ogden, et al., 2012; Ogden, et al., 2014). This is concerning for two reasons: (a) the strong likelihood of obesity persisting into adulthood (CDC, 2014) leading to co-occurring medical and psychosocial problems (Altman & Wilfley, 2014; Kelsey et al., 2014), and (b) there are few studies demonstrating successful reductions in obesity in children and even fewer successful demonstrations in adolescents (Altman & Wilfley, 2014; Tsiros et al., 2008). One way to evaluate the behaviors related to obesity is through an individual’s choice-making behavior between foods and exercises. Behavior Economic Theory (BET) is an operant methodology used to assess choice making and to describe relationships between choices. The purpose of this study was to describe the relationship between diet and exercise, through the BET framework, in adolescent females who are obese within a single case design. Participants’ recorded daily perceived calories consumed and expended with a concurrent schedules design using an electronic self-monitoring program for baseline (Phase 1). After Phase 1, the researcher presented a choice between diet and exercise and developed a behavioral contract with goals addressing that choice for Phase 2. A subsequent behavioral contract was developed to target the changes in diet or exercise in Phase 3. The participants continued to record daily consumption and expenditure during Phases 2 and 3. IOA was collected by two researchers who independently reviewed the recorded consumed and expended calories on at least 30% of days that the participant self-monitored. For all participants, IOA was calculated across 35.8% of days with an average 96.6% agreement. The results showed that 3 of 5 participants preferred to develop a behavioral contract which targeted exercise, but only one showed weight loss. Two of the 5 participants chose to target diet with the contracts. Similar to the exercise group, weight loss occurred for only one participant. Using the BET methodology to analyze the participant’s engagement in reducing calories, only participants that simultaneously worked on increasing exercise and reducing their calorie intake lost weight, showing a complementary relationship between diet and exercise. Regardless of intervention strategy, these results suggest that adolescent females may have to develop a complementary relationship between diet and exercise to achieve successful outcomes. These results suggest that further analysis of the relationship between diet and exercise are warranted.