Obesity is a complex condition that affects all age groups and socioeconomic strata and places significant burdens on health and social care systems in both developed and developing countries. Overeating and a lack of exercise, along with smoking and high alcohol use, are the most common causes of non-communicable diseases, which account for almost two-thirds of global deaths each year. This programme of PhD research aimed to better understand dietary and other health risk behaviours by considering the influence of evolutionary behavioural strategies, while controlling for other determinants of health risk behaviours, including childhood experience and socioeconomic variables. In the first study, young adults (n=393; aged 18-30 years) completed a bespoke self-report questionnaire and provided data on their developmental experiences and their socioeconomic environments, in addition to a range of behavioural choices and evolutionary strategies (e.g. reproductive behaviour). In the second study, a secondary analysis of the second iteration of the North West Mental Well-being Survey (NWMWBS) 2012/13 was undertaken to supplement findings from study 1. These studies were analysed using regression analysis and Latent Class Analysis. Across both studies, there was a clustering of risk behaviours. Adverse childhood experiences and lower socioeconomic status were found to be predictive of health risk behaviours, including unhealthy eating, binge drinking and smoking cigarettes. Various evolutionary behavioural strategies were found to be predictive of health risk behaviours. Reproductive strategy was found to be predictive of BMI; health offsetting was found to be predictive of risky eating behaviour and physical activity; investing behaviour was found to be predictive of BMI, general health risk taking, binge drinking, current daily smoking, and violence; altruism was found to be predictive of eating preference; trust was found to be predictive of general health risk taking, current daily smoking, and physical activity; cooperation was found to be predictive of current daily smoking; and, planning behaviour was found to be predictive of current daily smoking, and risky sexual practices. Overall, the research suggests that childhood experiences and socioeconomic inequality are key determinants of behavioural strategies, and that such strategies are likely to be adaptive.

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Childhood obesity in the UK is a serious public health concern. In some ethnic minority groups obesity prevalence is significantly higher than the national average (The NHS Information Centre, 2010). Therefore, it is recommended that interventions to manage childhood obesity are tailored to the needs of ethnic minority groups (NICE, 2006). GOALS (Getting Our Active Lifestyles Started!) is a community based, childhood obesity management programme that focuses upon physical activity, nutrition and behaviour change in families (Watson et aI., 2011). However, monitoring data has suggested an unrepresentatively low proportion of ethnic minority families who are referred to GOALS choose to access the service. Therefore the aim of this research was to improve the cultural relevance of the GOALS programme, whilst also contributing to the evidence-base for local and national strategic planning surrounding obesity and ethnicity. Studies set out to explore perceptions surrounding childhood weight, diet and physical activity in different ethnic groups; identify cultural preferences, and barriers to participation in healthy lifestyle interventions; to implement and pilot a culturally accessible intervention, using the GOALS framework for development; and to assess the acceptability and effectiveness of the pilot intervention. A multi-method, pluralistic, research design was employed that recognised the complexity of the research aims. In total three empirical studies were conducted, and parents (of children aged 4 to 16 years) and school-aged children participated. A combination of process and outcome data was obtained. Quantitative methods were used for descriptive and explanatory purposes and included questionnaire (Study 1,2 and 3b) and BMI measures (Study 3b). Qualitative methods included focus groups (Study 2 and 3a), face-to-face interviews (Study 3b) and the write-and draw-technique (Study 3b). Exploratory data gave context and depth to the research. In Study 1, parents (n=808) identified their ethnic background as Asian British, Black African, Black Somali, Chinese, South Asian, White British and Yemeni. Ethnic background was significantly associated to parental perceptions of weight in childhood. Results showed Black Somali parents exhibited the lowest level of concern for overweight in childhood in comparison to other ethnic groups. In Study 2, parents (n=36) and children (n=31) from six ethnic groups (Asian Bangladeshi, Black African, Black Somali, Chinese, White British and Yemeni) identified intrapersonal, interpersonal and environmental barriers to healthy weight. Findings demonstrated that influences to health behaviours were sometimes specific to particular ethnic groups. For example, dominant cultural norms valuing overweight in childhood were apparent among Yemeni, Black African, Black Somali and Asian Bangladeshi parents and Asian Bangladeshi children. Results from Study 3a with parents (n=33) from ethnically diverse backgrounds, identified barriers and preferences to attending an intervention were often related to cultural and religious values of ethnic groups. Parents considered the ethnic composition of the group important, and suggested an intervention should be relevant to the ethnic background of all families attending. Based on these findings, 'surface' and 'deep' (Reniscow et al., 1999) structural modifications were made to the GOALS programme. Nine families from Asian British, Asian Bangladeshi, Yemeni and Black Somali backgrounds attended the pilot intervention to examine its appropriateness. Process and outcome data from Study 3b illustrated families benefited from a healthy lifestyles intervention that was designed to be culturally acceptable to multiple ethnic groups. This thesis has added to the limited evidence base surrounding the cultural relevance of family-based childhood obesity management programmes for ethnic minority groups. Differences in cultural norms between ethnic populations, and variations in assimilation to Western norms and acculturation within groups, highlight the complex task in addressing childhood obesity in multiple ethnic groups. Knowledge gained from the successful engagement of ethnic minority families in a culturally sensitive healthy lifestyle intervention, has lead to the development of key recommendations for policy and practice that extend beyond childhood obesity management to health promotion more widely.

Childhood obesity is the most serious public health challenge of the 21st century. Whilst evidence supports a family-based lifestyle approach to childhood obesity treatment, research is needed to understand how interventions work and how practitioners can effectively support families to sustain behavioural changes in the long-term. This thesis evaluated the feasibility of a family-based behaviour change intervention for overweight children (GOALS) and explored the psychosocial process of long-term behavioural change in families with overweight children. Study 1 measured the impact of GOALS on the body composition, lifestyle behaviours and self-perceptions of children and parents who completed the intervention. A complete case analysis (n=70) showed a significant 6-month reduction in child BMI SOS (-0.07, p < 0.001) that was maintained at 12-month follow up. There was a significant year-on-year increase in the proportion of children reducing BMI SOS (42.9% year 1, 62.5% year 2, 80% year 3, p < 0.05) and a strong positive relationship between parent and child BMI change (r = .479, p < 0.001). Parents reported positive changes to their own and their children's physical activity and diet. BMI SOS reduction during the intervention was associated with improved global self-esteem and perceived physical appearance at 12 months. Study 2 explored the experiences of families six weeks into the 18-session intervention through focus groups with parents and children. Motivators to attend GOALS included the non-judgemental approach, being in the same boat as others and child enjoyment. The whole family approach was perceived positively and families used BCTs both as a core component of GOALS and to facilitate their behaviour change at home. As well as the challenges of living with childhood overweight, families described a lack of support from extended family members and a perceived need for on-going professional support. Study 3 followed up 15 families 3-5 years after they attended GOALS. Child and parent BMI was collected and parents took part in a semi-structured interview to explore their perceptions of "success" and their experiences of changing physical activity and eating behaviours. Mean child BMI SOS change from baseline was -0.47 for the 14 families who had completed GOALS. The majority of families perceived positive long-term outcomes, but these were not always aligned with actual child weight change. The most "successful" families placed a priority on changing child weight-related behaviours and parents took responsibility for these changes. While weight-control was a conscious process for these families, it was not necessarily made a "big issue" and parents used practices of an authoritative nature to facilitate change. Physical activity had become a way of life for the children, and mothers had reached a stage of feeling in control of their own weight. This is the first UK childhood obesity treatment study to follow children up beyond 12 months, and the first known study worldwide to employ qualitative methods to explore parental perceptions of long-term success. Findings provided a unique insight into the process of long-term behavioural change for overweight children and raised questions about the way "success" is defined following participation in childhood obesity treatment. Recommendations are made to enhance the delivery of family-based childhood obesity treatment and policy-makers are urged to adopt a multilevel approach to tackling childhood obesity, with child weight management care pathways that recognise the heterogeneity of familial needs. Further research is required to substantiate the impact of GOALS, and to prospectively explore the process of behavioural change in overweight children and the familial factors that serve as moderators in this process.