This is the final submission of my Masters Thesis. / OBJECTIVES: Cognitive disordered eating behaviours (body shape concerns) are prevalent among youth with higher unhealthy body mass indexes (BMIs), while physical disordered eating behaviours (unhealthy changes in eating habits) are common mechanisms in determining future BMI. This thesis investigates the associations between these disordered eating behaviours and BMI categories and evaluates potential covariate modification. As a secondary objective, this thesis investigates the association between unhealthy eating patterns and BMI categories. METHODS & DATA ANALYSIS: This study was conducted among Canadian youth aged 12-17 (n=12,350). Body shape concerns were measured as the frequency of having a preoccupied desire to be thin while changing eating habits was measured as the frequency of changing eating habits to manage weight. Unhealthy eating patterns were defined as frequent restaurant eating, energy drink consumption, and skipping breakfast. Categorical BMI classifications consisted of obesity, overweight and normal/underweight. Adjusted multinomial logistic regression models were constructed. Covariates were independently tested for statistical interaction in the primary relationships. Measures of association were reported as adjusted odds ratios (ORs) with 95% confidence intervals. RESULTS: Having a preoccupied desire to be thin was associated with increased odds of being overweight and having obesity. These relationships were modified by sex, physical activity, and sleep. Changing eating habits to manage weight was associated with increased odds of being overweight and having obesity. These relationships were modified by sex. Skipping breakfast increased the odds of being overweight and having obesity, while consuming energy drinks increased the odds of having obesity. CONCLUSION: Over 40% of the sample experienced some frequency of having body shape concerns or changing eating habits to manage weight. These disordered eating behaviours increase the odds of being overweight and having obesity. Continued monitoring through national–level surveys, will be crucial in understanding changes in rates of disordered eating behaviour. / Thesis / Master of Public Health (MPH)

Background: South Africa is a multicultural, multi-ethnic developing country currently experiencing a unique quadruple burden of disease, of which malnutrition (both over- and under nutrition) is one of them. The increase in childhood obesity within the current South-African health setting is of serious concern, approximately 14% boys and 18% girls currently are overweight and it is estimated that this number will increase to 25% within the next decade. Healthy eating habits and increased physical activity are important components of a healthy lifestyle, and decrease the risk of overweight and obesity. It is also often the corner stone of many lifestyle modification intervention programmes aimed at preventing or decreasing overweight/obesity. Aim: This sub-study was part of a larger intervention study where a nutrition education intervention programme (NEIP) for children in the form of a musical play (based on the South African Food Based Dietary Guidelines [SAFBDG]) was developed to increase nutrition knowledge and thereby also contribute towards healthy lifestyle behaviour. The aim of this sub-study was therefore to explore and describe the attitude of a specific group of primary school children (aged 6-12 years) towards healthy eating, unhealthy eating, and physical activity before and after a NEIP as well as the standard school curriculum. Secondly, it was aimed to identify possible barriers to and motivators for healthy eating, unhealthy eating and physical activity. Methods: Children were randomly selected from the experimental group (n=143) of the main study. Children were selected into one of four focus groups per school (6 children per focus group) from which qualitative data were gathered on children’s attitude and perception towards healthy eating, unhealthy eating, and physical activity. Focus groups were defined by age and gender (boys and girls seperately, grades I-III and grades IVVI seperately), totalling a number of 96 children. A total of 75 children completed this sub-study, 21 children dropped out due to school-related problems or after school activities that clashed with the time slots during which the NEIP was implimented. Quantitative data was gathered with a socio-demographic and physical activity questionnaire, as well as a 3-point hedonic facial expression scale which was used to quantify attitude towards healthy eating, unhealhty eating and physical activity. All data (quantitative and qualitative) were collected at both baseline and end measurements. Results: The main findings of this sub-study were that the attitude of most primary school children towards healthy eating, unhealthy eating or physical activity remained unchanged after a unique NEIP. Five major themes were identified out of focus group discussions namely health awareness, healthy eating, unhealthy eating, physical activity, and consequences of unhealthy eating and sedentary behaviour. Mothers were identified as the main motivator for eating healthy and avoiding unhealthy eating. The taste and smell of food were both either identified as motivators or barriers for healthy eating and unhealthy eating. Older girls associate unhealthy eating with becoming fat while many children associate the combination of unhealthy eating and being sedentary with becoming fat. Most children have a positive attitude towards physical activity and enjoy doing it although the biggest motivator for partaking in physical activity is their parents and not themselves. Conclusion: Even though some children’s attitude did change in the desired direction after the implementation of a unique and fun NEIP, most children’s attitude towards healthy eating, unhealthy eating and physical activity remained unchanged. This might have been due to the measurement tool that was not sensitive enough to detect subtle changes. Various factors that can influence children’s attitude and perceptions towards healthy eating, unhealthy eating and physical activity both positively or negatively were identified. This study is one of only a few that explored and described the ‘true’ motivators of and barriers for children’s attitude towards healthy eating, unhealthy eating and physical activity. Results generated from this sub-study can thus make a valuable contribution to the existing literature available in this specific study field. / Thesis (MSc (Dietetics))--North-West University, Potchefstroom Campus, 2012

Background: South Africa is a multicultural, multi-ethnic developing country currently experiencing a unique quadruple burden of disease, of which malnutrition (both over- and under nutrition) is one of them. The increase in childhood obesity within the current South-African health setting is of serious concern, approximately 14% boys and 18% girls currently are overweight and it is estimated that this number will increase to 25% within the next decade. Healthy eating habits and increased physical activity are important components of a healthy lifestyle, and decrease the risk of overweight and obesity. It is also often the corner stone of many lifestyle modification intervention programmes aimed at preventing or decreasing overweight/obesity. Aim: This sub-study was part of a larger intervention study where a nutrition education intervention programme (NEIP) for children in the form of a musical play (based on the South African Food Based Dietary Guidelines [SAFBDG]) was developed to increase nutrition knowledge and thereby also contribute towards healthy lifestyle behaviour. The aim of this sub-study was therefore to explore and describe the attitude of a specific group of primary school children (aged 6-12 years) towards healthy eating, unhealthy eating, and physical activity before and after a NEIP as well as the standard school curriculum. Secondly, it was aimed to identify possible barriers to and motivators for healthy eating, unhealthy eating and physical activity. Methods: Children were randomly selected from the experimental group (n=143) of the main study. Children were selected into one of four focus groups per school (6 children per focus group) from which qualitative data were gathered on children’s attitude and perception towards healthy eating, unhealthy eating, and physical activity. Focus groups were defined by age and gender (boys and girls seperately, grades I-III and grades IVVI seperately), totalling a number of 96 children. A total of 75 children completed this sub-study, 21 children dropped out due to school-related problems or after school activities that clashed with the time slots during which the NEIP was implimented. Quantitative data was gathered with a socio-demographic and physical activity questionnaire, as well as a 3-point hedonic facial expression scale which was used to quantify attitude towards healthy eating, unhealhty eating and physical activity. All data (quantitative and qualitative) were collected at both baseline and end measurements. Results: The main findings of this sub-study were that the attitude of most primary school children towards healthy eating, unhealthy eating or physical activity remained unchanged after a unique NEIP. Five major themes were identified out of focus group discussions namely health awareness, healthy eating, unhealthy eating, physical activity, and consequences of unhealthy eating and sedentary behaviour. Mothers were identified as the main motivator for eating healthy and avoiding unhealthy eating. The taste and smell of food were both either identified as motivators or barriers for healthy eating and unhealthy eating. Older girls associate unhealthy eating with becoming fat while many children associate the combination of unhealthy eating and being sedentary with becoming fat. Most children have a positive attitude towards physical activity and enjoy doing it although the biggest motivator for partaking in physical activity is their parents and not themselves. Conclusion: Even though some children’s attitude did change in the desired direction after the implementation of a unique and fun NEIP, most children’s attitude towards healthy eating, unhealthy eating and physical activity remained unchanged. This might have been due to the measurement tool that was not sensitive enough to detect subtle changes. Various factors that can influence children’s attitude and perceptions towards healthy eating, unhealthy eating and physical activity both positively or negatively were identified. This study is one of only a few that explored and described the ‘true’ motivators of and barriers for children’s attitude towards healthy eating, unhealthy eating and physical activity. Results generated from this sub-study can thus make a valuable contribution to the existing literature available in this specific study field. / Thesis (MSc (Dietetics))--North-West University, Potchefstroom Campus, 2012

Background: Lifestyle habits like tobacco use, hazardous use of alcohol, unhealthy eating habits and insufficient physical activity are risk factors for developing non-communicable diseases, which are the leading, global causes of death. Furthermore, ill health and chronic diseases are costly and put an increased burden on societies and health systems.  In order to address this situation, governmental bodies and organizations’ have encouraged healthcare providers to reorient the focus of healthcare and undertake effective interventions that support patients to engage in healthy lifestyle habits. In Sweden, national clinical practice guidelines (CPGs) on lifestyle interventions were released in 2011. However, the challenges of changing clinical practice and introducing guidelines are well documented, and health interventions face particular difficulties. The overall purpose of this thesis is to contribute towards a better understanding of the complexities of shifting primary health care to become more health oriented, and to explore the implementation environment and its effect on lifestyle intervention CPGs. The specific aims are to investigate how implementation challenges were addressed during the guideline development process (Study I), to investigate several dimensions of readiness for implementing lifestyle intervention guidelines, including aspects of the intervention and the intervention context (Study II), to explore the extent to which health care professionals are working with lifestyle interventions in primary health care, and to describe and develop a baseline measure of professional knowledge, attitudes and perceived organizational support for lifestyle interventions (Study III), and to assess the progress of implementing lifestyle interventions in primary care settings, as  well as investigate the uptake and usage of the CPGs in clinical practice (Study IV).   Methods and results: Interviews were conducted with national guideline-developers (n=7). They were aware of numerous implementation challenges, and applied strategies and ways to address them during the guideline development process. The strategies adhered to four themes: (a) broad agreements and consensus about scope and purpose, (b) systematic and active involvement of stakeholders, (c) formalized and structured development procedures, and (d) openness and transparent development procedures. At the same time, the CPGs for lifestyle interventions challenged the development-model at the National Board of Health and Welfare (NBHW) because of their preventive and non-disease specific focus (I). A multiple case study was also conducted, using a mixed methods approach to gather data from key organizational individuals that were accountable for planning the implementation of CPGs (n=10), as well as health professionals and managers (n=340). Analysis of this data revealed that conditions for change were favorable in the two organizations that served as case studies, especially concerning change focus (health orientation) and the specific intervention (national guidelines on lifestyle interventions). Somewhat limited support was found for change and learning, and change format (national guidelines in general). Furthermore, factors in the outer context were found to influence the priority and timing of the intervention, as well as considerable inconsistencies across the professional groups (II). A cross-sectional study among physicians and nurses (n=315) in Swedish primary healthcare showed that healthcare professionals have a largely positive attitude and thorough overall knowledge of lifestyle intervention methods. However, both the level of knowledge and the involvement in patients’ lifestyle change, differed between professional groups. Organizational support like CPGs and the development of primary health care (PHC) collaborations with other stakeholders were identified as potential strategies for enhancing the implementation of lifestyle interventions in PHC (III). In addition to interviews and case studies, a longitudinal survey among health professionals (n=150; n=73) demonstrated that their use of methods to encourage patients to reduce or eliminate tobacco or alcohol use, had increased. The survey also indicated that nurses had increased the extent to which they addressed all four lifestyle habits. The progress of the implementation of CPGs on lifestyle interventions in PHC was somewhat limited, and important differences in physicians and nurses’ attitudes, as well as their use of the guidelines, were found (IV). Conclusions: Health orientation differs in many ways from more traditional fields in medicine. To strengthen the implementation of this very important (but not “urgent”) field in health care, it needs, first of all, to be prioritized at all levels! The results of the studies demonstrate relatively slow adoption of lifestyle intervention CPGs in clinical practice, and indicate room for improvement. The findings of this thesis can inform healthcare policy and research on further development of the health orientation perspective, as well as on the challenges of implementing CPGs on lifestyle interventions in primary care. In summary, this thesis presents important lessons learned regarding health orientation - from the development of CPGs in the field, via assessing healthcare organizations’ readiness to change and health professionals’ attitudes to methods to support patients with lifestyle changes. / Bakgrund: Levnadsvanor som tobaksbruk, riskbruk av alkohol, ohälsosamma matvanor och otillräcklig fysisk aktivitet är riskfaktorer för att utveckla kroniska sjukdomar, vilka orsakar de flesta dödsfallen i världen. Ohälsa och dess följdsjukdomar utmanar också samhällen och hälsosystem världen över p.g.a. de höga kostnader som de medför. För att förbättra situationen så försöker regeringar och organisationer förändra hälso- och sjukvårdens perspektiv till att fokusera mer på hälsa och att arbeta med effektiva interventioner för att förebygga och att förändra människors ohälsosamma vanor. År 2011 i Sverige, publicerades nationella kliniska riktlinjer för vårdens arbete med att förebygga sjukdom genom att stödja förändring av patienters ohälsosamma levnadsvanor. Det är dock välkänt hur svårt det är att förändra klinisk praxis och att introducera riktlinjer, och interventioner på området hälsa i sjukvården brottas med specifika utmaningar. Det övergripande syftet med den här avhandlingen har varit att bidra till en bättre förståelse av komplexiteten i att hälsoorientera primärvården, och att utforska förutsättningarna till att implementera kliniska riktlinjer för att stödja förändring av patienters levnadsvanor. De mer specifika syftena var: att (I) utforska hur implementeringsutmaningarna behandlades i utvecklingsprocessen av riktlinjerna ; att (II) undersöka dimensioner av beredskapen för förändring i primärvården för att implementera riktlinjerna om levnadsvanor inkluderande aspekter av interventionen själv samt kontexten ; att (III) utforska i vilken utsträckning hälsoprofessionerna arbetar med levnadsvanor i primärvården, och att beskriva deras kunskap, attityder och uppfattat organisatoriskt stöd för livsstilsinterventioner ; att (IV) i en två-årig uppföljning utvärdera utvecklingen av arbetet med levnadsvanor i primärvården, och användningen av de specifika nationella riktlinjerna för levnadsvanor. Metod och resultat: En intervjustudie med riktlinjeutvecklare på nationell nivå (n = 7) visade att många utmaningar för implementeringen av riktlinjerna identifierades och bemöttes under utvecklingsprocessen i fyra teman av strategier: breda överenskommelser och konsensus om inriktning och syfte, systematiskt och aktivt inkluderande av stakeholders, formaliserad och strukturerad utvecklingsprocess, öppenhet och insyn utvecklingsprocess. Samtidigt utmanade dock riktlinjerna om livsstilsinterventioner Socialstyrelsens utvecklingmodell p.g.a. deras förebyggande och icke sjukdomsspecifika fokus (I). En multipel fallstudie med nyckelpersoner ansvariga för implementeringen av riktlinjerna i sjukvårdsorganisationerna (n = 10) samt vårdpersonal och chefer (n = 340), visade på gynnsamma villkor för förändring i båda organisationerna rörande förändringsfokus (d.v.s. hälsoorientering) och den specifika interventionen (d.v.s. riktlinjer om metoder för att stödja förändring av ohälsosamma levnadsvanor). Stödet för förändring och lärande visade på något svagare resultat, likaså formen för förändringen d.v.s. nationella riktlinjer i allmänhet. Faktorer i den yttre kontexten visade sig kunna påverka prioritering av och optimalt val av tidpunkt för interventionen, likaså betydande skillnader i uppfattningar mellan yrkesgrupperna (II). En tvärsnittsstudie bland läkare och sjuksköterskor (n = 315) i primärvården visade att de har en positiv attityd och en god kunskapsnivå om metoder för livsstilsförändring. Både kunskapsnivå och i vilken utsträckning man arbetar med patienters livsstil skiljer sig mellan yrkesgrupper. Organisatoriskt stöd som nationella riktlinjer och utvecklandet av primärvårdens samarbete med intressenter i närområdet identifierades som viktigt för att förbättra arbetet med livsstil interventioner (III). En longitudinell undersökning bland vårdpersonal visade att användning av metoder för att förändra patientens vanor beträffande tobaksbruk och riskbruk av alkohol har ökat över tid, och att sjuksköterskorna arbetar i högre utsträckning med alla fyra levnadsvanorna än i tidigare. Implementeringen av de nationella riktlinjerna för levnadsvanor hade inte kommit så långt vid det andra mättillfället, och stora skillnader visade sig i hur läkare och sköterskor ser på riktlinjer och i vilken utsträckning de använder dem (IV). Slutsats: Hälsofrämjande och prevention skiljer sig på många sätt från mer traditionella fält inom medicinen. För att stärka implementeringen av det här viktiga (men ej akuta) fältet i hälso- och sjukvården, så måste det först av allt prioriteras på alla nivåer! Resultatet visar på ett svagt upptag av riktlinjerna för livsstilsinterventioner i klinisk praxis, och lämnar utrymme till förbättring. Aspekter av resultatet som presenteras i avhandlingen kan vägleda fortsatt utveckling och implementering av hälsoorientering och riktlinjer för livsstilsinterventioner inom primärvården, samt användas för att påverka policy, praxis och framtida forskning. Det gäller framför allt aspekter av utveckling av nationella riktlinjer på området; hälso- och sjukvårdsorganisationernas beredskap till förändring; hälsoprofessionernas attityder, kunskap och i vilken utsträckning de arbetar med livsstilsinterventioner och riktlinjer.