Over two thirds of adults in the United States are affected by overweight or obesity. Weight management, which requires multi-component, intensive interventions targeting dietary and physical activity behaviors, should be offered as part of routine primary care services. Unfortunately, there is a paucity of evidence to guide the implementation of feasible and effective strategies within primary care settings. This DNP Project utilized a cross-sectional descriptive needs-assessment to survey obese patients' perceptions and preferences regarding weight and the primary care provider role in weight management. The findings from the needs assessment were used to inform the development of a feasible, patient-centered, weight management program.

Childhood overweight is a leading global public health issue. Chapter One of this thesis is a three part literature review of the evidence concerning the issue of childhood overweight and its management. Section One of the literature review describes this issue in terms of Australian and international prevalence rates and trends, health outcomes and aetiology. Sections Two and Three of the literature review examine the evidence to guide effective management of childhood overweight and analyse the thoroughness by which this evidence has been determined and translated into practice recommendations. The assumed cornerstones of child weight management are dietary change, increased physical activity, decreased sedentary behaviour, family support and behaviour modification. Recently, the role of parenting skills in the management of childhood overweight has been identified as a promising area of research. This thesis study examined the effect of the addition of parenting skills training to a parent-led, family-focussed healthy lifestyle intervention for the management of overweight in 5-9 year old children (The Parenting, Eating and Activity for Child Health (PEACH) Study). The methodology of the intervention is presented in Chapter Two. Families of overweight 5-9 year old children across two sites (three cohorts per site) were randomized to either a healthy lifestyle group program (HL) or a healthy lifestyle plus parenting group program (HL+P). Parents in both groups received eight 1.5hour group education sessions covering topics on child/family nutrition, physical activity and positive body image. Parents in the HL+P group were offered a four week parenting skills training program prior to this. All information was directed to parents and they were responsible for initiating and maintaining healthy lifestyle changes with their families. The intervention was delivered over a six month period and group differences were examined at this time point (intervention effect) and six months following with no further program contact (maintenance effect). The sample size (n=169) was calculated to demonstrate an estimated reduction in BMI z-score of 30% in the HL+P group and 10% in the HL group over 12 months, allowing for a drop out rate of one third (power=80%, significance=95%). Intention to treat analysis was conducted using ANCOVA. The effectiveness of the intervention was measured against a comprehensive evaluation plan consisting of: • primary outcome indicators (body mass index (BMI) z-score and waist circumference (WC) z-score) (Chapter Three), • secondary outcome indicators (health-related quality of life (HRQoL), body size dissatisfaction and height z-score) (Chapter Three), • impact evaluation indicators (children’s lifestyle behaviours and parent’s parenting practices) (Chapter Four), • process evaluation indicators (participant attendance and satisfaction and maintenance of program integrity across sites) (Chapter Four) and • qualitative evaluation of the factors external to the intervention that supported or inhibited families to achieve their healthy lifestyle goals (Chapter Five). Analysis of the primary outcomes (Chapter Three) found a significant group difference at the six month time point for BMI z-score (HL: -8%, HL+P: -13%, p=0.005), but not WC z-score (HL: -9%, HL+P: -11%, p=0.39). There were no group differences at the 12 month time point (six months following intervention end and with no further program contact). Application of the IOTF definition for childhood overweight and obesity to the full study sample found that 39 (23%) and 130 (77%) children were classified as overweight and obese respectively at baseline. By the six month time point (n=135), six (4%) children fell within the healthy weight range and 38% were classified as overweight and 58% as obese. At 12 months (n=123), 4% of children remained in the healthy weight range, 35% as overweight and 61% as obese. Children’s psychosocial health and linear growth were sustained during the intervention and maintenance periods. There were no between-group difference observed for any of the children’s lifestyle behaviours (dietary and activity behaviours) or parents’ parenting practices. However, the group as a whole exhibited significant improvements from baseline for scores of diet quality at the six month time point that were maintained during the following six month non-contact period (p&lt0.001 for 0-6mth and 0-12mth) (Chapter Four). Small screen usage significantly decreased for the full sample from 0-6 months and 0-12months (p&lt0.001 for both), however time spent being physically active did not change. Parents in both groups reported improvements in aspects of parenting over both time periods. Evaluation of process indicators showed that the intervention was well attended and accepted by families (Chapter Four). Seventy three percent (123) of subjects were retained to the 12 month time point and 44% (75) attended at least 75% of scheduled program sessions. Of the 131 parents who responded to a program satisfaction questionnaire, ninety four percent reported receiving the help they desired and 99% would recommend the program to others. The integrity of intervention sessions was upheld across sites providing reassurance that the program protocol was adhered to and demonstrating a good degree of generalisability. The thematic analysis of interviews conducted with parents at the 12month time point identified more references to barriers than facilitators of healthy lifestyle goal achievement (433 vs 375) (Chapter Five). This chapter highlights the contextual nature of family-based interventions and weight management strategies and the need to consider these during program planning and delivery. Chapter Six concludes the thesis by summarising its results and highlighting how they have contributed to the evidence base. Study strengths and limitations are described and implications of the findings on practice and future research are presented.

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Few studies have evaluated structured, long-term, family-based, weight management programs in children. This study’s purpose was to determine if completion of such a program resulted in reduced body mass index (BMI) z-scores and improved lifestyle habits. An observational study overtime from 2008-2010 was conducted with 89overweight/obese children. Subjects were divided into two groups, compliers (completed ≥ 7 intervention classes) and non-compliers (completed <7 intervention>classes.) The LiVe program, a 12-month structured, multi-component, family-based program, served as the study intervention. Anthropometric measurements and a written survey on lifestyle habits were used to obtain changes over 12 months in anthropometric, nutrition, activity, and behavior habits for subjects. Descriptive statistics, chi square, analysis of co-variance, and a mixed modellogistic regression were used to determine anthropometric and lifestyle habits changeover time as well as differences between age, gender, and compliance groups. Nodemographic differences were seen between compliance groups. Compliers had asignificant decrease in BMI z-score (-0.1903 p=.0004) and BMI percentile (-2.02p=.0235) over time. Compliers had a higher probability of meeting vegetable intake (pre 0.31%, post 55.67%; p=<.0001), and physical activity guidelines (pre 13.58%, post 56.58%; p=.0032) post intervention. Males were more likely than females to meet the physical activity guideline (p=.0007). Both compliers and non-compliers had a higher probability of meeting fruit (p=.0015) and sugar-sweetened beverage intake guidelines (p=.0337) at 12 months. No significant differences in age and gender were seen for changes in anthropometric or lifestyle habits except as noted above. Long-term, family-based, structured weight management programs are effectivein reducing BMI z-scores and improving lifestyle habits in children. Continueddevelopment and evaluation of these programs is warranted to address childhood obesity treatment methods.

Yes / Obesity is a global public health concern. Interventions rely predominantly on managing dietary intake and increasing physical activity; however, sustained adherence to behavioral regimens is often poor. The lack of sustained motivation, self-efficacy, and poor adherence to behavioral regimens are recognized barriers to successful weight loss. Avatar-based interventions achieve better patient outcomes in the management of chronic conditions by promoting more active engagement. Virtual representations of self can affect real-world behavior, acting as a catalyst for sustained weight loss behavior. We evaluated whether a personalized avatar, offered as an adjunct to an established weight loss program, can increase participant motivation, sustain engagement, optimize service delivery, and improve participant health outcomes. A feasibility randomized design was used to determine the case for future development and evaluation of avatar-based technology in a randomized controlled trial. Participants were recruited from general practitioner referrals to a 12-week National Health Service weight improvement program. The main outcome measure was weight loss. Secondary outcome measures were quality-of-life and self-efficacy. Quantitative data were subjected to descriptive statistical tests and exploratory comparison between intervention and control arms. Feasibility and acceptability were assessed through interviews and analyzed using framework approach. Health Research Authority ethics approval was granted. Overall, 10 men (n=7, 70% for routine care and avatar and n=3, 30% for routine care) and 33 women (n=23, 70% for intervention and n=10, 30% for routine care) were recruited. Participants' initial mean weight was greater in the intervention arm than in the routine care arm (126.3 kg vs 122.9 kg); pattern of weight loss was similar across both arms of the study in T0 to T1 period but accelerated in T1 to T2 period for intervention participants, suggesting that access to the self-resembling avatar may promote greater engagement with weight loss initiatives in the short-to-medium term. Mean change in participants' weight from T0 to T2 was 4.5 kg (95% CI 2.7-6.3) in the routine care arm and 5.3 kg (95% CI 3.9-6.8) in the intervention arm. Quality-of-life and self-efficacy measures demonstrated greater improvement in the intervention arm at both T1 (105.5 for routine care arm and 99.7 for intervention arm) and T2 (100.1 for routine care arm and 81.2 for intervention arm). Overall, 13 participants (n=11, 85% women and n=2, 15% men) and two health care professionals were interviewed about their experience of using the avatar program. Participants found using the personalized avatar acceptable, and feedback reiterated that seeing a future self helped to reinforce motivation to change behavior. This feasibility study demonstrated that avatar-based technology may successfully promote engagement and motivation in weight loss programs, enabling participants to achieve greater weight loss gains and build self-confidence. ISRCTN Registry 17953876; https://doi.org/10.1186/ISRCTN17953876. / This study was funded by the National Institute for Health Research (Research for Patient Benefit program [project reference PB-PG-1215-20016]).

Many stories exist within the professional landscape of child weight management programming and health services. Grand narratives within these spaces story fat bodies as “unhealthy”, “risky” and in need of transformation, and often position the family and mothers in particular given gendered caregiving norms, as responsible for their children’s weight and poor health. Mothering stories and experiences are rarely told by the mothers themselves within this professional landscape. This study is a narrative inquiry that explores the in-depth experiences of two mothers who previously participated with their children in an Ontario paediatric weight management program. Given my work as a social worker within child weight management clinics I also explore my experiences alongside the participants. Clandinin and Connelly’s conceptualization of narrative inquiry and the three dimensional framework of temporality (past, present, future), sociality and place, inquiring inward, outward, backward and forward, were used in order to find meaning in mothering experiences of child weight management. Narrative beginnings share my own experiences of mothering and child weight management. Relational ethics were central as the inquiry unfolded, allowing for simultaneous exploration of experiences, continuous negotiation, awareness and re-evaluation with each mother, from recruitment, field work, to field text, interim text and the writing of the final text. Given the current social distancing restrictions related to the COVID-19 pandemic, conversations took place over zoom and telephone and were audio-recorded and transcribed verbatim. Detailed narrative accounts were written for each mother capturing individual experiences of child weight management as they intersected with many other experiences in their everyday lives. Narrative threads weaved together the mother’s experiences throughout the inquiry and focused on disrupting the grand narrative and resisting fragmentation. The inquiry contributes to the scholarship within fields of social work, social justice, mothering and health care by providing new ways of knowing about and engaging in conversations about mothering, weight, fatness and health. / Dissertation / Doctor of Philosophy (PhD) / This narrative inquiry explores the in-depth experiences of two mothers who previously participated in a child weight management program. As part of this research, I also explore my experiences in relation to the mothers, as a social worker who historically worked in the clinic. Mothers were often positioned as responsible for their children’s body weight and poor health and stories and experiences were rarely told by the mothers themselves across research and policy in the field. Clandinin and Connelly’s three-dimensional framework was used to find meaning in mothering experiences of child weight management. Conversations took place over zoom and telephone over a year. Detailed narrative accounts capture the individual mothering experiences of child weight management and come together in narrative threads that focus on disrupting the grand narrative and resisting fragmentation. The inquiry contributes to the scholarship within fields of social work and health care, providing new ways of knowing about and engaging in conversations about mothering, weight, fatness and health.

Guided by a conceptual framework regarding how supportive messages interpreted as negatively controlling are related to individuals’ relational health and weight management efforts, this research explored participants’ interpretations of their romantic partner’s weight management messages in a two-phase study. In phase one, college students were presented with a sample of supportive weight management messages. Participants were asked to describe the degree to which each message communicated support and negative control as well as respond to items concerning their personal and relational characteristics. In phase two, participants were asked to report a memorable weight management message they received from their current romantic partner. These messages were then assessed for their degree of support and negative control by the participant. Additionally, students responded to measures concerning how perceptions of their health attitude and relational qualities changed after receiving the message. Results from phase one indicated that readiness to change, body esteem, external and internal locus of control, history of received support, and level of relational distress were all significant predictors of interpreting a supportive weight management message as negatively controlling. Phase two results indicated that perceived negative control in a partner’s weight management message is a significant predictor of perceived level of trust in their relationship, weight management commitment, exercise self-efficacy, diet self-efficacy, and perceived negative change in relational quality. The relevance of perceived negative control for relational functioning and health attitudes is discussed. / text

The prevalence of obesity (BMI≥30kg/m²) in the Scottish population is rising at an alarming pace. The health implications for those affected and the lack of sustained success in treatment, demands that new strategies be explored to improve patient outcomes (Harvey et al. 2005). Primary care nurses appear well placed to address obesity management. Therefore, the aim of this research was to develop and evaluate an evidence based, holistic, person centred approach to management, which was relevant to both professionals and those who are obese. A conceptual framework was developed to encompass the physical, social and emotional components of weight management in conjunction with the nursing models of Roper, Logan and Tierney and Peplau. The approach used mixed methods of data collection, which was carried out in two phases. Outcomes from the initial exploratory, longitudinal survey phase, involving 64 outpatients attending a specialist obesity clinic, showed that physical, social and emotional factors, in conjunction with beliefs about weight management are interrelated. Evidence from the exploratory phase contributed to the development of materials for the intervention phase which was implemented in primary care by nine practice nurses (PNs) who recruited 28 obese individuals for a three month period. Methods of data collection included questionnaires, booklets, field notes and interviews. ii The key findings of this study confirmed that obesity is complex and a holistic, person centred approach to weight management through partnership working between nurses and obese individuals can be effective. While PNs have a key role to play in obesity management they recognised their need for appropriate tools and education to help individuals towards self-management. The results also suggested that nurses and individuals who took ownership of this approach had successful outcomes in terms of weight loss.

The home environment, parental health attitudes, and parental diet and exercise behaviors have been associated with childhood obesity. The current study utilized a family systems framework to examine the effect of these variables on weight and health changes in a primarily Black sample of 530 parent-adolescent dyads enrolled in a multidisciplinary weight loss intervention. Parent-reported psychosocial variables and demographic information were used to test models predicting changes in adolescents’ body mass index, cholesterol, and percentage body fat over the first six months of the intervention. The effect of parent participation in a psycho-education parent group on adolescent health outcomes was also examined. Several significant demographic, parental, and home environment predictors emerged in the models. By identifying specific aspects of the home environment, parent attitudes, and parent behavior to modify in interventions, these findings have significant implications for the prevention and treatment of childhood obesity.

Polycystic ovary syndrome (PCOS) is the most common endocrinopathy disorder in reproductive age women. The symptoms of this disorder are the androgen excess seen with anovulation/oligoovulation or morphologically ovarian cysts. The aim of the study was to assess the efficacy of public health nutrition intervention designed to enhance healthy eating and lifestyle modification among PCOS patients attended the obstetrics and gynecology clinic at the American University of Beirut Medical Centre (AUB-MC) in Beirut, Lebanon. A prospective hospital based public health nutrition intervention was proposed in which 76 women with PCOS were recruited in the pilot study and 588 women were recruited in the scale-up intervention divided between PCOS and non-PCOS. During the scale up phase non-PCOS women were recruited to study the effect of the nutritional counseling on them as a way to compare the outcome with PCOS women. Recruited population were divided into 8 groups; group A: overweight/obese PCOS patient’s intervention (received weight management program with nutritional guidelines). Group B: overweight/ obese PCOS controls (received the usual heath care by the gynecologist), Group C: lean PCOS controls (received the usual heath care by the gynecologist), Group D: lean PCOS intervention (received weight maintenance program with nutritional guidelines ), Group E: overweight/obese non-PCOS patient’s intervention (received weight management program with nutritional guidelines) ,Group F: overweight/ obese non-PCOS controls, Group G: lean non- PCOS intervention (received weight maintenance program with nutritional guidelines), Group H: lean non-PCOS controls. Data were collected using a pre-validated questionnaire to capture sociodemographic variables, nutritional status, and physical activity, psychological and medical status. Blood analysis was carried out to determine biochemical indices. Assessment of study indicators were carried out at baseline, after 3 and 6 months from inception of intervention (pilot as well scale up). Patients in intervention groups attended a 6 month tailored nutrition counseling/education program (2 sessions per month), to enhance their understanding of their dietary intake and assist them with weight management, physical activity, healthy cooking, lifestyle, and food shopping. Following a six months pilot study intervention results have shown that 7% weight loss was achieved in overweight/ obese intervention groups and weight maintenance in lean intervention groups( Group A,B,C and D). There was a significant reduction in waist (-4.2 cm (±5.6)) and hip circumference (-3.1cm (±3.5)) with P < 0.001. There was no significant biochemical markers change (fasting blood sugar, CRP, LDL-C,HDL-C,TG,total cholesterol, fasting insulin, total testosterone,Vit D), however there was an increase in physical activity (3.1 hours/week (±1.5)) , and decrease in anxiety and depression score ( BDI-II and BAD-7); -0.8 (±0.8) and -0.7 (±0.7) with P < 0,001 compared to interventions. Following six months scale up intervention, the results have shown a weight reduction among overweight/obese PCOS women (group A) who lost, on average, 8.2 kg (P=0.001). Whilst non-PCOS women lost, on average 11.6 kg (P < 0.001)(Group E). Controls gained weight (Group B, D F and H). The biochemical, psychological and reproductive profile showed significant improvements among PCOS women (P < 0.001). Pregnancy rate increased to 70% among women trying to conceive. The results of this study have shown this intervention to be effective in Lebanese women with PCOS, decreasing their initial body weight by 5%- 10% and improving their reproductive, metabolic and endocrine profiles. This suggests the need for a nutritional intervention (nutritional guidelines) for women diagnosed with PCOS patients as a first line treatment. The study results support the effectiveness of lifestyle modification diet for PCOS women.