Postpartum weight retention is commonly considered an important precursor to long-term weight gain, with existing research suggesting that failure to lose weight in postpartum has significant future health implications. While postpartum has been identified as a possible ‘window of opportunity’ for women to make health behaviour change and manage their weight, it remains unclear how mothers, and in particular ‘large’ (BMI ≥ 40 kg/m2) mothers, experience health and engage with health-related behaviours at this particular point in the life course. Existing research has done little to enhance our understandings of the lived, embodied and practical realities of caring for an infant and, crucially, how this impacts health and weight management during the postpartum period. In addition, qualitative research focusing on postpartum has largely ignored the temporal dimensions of this period and, instead, has tended to focus attentions on a single ‘snapshot’ in time. To address these gaps in the literature, this study employed longitudinal qualitative methodology to explore 15 ‘large’ (BMI ≥ 40 kg/m2) women’s lived experience of health and weight management over the first six months following childbirth. Participants were recruited from a specialist antenatal metabolic clinic based in Edinburgh, Scotland. When possible, three in-depth semi-structured interviews were carried out with each participant: the first at six weeks postpartum, the second at three months and, the third at six months postpartum. Both six weeks and six months have consistently been identified in the literature as important markers for postpartum women. Hence, it was hoped that by interviewing at these and an intervening time point (i.e. three months) it would be possible to capture and understand processes of change with regards to weight management in the postpartum period. The analysis revealed that accounts of health and weight were far from straightforward and seemed to be heavily influenced by the wider social context, which routinely pathologises, demonises and stigmatises ‘fatness’. Challenging contemporary discourses of the ‘obesity epidemic’ which frame the large body as a direct consequence of individual lifestyle, participants principally drew upon lay notions of inheritance and implicated a genetic predisposition to resist individual responsibility for weight and body size. The analysis suggests that concerns for health were largely predicated on subjective experiences and, in the absence of tangible and embodied experiences of ill-health, participants expressed little if any impetus to engage in weight management for the purpose of improving their health. In short, the idea that their weight was an indicator of poor health, or future health risk, was not a view shared by participants. Instead, they expressed more complex understandings of their weight, and their responsibilities to engage in health changing behaviour. Despite articulating often strong desires to engage in weight management ‘for the baby’, the longitudinal focus revealed a disjuncture between these intentions and the reality of those engagements. Influential in this discordance was the transition from an intensely medicalised and closely monitored pregnancy, to a period of minimal or no follow up in postpartum. The lack of ‘surveillance’ appeared to have a notable impact on participants’ engagements with health-related behaviours once at home and going about the day-to-day tasks of caring for their infant. Dominant discourses around ‘good’ mothering also made it difficult for participants to prioritise their own needs (such as weight management) ahead of those of their children and other family members. When participants reflected on their experiences of mothering they frequently drew upon understandings of themselves as relational beings and, at times, positioned themselves as phenomenologically inseparable from their baby. This relationality was often experienced as a diminishing of individual autonomy, as the body of the mother and the baby became inter-embodied and bounded. Consequently, my analysis serves to problematise the individualised expectation surrounding a mother’s ability to act autonomously and engage in health-related behaviours in postpartum. These findings also call for a stronger appreciation to be developed of the complexities surrounding engagements with health-related behaviours at this particular point in the life course. In particular this research demonstrates the importance and utility of adopting a more embodied approach, which in turn has some notable implications for public health policy and practice.

Over a quarter of children and two thirds of adults in Australia are overweight, with these estimates reflecting global trends. The literature review in Chapter 1 highlights that treatment of childhood overweight is an important part of the public health approach required to address the obesity epidemic. Energy moderation, behaviour modification and family support are the cornerstones of treatment of childhood overweight. However the evidence to guide best practice is limited, with a call being made for well designed studies to inform age-appropriate effective, long term child weight management. Studies are needed in a range of populations and to assess a range of health outcomes. This thesis tested the hypothesis that, pre-pubertal children whose parents participate in a parent-led, family-focused child weight management intervention comprising parent skills training and intensive lifestyle education will have adiposity, metabolic profiles and indicators of physical and psychosocial functioning after 12 months that are a) improved compared to children wait listed for intervention and b) no different to children whose parents participate in parenting skills training alone (without intensive lifestyle education). Methods of the randomised controlled trial undertaken with 111 overweight, pre-pubertal 6-9 year olds to test this hypothesis are detailed in Chapter 2. Parents were defined as the agents of change, responsible for attending intervention sessions and implementing family-focused lifestyle change to support child weight management. Two interventions, both utilising parenting skills training, but differing in the presence or absence of intensive lifestyle eduction were compared to a group waitlisted for intervention with a brief pamphlet. Program effectiveness was defined in terms of adiposity together with broader health and evaluation outcomes. Chapter 3 describes the study population, their flow through the study, the primary outcome BMI z score and waist circumference z score. With parenting plus intensive lifestyle education there was a 10% reduction in BMI z score over 12 months. However this was not statistically different to the 5% reduction observed with parenting alone or intervention waitlisting. There was a significant reduction in waist circumference between baseline and 12 months with parenting alone and parenting plus lifestyle education, but not waitlisting. There was a group, time and gender interaction, with boys receiving intervention having greater reductions in adiposity. In determining intervention effectiveness, growth, metabolic profile and psychosocial outcomes are presented in Chapter 4. While there were limited improvements in metabolic profile and body dissatisfaction, significant improvements were observed in parent-perceived HR-QOL relating to psychosocial and family functioning. Improvements were confined to the intervention groups, parenting plus lifestyle education more than parenting alone. Chapter 5 presents the study process and impact evaluation. Parents were satisfied with the program and reported that it provided the type of help they wanted. Personal, rather than program factors such as work and family commitments limited intervention attendance to 60%. Child health behaviours and parental weight status show positive change in all groups, but favour intervention. Chapter 6 highlights key findings, study strengths/limitations and areas for further research. In conclusion, a parent-led family-focused intervention utilising parenting skills training and healthy family lifestyle is a promising intervention for young overweight children.

Introduction: Prevalence of obesity and overweight in children is growing in Canada and worldwide. In recent years multiple approaches have been utilized to treat childhood obesity. Multidisciplinary and family-based approaches have been shown to be successful in the management of obesity and overweight in children however, there is limited evidence about their use with younger children. Therefore the purpose of this thesis was to explore the translation of a family-based intervention, MEND 5-7, for the British Columbia (BC) context using the RE-AIM framework. Methods: A mixed methods design was used. Twenty-four children and their families who were enrolled in MEND program across 3 cities participated in the study. Anthropometrics and self-reported lifestyles and attitudes were measured for both children and parents pre and post program. MEND staff completed recruitment and registration tracking, and session feedback forms; were interviewed about implementation and meeting minutes were analysed for the process evaluation. In addition parent feedback surveys and site visit feedback forms were also included. Data were organized and analysed based on the RE-AIM framework. Results: The sample was too small to be representative but the demographics of the group appeared to be similar to the BC population. A number of significant improvements were seen related to physical activity (screen-time, p = .002; parent self-efficacy for increasing play and enjoyment, p = .05) and eating habits (parent fruit and vegetable consumption, p = .009). The small number of participants made in difficult to draw a valid conclusion about the changes in anthropometry. Data on implementation showed that families and group leaders were highly satisfied with the program. The program was found to be feasible and facilitators included team work, flexibility, participants’ engagement, community relations, preparation and planning, and support. Barriers to implementation included were time, recruitment, parental involvement, diversity, lack of flexibility in manual and location. Conclusion: MEND 5-7 appeared feasible for the BC population, however recruitment remains a significant challenge to program operations. Further research using an experimental design is needed. / Graduate

Background: The majority of adults in the UK are overweight or obese, and many embark on weight loss attempts, often without professional support. This dissertation set out to hone in on the cognitive and behavioural strategies used by adults with overweight and obesity attempting to lose weight, particularly in self-guided attempts, and to test the relationship between use of these strategies and weight loss success. Methods: A new taxonomy and questionnaire were developed to provide a framework to identify the cognitive and behavioural strategies used by individuals during weight loss attempts. The taxonomy was used in a systematic review and meta-analysis of self-help interventions for weight loss and in a systematic review of qualitative studies of self-directed weight loss. The questionnaire was used in an observational cohort study in adults with overweight and obesity trying to lose weight. Results: The taxonomy and questionnaire consist of 117 strategies. The qualitative review illuminated a range of attitudes and beliefs towards these strategies and highlighted the centrality of interpretation of self-monitored data. The quantitative review found that self-help interventions led to greater weight loss than unsupported attempts to lose weight at six months. In the cohort study, despite heterogeneity in the strategies employed, coherent patterns of behaviours emerged for individual participants. Strategies related to motivational support, dietary impulse control, and weight loss planning and monitoring were associated with greater weight loss. Conclusion: This dissertation demonstrates that self-help interventions can lead to significant weight loss and provides results to guide the content of such interventions. It maps out a previously uncharted area and provides a set of tools for further research and intervention development.

Thesis title: Health Professional-patient communication in relation to weight managementBackground: Global obesity levels have doubled since 1980 and are expected to rise. It is associated with key health risks such as heart disease, some cancers and osteoarthritis and hence has considerable economic consequences for health care resources. Key policy guidelines recommend that all health professionals (HPs) should discuss weight management with their patients making every contact count. However, we know HPs find discussions about weight challenging due to lack of time, training and skills. Knee Osteoarthritis (KO) and obesity are inextricably linked and together with a rise in obesity levels and growing numbers of older citizens rates of KO are set to escalate. As obesity is the key modifiable risk factor for KO, discussions about weight are paramount. This thesis explored this relationship further from the perspectives of patient and HPs, focusing on KO as an exemplar condition where there is scope for improved weight management. Methods: Utilising qualitative methods, three studies were undertaken. Firstly, a systematic review and thematic synthesis was conducted of published literature of physicians' views and experiences of discussing weight management within routine clinical consultations, not specific to KO. Secondly, HPs' experiences of discussing weight in consultations with KO patients through semi-structured interviews were conducted with 26 HPs. Interviews were audio recorded and analysed using TA. A final study recruited 25 overweight/obese patients with KO and investigated their experiences of talking about weight with HPs. Results: Overarching themes were identified across the studies. Firstly, HPs are pessimistic about patients' desire to lose weight and their capacity to help them. Several factors lead physicians and HPs to be reticent to accept responsibility for discussions about weight. Within routine consultations and between HPs and KO patients, weight was viewed as a sensitive topic. Both HPs and patients recognized the difficult cycle of pain, reduced mobility and weight gain. Patients with KO desire patient-centred (PC) care but, despite HPs recognizing its value, they do not receive it. Both physicians and HPs lack communication skills in weight management. Conclusions: The work undertaken in this thesis demonstrates that barriers preventing effective clinical interactions about weight identified in routine consultations still exist, even when two conditions such as KO and obesity are inextricably linked. Although HPs and patients hold similar understanding of these interrelationships and recognise the value of PC discussions, HPs struggle in effective behavior change talk. HPs expressed impatience with the efforts of their patients. To readdress this imbalance all consultations about weight should be PC. Both physicians and HPs were inadequately trained to discuss weight and patients' views supported this. HPs working with overweight patients should be trained in evidence-based behaviour change techniques and PC communication techniques to increase their confidence to support patients in weight management. Finally, health psychologists have the skills to both deliver and guide discussions about weight.

Background: The number of women considered overweight (OW) and obese (OB) in Canada has steadily increased over the past thirty years. In addition, there has also been a rise in the amount of weight women gain during pregnancy. Many adverse pregnancy outcomes are associated with maternal overweight, obesity and/or excessive gestational weight gain (GWG), which have been widely studied and reported. In 2009, the Institute of Medicine (IOM) developed healthy GWG guidelines, based on trial and observational evidence, that provide BMI-related weight gain targets. This evidence has shown that weight gain within the guidelines results in better health outcomes for the mother and baby, during pregnancy, as well as postpartum. Objectives: (1) To address diet quality and patterns using data collected from the Maternal Obesity Management (MOM) Intervention Trial, and (2) Develop and validate a comprehensive web-based questionnaire that can be used in a future study to examine women’s knowledge of the IOM GWG guidelines, dietary recommendations, physical activity (PA) practices, as well as other lifestyle habits. Methods: (1) Exploratory pooled analysis of dietary data from Maternal Obesity Management (MOM) trial - To identify diet quality of women who exceeded (EX) versus did not exceed (NEX) the 2009 IOM pregnancy weight gain targets. Participants (n=50) completed 7-day food records at 3 points during pregnancy (baseline (V1: 12-20 weeks), between 26-28 weeks (V2) and between, 36-40 weeks (V3). Data were analyzed in ESHA Food Processor Program and SPSS (version 13) to see if there was any difference found in diet between EX and NEX women. (2) Development and validation of a comprehensive maternal health questionnaire aimed to establish gaps in women’s behaviours and perceptions of the IOM GWG guidelines - An expert panel was consulted in the development of questionnaire constructs and items to gain content validity of the questionnaire. After multiple phases of questionnaire development and revisions, a 14-day test re-test validation pilot study was conducted to establish test re-test validity. Results: (1) In the EX and NEX analysis, significant decreases were found in total energy intake, including fat and protein, across pregnancy in the NEX GWG group. Significant group-by-time interaction was also found for energy intake and protein. (2) Most constructs included in the electronic maternal (EMat) Health questionnaire all proved to have sufficient test re-test validity via correlation analysis. Conclusion: In order to address the knowledge gaps regarding excess weight and changes in dietary habits during pregnancy, it is beneficial to explore pregnant women's knowledge and behaviours regarding these issues and collect information on what women report as barriers and facilitators to gestational weight management. The conclusions drawn from both of these studies may inform future interventions, as well as indicate where further education strategies are needed.

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Obesity is a public health concern and a major risk factor contributing to physical and psychological problems. It affects participation in occupations and increases healthcare-related costs. Certain populations are at risk of being overweight and obese. These include people of low socioeconomic status, racial/ethnic minorities, and individuals with disabilities. Adolescents diagnosed with learning disabilities (LD), and/or attention-deficit / hyperactivity disorders (ADHD) were also found to face difficulties in maintaining a healthy weight and engaging in healthy behaviors. While occupational therapy practitioners often address the academic and behavioral performance of children and adolescents with LD or ADHD, special attention should be given to weight-management and health promotion. An occupational therapy guided, health-promoting program was designed to address this gap. The 12-week program, named “Keep moving!” is intended for adolescents with LD or ADHD in schools and community centers. It incorporates Zumba dance activity, which is a form of a moderate-to-high intensity aerobic exercise. The foundations of the program are based on The Trans-Theoretical Model of Behavioral change and The Individual and Family Self-Management Theory, which enable individuals to take a significant part in the process of managing their health. The key features that were identified in the literature as most effective are applied in the program; establishing health-promoting habits and routines at home and school, adding weekly fun and engaging physical activities, providing information regarding healthy lifestyle components, instilling self-management skills, and establishing family support. The program evaluation plan utilizes both formative and summative evaluation approaches. A similar program could be applied to other populations at risk for overweight and obesity by adjusting the type of physical activity to accommodate the abilities and interests of other at-risk population groups.

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