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Child overweight has reached an epidemic level throughout the United States. A total of 65 primary care providers in southern Appalachia were surveyed to understand current issues in addressing child overweight in rural primary care practice. The study shows that while providers realized the importance of child overweight intervention, many were not ready and did little to address child overweight in their practices. The providers' skill levels in addressing child overweight were generally less than sufficient. Common barriers to child overweight treatment included lack of parental motivation and involvement, lack of supportive services, and lack of clinician time. In conclusion, rural primary care is facing many challenges in addressing child overweight. However, with more training in behavioral intervention skills and through establishing a family-based intervention and a group visit approach, primary care providers could play a more active role in the fight against the epidemic of child overweight.

Since 1980, the obesity rate in children 5 to 11 years of age has increased from 7% to 18%. The lack of structured physical activity and poor dietary habits childhood are primary risk factors for obesity related comorbidities in adulthood. Guided by primary care providers, families can reverse childhood obesity by implementing healthy dietary habits and engaging in structured physical activity. The purpose of this quality improvement project was to develop an evidenced-based policy with procedures to standardize the timely and consistent identification of overweight children at a primary care clinic serving military families. With an emphasis on obesity prevention within families through primary care interventions, the revised health belief model guided the project design. A literature review was conducted in a systematic manner to identify effective strategies and interventions to inform the policy development. Then, the Delphi technique guided a 12-member expert panel to evaluate the policy and procedures in terms of the level of evidence and the implementation plan with the goal of achieving consensus with recommendations for revisions. Consensus was achieved with multiple revisions following the completion of two Delphi rounds. The first panel session (n=12) concluded with a 70% consensus, including recommended revisions to improve the policy implementation. The second panel session (n=12) concluded with 100% consensus for the revised policy. The final policy and procedures addressed the clinical practice gap with a robust process to identify, counsel, and refer overweight children to external specialty programs for obesity management. By intervening to reverse the progression of childhood obesity, this project achieved positive social change at an organization level.

<p>Over the past three decades, the phenomenon of children's health in China has been marked by a co-existence of overweight and underweight. As the primary institution for a child, family is an opportune place for child malnutrition intervention. By advancing a framework that addresses the contextual factors which shape the heterogeneity of socioeconomic gradients of child overweight/obesity, this dissertation has sought to understand the channels through which access to family resources influences child overweight/obesity in China. Based on these developed understandings, I identified the mechanisms by which having any younger siblings and three generation living together or proximately affect child malnutrition in China. Using data drawn from China Health and Nutrition Survey, this dissertation uncovered remarkable differences in multiple levels of contextual factors that shape a child's risk of overweight/obesity and underweight in China as compared to Western society. China's stage of economic development together with the drastically increasing income inequality has created an ever-increasing socioeconomic gap in child overweight/obesity, especially after 1997. This finding confirmed the position of the Ecological System framework that access to obesogenic environment is much more important than willpower based on knowledge in shaping one's obesity-related risk behavior. Although the fertility level has been lowered by One Child Policy, resource dilution effect still affects girls' nutrition status, especially for those exposed to poverty and food insecurity. Children in the care of grandparents are healthier, probably due to the generally low degree of access to obesogenic foods and a closer intergenerational relationship that facilitates effective communication and promotes healthy lifestyle formation.</p> / Dissertation

Introduktion: Barnfetma och övervikt är växande folkhälsoproblem där var femte barn iSverige lider av det. Barn som tillhör svaga socioekonomiska grupper drabbas i störreutsträckning än andra barn. Detta förklaras av föräldrarnas låga utbildningsnivå, lågayrkesstatus och låga inkomstnivåer. Enligt WHO led 340 miljoner barn i åldrarna 5–19 år avövervikt eller fetma globalt år 2016. Obehandlad övervikt och fetma hos barn kan leda tillkroniska följdsjukdomar i vuxenlivet. Syfte: Syftet med denna studie var att undersöka vilkafaktorer inom områdena inkomst, utbildningsnivå och yrke som har störst bidragande orsak tillövervikt och fetma hos barn i familjer med låg socioekonomisk status. Metod: En kvalitativsystematisk litteraturöversikt. Analys av fynd gjordes med tematisk analys. Totalt inkluderades20 artiklar och tre databaser användes till studien; PubMed, CINAHL och Academic SearchPremier. Resultat: Föräldrars utbildningsnivå skapar de hälsoförutsättningar som barnet får.Låg utbildningsnivå var förknippat med sämre förutsättningar, sämre arbetsmöjligheter och eninkomst som inte täcker mer utöver de basala behoven. Låg utbildningsnivå resulterar även ibristande kunskaper om hälsosamma matvanor hos föräldrar. Detta påverkar hur de och derasbarn konsumerar mat som är mer energirik och näringsfattig. Flera studier visar att främstmoderns övervikt, lågutbildning och låga yrkesstatus är en riskfaktor för barnfetma. Slutsats:Högre utbildning är en skyddsfaktor som innebär bättre arbetsmöjligheter samt bättrekunskapsunderlag om hälsan och positiva hälsobeteenden. Insatser för att angripa den ojämlikahälsan i samhället bör prioriteras. Satsningar på att öka utbildningsnivån hos utsatta grupper,förbättra arbetsmöjligheter framförallt för mödrar. / Introduction: Childhood overweight and obesity are growing public health problems whereevery fifth child in Sweden suffers from it. Children belonging to weak socio-economic groupsare affected to a greater extent than other children. This is explained by the parents' low levelof education, low occupational status and low-income levels. According to the WHO, 340million children aged 5–19 years suffered from overweight or obesity globally in 2016.Untreated overweight and obesity in children can lead to chronic diseases in adulthood. Aim:The aim of this study was to investigate which factors in the areas of income, level of educationand occupation have the greatest contributing factor to overweight and obesity in children infamilies with low socio-economic status. Method: A qualitative systematic literature review.Analysis of findings was done with thematic analysis. A total of 20 articles were included andthree databases were used for the study: PubMed, CINAHL and Academic Search Premier. Result: Parents' level of education creates the health state that the child develops. Low level ofeducation was associated with poorer conditions, poorer job opportunities and an income thatdoes not cover more than the basic needs. Low levels of education also result in a lack ofknowledge about healthy eating habits in parents which affect how they consume foods that aremore energy-rich and nutrient-poor. Several studies show that mainly the mother's overweight,low education and low occupational status are a risk factor for childhood obesity. Conclusion:Higher education acts as a protective factor and means better job opportunities as well as abetter knowledgebase about health and positive health behaviors. Health interventions to tackleunequal health in society should be a priority. Efforts to increase the level of education ofvulnerable groups, improve job opportunities, especially for mothers are needed.

Au cours des 30 dernières années, l’embonpoint et l’obésité infantile sont devenus de véritables défis pour la santé publique. Bien que l’obésité soit, à la base, un problème physiologique (i.e. balance calorique positive) une série de facteurs psychosociaux sont reliés à son développement. Dans cette thèse, nous avons étudié le rôle des facteurs périnataux et de la petite enfance dans le développement du surpoids, ainsi que la relation entre le surpoids et les troubles internalisés au cours de l’enfance et au début de l’adolescence. Nous avions trois objectifs généraux: 1) Modéliser le développement de l’indice de masse corporelle (IMC) ou du statut pondéral (le fait d’être en surpoids ou non) durant l’enfance, ainsi qu’estimer l’hétérogénéité dans la population au cours du temps (i.e. identification de trajectoires développementales de l’IMC). 2) Identifier les facteurs périnataux et de la petite enfance pouvant accroitre le risque qu’un enfant suive une trajectoire menant au surpoids adolescente. 3) Tester la possibilité que le surpoids durant l’enfance soit associé avec des problèmes de santé mentale internalisés à l’adolescence, et vérifier la possibilité qu’une telle association soit médiatisée par l’expérience de victimisation par les pairs et l’insatisfaction corporelle. Ce travail est mené dans une perspective de développement au cours de la vie (life span perspective), considérant l’accumulation des facteurs de risques au cours du temps ainsi que les facteurs qui se manifestent durant certaines périodes critiques de développement.1,2 Nous avons utilisé les données provenant de l’Étude Longitudinale du Développement des Enfants du Québec (ELDEQ), une cohorte de naissances de la province de Québec, Canada. L’échantillon initial était composé de 2120 familles avec un bébé de 5 mois nés au Québec en 1997. Ces familles ont été suivies annuellement ou à tous les deux ans jusqu’à ce que les enfants atteignent l’âge de 13 ans. En ce qui concerne le premier objectif de recherche, nous avons utilisé la méthode des trajectoires développementales fondée sur des groupes pour modéliser l’IMC en continu et en catégories (surpoids vs poids normal). Pour notre deuxième objectif, nous avons effectué des modèles de régression multinomiale afin d’identifier les facteurs périnataux et de la petite enfance associés aux différents groupes développementaux du statut pondéral. Les facteurs de risques putatifs ont été choisis parmi les facteurs identifiés dans la littérature et représentent l’environnement périnatal, les caractéristiques de l’enfant, ainsi que l’environnement familial. Ces facteurs ont été analysés longitudinalement dans la mesure du possible, et les facteurs pouvant servir de levier potentiel d’intervention, tels que l’usage de tabac chez la mère durant la grossesse, le sommeil de l’enfant ou le temps d’écoute de télévision, ont été sélectionnés pour l’analyse. Pour notre troisième objectif, nous avons examiné les associations longitudinales (de 6 à 12 ans) entre les scores-z d’IMC (selon la référence CDC 2000) et les problèmes internalisés avec les modèles d’équations structurales de type « cross-lagged ». Nous avons ensuite examiné comment la victimisation par les pairs et l’insatisfaction corporelle durant l’enfance peuvent médiatiser un lien potentiel entre le surpoids et les troubles internalisés au début de l’adolescence. Les contributions scientifiques de la présente thèse incluent l’identification de trajectoires distinctes du statut pondérale durant l’enfance (précoce, tardive, jamais en surpoids), ainsi que les facteurs de risques précoces et les profils de santé mentale pouvant différer selon la trajectoire d’un enfant. De plus, nous avons identifié des mécanismes importants qui expliquent une partie de l’association entre les trajectoires de surpoids et les troubles internalisés: la victimisation par les pairs et l’insatisfaction corporelle. / Child overweight and obesity has challenged the field of public health for several decades. While its direct underpinnings may be physiological, its development and outcome are intertwined with an array of psychosocial factors. This dissertation has sought to answer questions relating to the perinatal and early life risk factors associated with overweight development, as well as its potential psychological correlates during middle childhood and early adolescence. Specifically, this project had three research goals: 1) To model the developmental pattern of BMI or weight status throughout childhood and estimate population heterogeneity. 2) To identify the perinatal and early childhood risk factors that may increase the likelihood that a child follows a path leading to overweight by adolescence. 3) To examine whether being overweight in middle childhood is associated with internalizing mental health symptoms in early adolescence, and whether such an association is mediated by the experience of peer victimization and body dissatisfaction. This work takes a developmental life-course perspective in that it considers both the accumulation of risk factors over time as well as risk factors occurring during critical periods of development.1,2 We examined data drawn from the Quebec Longitudinal Study of Child Development (QLSCD), a population-based birth-cohort study in the province of Quebec, Canada. The initial sample consisted of 2120 families with a 5-month old baby born in Quebec in 1997. These families were monitored yearly or biennially until children were 13 years of age. For our first research goal, we modeled group-based developmental trajectories of child BMI and child weight status (overweight vs. not overweight). For our second goal, multinomial logistic regression analyses were conducted in order to identify the perinatal and early risk factors associated with the different developmental groups of weight status. Putative risk factors were chosen from the literature and represent the perinatal environment, child behavioral characteristics, as well as the family home environment. These were analyzed longitudinally when possible, and factors that could be targeted for intervention, such as maternal smoking during pregnancy, child sleep times or television viewing were selected for analysis. In order to complete our third research goal, we examined the longitudinal associations (from age 6 to 12) between BMI z-score (CDC 2000 reference) and internalizing and externalizing problems by way of cross-lag panel models in the Mplus program. Our results indicating sparse cross-lagged links, we then examined whether peer victimization and body dissatisfaction during childhood mediate the association between early overweight development and self-reported internalizing symptoms in early adolescence. Important scientific contributions stemming from this project include the identification of distinct weight status trajectories during childhood (i.e. early onset, late onset, never overweight) and the identification of perinatal and early life risk factors and mental health outcomes that may differ depending on a child’s developmental trajectory. Additionally, we identified two important mechanisms of the association between overweight and internalizing problems: peer victimization and low body satisfaction.