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.

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.

The present study evaluated associations between parent-child connectedness and communication, parent perceptions of child weight, parent feeding behaviors (restriction, pressure to eat, and monitoring), and child body mass index percentile among a sample of children aged 8-12 years. To evaluate these associations, this study used a cross-sectional design and maximum likelihood (ML) structural equation modeling to examine a mediation model with parental feeding behaviors mediating the associations between parent-child relationship quality and child body mass index. Furthermore, because of the known associations between parental perceptions of child weight and parent feeding practices, models examining the mediating effects of parent feeding practices between parent perceptions of child weight and child body mass index were also examined. Finally, we used mixture modeling to conduct latent profile analyses, specifying high, moderate, and low levels of each feeding behavior, in order to examine the mediation effects of specific levels of feeding behaviors. Study findings supported restriction as a mediator between parent reported communication (PRC) and child weight, as well as between parent perceptions of child weight (PCW) and child weight. The results also indicated that parent perceptions of child weight predicted feeding practices and child weight. Both restriction and monitoring predicted child weight. Overall, these findings provide evidence for the role of parent-child relationship quality in predicting parent feeding behavior. However, study findings suggest that these associations may differ depending on the rater (i.e., child, parent).

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.

Objectives: This thesis aims to further our understanding in relation to childhood obesity and associated psychological difficulties. Design: The systematic review aimed to investigate the relationship between childhood psychological functioning in overweight and obese children and parental mental health difficulties. The empirical study aimed to examine possible relationships between Body Mass Index (BMI), self-esteem, quality of life and resilience, in order to determine any factors which may protect against the negative psychological consequences of obesity. Methods: A systematic review was completed using a comprehensive literature search of relevant databases to identify studies examining the relationship between childhood psychological functioning in children who were deemed overweight or obese and parental mental health difficulties. In the empirical study children of a variety of differing Body Mass Indexes (BMI) were asked to complete measures of quality of life, resilience and self-esteem. Correlation analyses were carried out to determine any relationships between BMI, quality of life, resilience and self-esteem. Moderation analyses were then completed to examine whether resilience moderates the relationship between BMI and quality of life or between BMI and self-esteem. Results: Ten studies met inclusion criteria for the systematic review. Although the reviews appeared to indicate a significant relationship between parental mental health and childhood psychological functioning, the studies were predominantly of average or low methodological quality, weakening any conclusions drawn. Results of the empirical study indicated significant correlations between resilience and quality of life and resilience and self-esteem. BMI was not found to significantly correlate with any other factors. Further moderation analyses indicated no moderating effect for resilience. The lack of association between BMI and either quality of life or self-esteem may in part be because most children who took part were of normal weight. Conclusions: Interventions targeting childhood overweight/obesity and their psychological effects may need to take into account wider psychosocial factors including parenting and positive factors which may protect against the negative psychological effects of obesity. However, further research is needed, particularly in relation to resilience.

Background: Childhood obesity is a critical public health problem. There is a crucial need to identify environmental factors that either encourage or prevent obesogenic behaviors. The home food environment is one of the primary environments in which children are exposed to food. Therefore, it is crucial to study how the home food availability influences dietary intake and weight status. Objective: This study examines parental report of household food availability of fruits, vegetables, and milk, and its association with child weight status and child dietary intake of these foods. Methods: This is a cross-sectional study, based on surveys from 489 students in grades 3-12 their parents in 2009. Child participants were Destination ImagiNation® finalists. Child data collection included surveys based on the Youth Risk Surveillance Survey and anthropometric measurements of height and weight used to calculate child z-BMI. Parents self-reported their heights and weights and home food availability. Descriptive statistics were conducted and multiple linear regression was used to predict whether or not a relationship existed between home food availability, child weight status, and dietary intake of fruits, vegetables, and milk. Results: Overall, 12.5% of participants were overweight and 6.7% were obese. Approximately26% of participants consumed 5 or more servings of fruits and vegetables per day and 17% consumed 3 or more glasses of milk per day. However, a no significant relationship was found between home availability of fruits, vegetables, and milk and the reported intake of these foods. Although a significant association was also found between parent and child weight status, no significant association was found between home food availability and child weight status. Conclusions: Compared to national data, a larger proportion of this sample was classified as normal weight and consumed the recommended intake of fruits and vegetables and milk. Parents reported high availability of fruits, vegetables, and milk products. However, no significance was found between the reported availability of these foods and weight status or dietary intake of fruits, vegetables, or milk.

The growing childhood obesity epidemic and its association with adverse health outcomes have prompted increasing research in the recent past. Researchers have examined numerous aspects of the obesity epidemic. For example, the impact of parent behavior on child behavior has been considered. Likewise, researchers have examined the connection between parent perceptions of obesity and concern regarding a child’s weight status. Still other research has focused on the influence of a child’s behavior on weight status. Existing research has reported that within the African American community there is an apparent inaccuracy in perceptions regarding weight. Children who would be classified as overweight or obese according to body mass index (BMI) calculations are viewed by parents as having normal or healthy weight. Thus, among African-American parents, there is often no correlation between a child’s weight status and the parent’s perception of a weight concern. Moreover, it is not clear that there is a relation between parent concern regarding a child’s weight status and the amount of physical activity that the child engages in among African-American individuals. Further, it is not clear what relations may exist among parent physical activity level, child physical activity level, and the child’s BMI status. Finally, after conducting a semi-exhaustive study of the research, the links among child dietary habits, parent dietary habits, and the child’s BMI status in the African American population have not been addressed. The purpose of this study is to more closely examine the impact of risk factors such as parental physical activity, dietary habits, and parent concern and perception regarding weight on children’s weight status within an African American sample.

L’étiologie de l’obésité infantile est multifactorielle et complexe. Le patrimoine génétique tout comme l’environnement d’un enfant peuvent favoriser l’apparition d’un surplus de poids. C’est pourquoi plusieurs études se sont penchées sur le lien entre l’environnement familial et en particulier le rôle de la mère et le risque d’obésité chez l’enfant. L’objectif est de mieux comprendre quels sont les facteurs de risque maternels spécifiques à chaque population afin de mieux prévenir ce fléau. Ce projet a donc cherché à identifier quelles sont les relations entre les facteurs de risque maternels et l’indice de masse corporelle d’enfants québécois avec surcharge pondérale. Parmi les facteurs de risque étudiés, on note des liens entre le niveau de scolarité de la mère, son statut familial et son niveau d’insécurité alimentaire. Sur le plan cognitif et comportemental, le lien entre l’indice de masse corporelle (IMC) de l’enfant et la perception maternelle du poids de son enfant ainsi que le niveau de restriction alimentaire maternel ont également été analysés. Au total, 47 entrevues ont été complétées par téléphone auprès des mères d’enfants obèses ou en embonpoint grâce à un large questionnaire destiné à décrire le profil des familles consultant les cliniques externes du CHU Ste Justine. Les tests de Fisher pour les variables catégorielles, le test de T de comparaison des moyennes du Z-score de l’IMC des enfants ont permis d’effectuer les analyses statistiques. Les résultats obtenus démontrent qu’un lien existe entre le niveau de scolarité maternel et la présence d’insécurité alimentaire. De même, il a été possible de constater que les enfants avec une mère restrictive des apports alimentaires de leur enfant avaient un Z-score de l’IMC significativement plus élevé. Ces résultats suggèrent qu’il existe des liens entre le profil socio-économique et comportemental de la mère et le surplus de poids de l’enfant. Des tests auprès d’un plus large échantillon seront nécessaires afin de confirmer ces résultats, l’objectif étant, entre autres, de mieux cibler les enfants à risque d’embonpoint ou d’obésité et de mieux outiller les professionnels de la santé en contact avec ces familles. / The etiology of childhood obesity is multifactorial and complex. Both the genetic inheritance and the environment of the child can contribute to overweight. As a result several studies have focused on the link between the family environment and in particular the role of the mother, and the child’s risk of obesity, in order to understand the maternal risk factors specific to each type of population and prevent this public health problem. This project aims to identify the relationships between maternal risk factors and the body mass index of overweight Quebecois children. Among the risk factors studied, relationship were observed among the mother’s level of education, her family status and the level of food insecurity. On the cognitive and behavioral level, we analysed the relation between the child’s body mass index (BMI) and the maternal perception of the child’s weight as well as the maternal level of dietary restriction. Forty seven telephone interviews were completed with mothers of obese or overweight children with a large questionnaire aimed to describe the profile of the family during their visit to Sainte Justine Hospital outpatient clinic. The tests of Fisher for category-specific variables and the T test for the comparison of the averages of children’s BMI Z-score were used to perform the statistical analyses. The results show that there is a significant correlation between the mother’s level of education and the presence of food insecurity in families of overweight children. Concerning the cognitive aspect, children whose mother restricted their food consumption had obtained a significantly higher BMI Z-score than those whose mother did not restrict food. These results suggest that there are links between the socioeconomic and behavioural profil of the mother and the child’s body mass index. Tests taken over a larger sample will be necessary in order to confirm those results. The objective, among other things, is to better target children with risks regarding stoutness or obesity and to improve tools for health professionals that are in contact with those families.

L’étiologie de l’obésité infantile est multifactorielle et complexe. Le patrimoine génétique tout comme l’environnement d’un enfant peuvent favoriser l’apparition d’un surplus de poids. C’est pourquoi plusieurs études se sont penchées sur le lien entre l’environnement familial et en particulier le rôle de la mère et le risque d’obésité chez l’enfant. L’objectif est de mieux comprendre quels sont les facteurs de risque maternels spécifiques à chaque population afin de mieux prévenir ce fléau. Ce projet a donc cherché à identifier quelles sont les relations entre les facteurs de risque maternels et l’indice de masse corporelle d’enfants québécois avec surcharge pondérale. Parmi les facteurs de risque étudiés, on note des liens entre le niveau de scolarité de la mère, son statut familial et son niveau d’insécurité alimentaire. Sur le plan cognitif et comportemental, le lien entre l’indice de masse corporelle (IMC) de l’enfant et la perception maternelle du poids de son enfant ainsi que le niveau de restriction alimentaire maternel ont également été analysés. Au total, 47 entrevues ont été complétées par téléphone auprès des mères d’enfants obèses ou en embonpoint grâce à un large questionnaire destiné à décrire le profil des familles consultant les cliniques externes du CHU Ste Justine. Les tests de Fisher pour les variables catégorielles, le test de T de comparaison des moyennes du Z-score de l’IMC des enfants ont permis d’effectuer les analyses statistiques. Les résultats obtenus démontrent qu’un lien existe entre le niveau de scolarité maternel et la présence d’insécurité alimentaire. De même, il a été possible de constater que les enfants avec une mère restrictive des apports alimentaires de leur enfant avaient un Z-score de l’IMC significativement plus élevé. Ces résultats suggèrent qu’il existe des liens entre le profil socio-économique et comportemental de la mère et le surplus de poids de l’enfant. Des tests auprès d’un plus large échantillon seront nécessaires afin de confirmer ces résultats, l’objectif étant, entre autres, de mieux cibler les enfants à risque d’embonpoint ou d’obésité et de mieux outiller les professionnels de la santé en contact avec ces familles. / The etiology of childhood obesity is multifactorial and complex. Both the genetic inheritance and the environment of the child can contribute to overweight. As a result several studies have focused on the link between the family environment and in particular the role of the mother, and the child’s risk of obesity, in order to understand the maternal risk factors specific to each type of population and prevent this public health problem. This project aims to identify the relationships between maternal risk factors and the body mass index of overweight Quebecois children. Among the risk factors studied, relationship were observed among the mother’s level of education, her family status and the level of food insecurity. On the cognitive and behavioral level, we analysed the relation between the child’s body mass index (BMI) and the maternal perception of the child’s weight as well as the maternal level of dietary restriction. Forty seven telephone interviews were completed with mothers of obese or overweight children with a large questionnaire aimed to describe the profile of the family during their visit to Sainte Justine Hospital outpatient clinic. The tests of Fisher for category-specific variables and the T test for the comparison of the averages of children’s BMI Z-score were used to perform the statistical analyses. The results show that there is a significant correlation between the mother’s level of education and the presence of food insecurity in families of overweight children. Concerning the cognitive aspect, children whose mother restricted their food consumption had obtained a significantly higher BMI Z-score than those whose mother did not restrict food. These results suggest that there are links between the socioeconomic and behavioural profil of the mother and the child’s body mass index. Tests taken over a larger sample will be necessary in order to confirm those results. The objective, among other things, is to better target children with risks regarding stoutness or obesity and to improve tools for health professionals that are in contact with those families.

Nell'ambito dell'economia dei disastri naturali ho elaborato uno studio macroeconomico e due microeconomici. A livello macro ho elaborato una meta-analisi della letteratura empirica sugli effetti dei disastri naturali in termini di costi diretti e indiretti. Ho analizzato gli effetti di caratteristiche del database,tecniche di stima, fattori di resilienza considerati e publication bias. Studi sui costi diretti che includono paesi Africani hanno 65% maggiore probabilità di riportare un risultato negativo e significativo mentre studi sui costi indiretti sembrano soffrire di publication bias. I lavori microeconometrici si focalizzano su due paesi africani. Nel primo analizzo gli effetti di un aumento della variabilità climatica sul consumo di beni alimentari delle famiglie in Uganda nel periodo 2005/06-2009/10. In media un incremento di 1% delle temperature porterebbe a una diminuzione del consumo di alimenti del 3-5% mentre le famiglie sarebbero in grado di contrastare variazioni delle precipitazioni con varie strategie. Nel secondo, con approccio multi-shock analizzo gli effetti di siccità e incremento dei prezzi di acquisto sullo stato nutrizionale di bambini in famiglie residenti in zone rurali del Senegal nel periodo 2009-2011. Singolarmente entrambi gli eventi sembrano avere effetti negativi sul livello nutrizionale. Tuttavia la concomitanza dei due eventi sembra non avere effetto sul peso dei bambini grazie a un positivo effetto reddito. / In this work I deal with the economics of natural disasters conducting one study at the macroeconomic level and two studies at the microeconomic level. In the first I conduct a meta-analysis of the macro literature on the direct and indirect costs of natural disasters. I investigate the effects of empirical design, estimation technique, resilience factors included and publication bias. I find that direct costs studies have 65% probability to report negative and significant results if they include African countries while indirect costs studies show publication bias. Second, I conduct a microeconometric analysis of the effects of weather variability on households food consumption in Uganda in the period 2005/06-2009/10. I show that on average 1% increase in maximum temperatures would reduce food consumption by 4-5% while precipitation amount and distribution would not affect household food consumption thanks to coping strategies. Finally I consider the effects of droughts and increasing purchasing prices on weight-for-age of children in rural households in Senegal using a multishock approach and a unique dataset (2009-2011). Results of drought(increase in prices) econometric analyis show deterioration in child weight-for-age. However, concomitance of drought and increasing prices would leave child weight-for-age unaffected thanks to positive income effects.