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.

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.