INTRODUCTION: Studies have shown that school-based childhood obesity programs can be effective, however, little is known about the effects of policy and environmental changes on student health outcomes. This study assessed the policy, environmental, and BMI percentile changes of 32 Georgia elementary schools participating in HealthMPowers programming. METHODS: This thesis used multilevel analysis to examine the changes to policy and environmental indicators within school participating in HealthMPowers and the extent to which these indicators predict BMI percentile change of 5th grade students. This research evaluated seven key indicators related to policy and environmental changes within 32 schools and the BMI percentile changes of 3458 students over the 2011-2012 academic year. Multilevel regression models were used to estimate the effects of school policy and environmental changes on mean BMI percentiles. RESULTS: Only 12 schools experienced a decrease in mean BMI percentiles from baseline to post-test, whereas 17 schools experienced increases in mean BMI percentiles. Students who were at or above the 85th percentile did not change significantly from baseline to post-test. For physical activity, schools that reported positive or no change in this indicator reported statistically significant increases in mean BMI percentiles from baseline to post-test. Schools that increased their CITT scores for physical education, school health team, assessment, and environment and policy indicators experienced, on average, a non-statistically significant increase in mean BMI percentiles from baseline to post-test. Schools that increased their CITT scores for improvement plan and communication experienced, on average, a non-statistically significant decrease in mean BMI percentiles from baseline to post-test. Schools that reported no change to their CITT scores for physical education, assessment, and environment and policy indicators experienced, on average, a non-statistically significant increase in mean BMI percentiles from baseline to post-test. Schools that reported no change for CITT scores for the school health team, improvement plan, and communication indicators experienced, on average, a non-statistically significant decrease in mean BMI percentiles from baseline to post-test. Lastly, when the school health team, assessment, improvement plan, and communication indicators were combined, schools who reported positive or no changes experienced, on average, a non-statistically significant increase in mean BMI percentiles from baseline to post-test. CONCLUSION: The findings of this study were inconclusive but do shed light on the importance of understanding system level policy and environmental change on individual level health outcomes. Additional research should be conducted to explore this relationship as well as evaluation of the Continuous Improvement Tracking Tool that HealthMPowers uses to help schools better capture the current state of their programs, policies, and environment in regards to student and staff health.

Childhood obesity is a major public health issue. Canada has one of the highest childhood obesity rates in the world. Food advertising and marketing have contributed to the rapid rise in childhood obesity. High energy and low nutrient foods have been promoted directly to children through attractive imagery on packages, including the use of popular cartoon characters. Children’s food packaging also features a range of nutrition information targeted at parents, including nutrition claims; however, there is relatively little research on the impact of these nutrition claims and the extent to which they may interact with child-friendly imagery to influence parents’ perception of food quality. The current study used a 2 x 2 experimental design to examine the effect of four front-of-package (FOP) nutrition information and four cartoon characters on parental perceptions of children’s food products. Participants consisted of 897 parents recruited across Canada through GMI, a market research company. Participants were over 18, had at least one child between ages 4-10 and the primary shopper of their household. Participants completed an online survey in July 2011. Participants were shown images of food products with or without cartoon characters and with or without FOP nutrition information and were asked to rate the food product on appeal, nutritional quality, intention to buy and willingness to pay. Participants were also asked to rate the FOP nutrition information on believability, ease of understanding and perceived effectiveness. Linear mixed modelling examined the influence of cartoon characters, FOP nutrition information and socio-demographic factors on these outcomes. Results indicated that cartoon characters increased product appeal and FOP nutrition information increased the perceived nutritional quality of food products with low nutritional value. No significant differences were observed for intention to buy or willingness to pay. There was no consistent pattern between socio-demographic factors and product rating outcomes. For FOP nutrition information ratings, Health Check and Source of Fibre were rated more believable, easier to understand and more effective overall than Sensible Solution and Given the Thumbs Up by Kids. Overall, the findings indicate that cartoon characters can increase the perceived appeal and FOP nutrition information can increase the perceived nutritional quality of food products with low nutritional value.

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The rates of childhood obesity remain high in spite of the enormous efforts dedicated to tackling the disease. This dissertation investigates the effect of two of its causes, including parental time and children's obesity risk behaviors. Trends in these causes have changed over time and might explain changes in obesity. The two factors are analyzed separately given the differences in impact process and concentration of literature. The data for the investigation is drawn from the Parental Time, Role Strains, Coping, and Children's Diet and Nutrition project. In examining parental time, the attention is directed towards the mother's actual time spent with the child which has been associated with reduction in child weight status. The major aim is to test and correct for the problem of endogeneity stemming from unobserved health factors that can distort any meaningful causal impact of maternal time on child weight status. Using the household production theory, parental time allocation decisions towards child health are modeled and analyzed using instrument variable (IV) methods. Results indicate that the effect of mother's time allocation reduces child weight status. Her decision to allocate time to the child is affected by unseen factors. Father's work to family spillover was found to be a valid instrument for mother's time with the child. Results were robust across different estimators. In analyzing the relationship between childhood obesity risk behaviors and weight status, this study focuses on three child practices including breakfast intake, fast food consumption and sleep patterns. The main aim was to score their joint impact, while at the same time accounting for contextual factors. This work adopted the ecological systems framework which accommodates multiple factors. Based on this theory, a simultaneous system of equations considering child weight status, risk behavior and contextual factors was set up and analyzed using 3SLS. Findings indicated that dietary behaviors remain a major factor in affecting weight status. In addition, feedback mechanism from child weight status will influence the diet pattern adopted by the child. Sleep sufficiency had no effect on child weight status.

This study examined the interrelationships between adolescent weight and several other variables thought to impact weight and obesity: physical activity, depressive symptoms, binge-eating symptoms, dieting, socio-economic status, special education status, gender, and ethnicity. The sample consisted of 251 high school students in rural Florida who completed measures of depression, binge-eating, dieting, and physical activity. Measurement instruments included the Reynolds Adolescent Depression Scale-2nd Edition (RADS-2), the bulimia scale of the Eating Disorder Inventory-2 (EDI-2), the dieting scale of the Dutch Eating Behavior Questionnaire (DEBQ), and a physical activity questionnaire derived from the Youth Risk Behavior Scale for Students (YRBSS). The study utilized path analysis, a group correlational design, to determine whether the proposed path model fit the data. Obese and non-obese students also were compared with regard to a) the levels of binge-eating symptoms, and b) the relationship between binge-eating and depression. Path analysis results were not statistically or clinically significant, suggesting a poor fit of the model to the data. Results indicated 19% of participants were obese and 20% were overweight. More than three times as many obese students than non-obese students reported experiencing a binge-eating experience at some time in the past. However, on the bulimia scale of the EDI-2, obese and non-obese participants did not differ statistically in their responses. Statistically but not clinically significant correlations were revealed between depression and binge-eating for the sample and also for non-obese students. For the sub-sample of 13 students who had both binged and dieted, 7 had binged first, 3 had dieted first, and 3 binged and dieted for the first time at the same age. Future research should continue to investigate the relationships of the variables related to obesity. Future directions might include a larger sampl e size and a modified sample selection process. Action research should continue in the areas of obesity prevention and intervention, and student services personnel should promote healthy lifestyle choices and a recognition of obesity as a socio-cultural problem.

This dissertation examines methods used to evaluate the cost-effectiveness of childhood obesity interventions in order to help decision-makers prioritize among competing health programs using standardized outcomes. Chapter 1 generates inputs for use in cost-effectiveness analyses (CEAs) of childhood obesity interventions. In Chapter 1.1, I use data from the Medical Expenditure Panel Survey to predict expenditures associated with obesity in childhood and adolescence. I found that obese children and adolescents have significantly different expenditures than their normal weight counterparts. I conclude that exclusion of obesity-related medical expenditures can potentially undervalue the cost-effectiveness of interventions. In Chapter 1.2, I use data from the Study of Early Child Care and Youth Development to examine the longitudinal trajectory of child weight. I derived probabilities of transitioning between weight classes that can be used in a decision-analytic model to extrapolate the effectiveness of childhood obesity interventions beyond childhood. I found that deviating from CDC BMI reference categories can more accurately capture the risk of future obesity. In Chapter 2, I evaluate the cost-effectiveness of a primary care-based obesity prevention program, High Five for Kids. Over two years, High Five for Kids was low-cost, but only marginally effective in reducing BMI. I used a decision analytic simulation model to extrapolate trial outcomes over a 10-year horizon, and found that in the long-term, primary care based obesity prevention was likely to be cost-effective relative to usual care. I also found that key methodological considerations can meaningfully influence the cost-effectiveness of childhood obesity interventions. In Chapter 3, I develop an agent-based model to explore the dynamics of the potential spread of obesity within families. I found that the “contagion” of obesity could result in significant collateral weight loss in family members not targeted in an intervention. As a result, CEAs may underestimate the benefits of obesity interventions. Moreover, I found that unless interventions are targeted toward all obese children in a family, the contagion of obesity can hinder weight loss in intervention targets. This model can be leveraged as a tool to optimize family-based obesity intervention strategies and inform randomized controlled obesity prevention trials.

Osteoporosis is a major public health concern with origins in childhood and is potentially linked to childhood obesity. This study used novel approaches in bone imaging to characterize skeletal development in girls and to assess the influence of whole body and regional soft tissue composition on bone material, structural and geometric properties, the primary determinants of bone strength, controlling for important covariates such as maturation, diet and physical activity. Prospective analyses were conducted to assess associations between measures of total body fat (TBFM) and android fat masses (AFM) and skeletal muscle fat (SMF) content on bone mineral content, density and strength. The results showed that higher TBFM and AFM were inversely associated with changes in cortical bone sites of the femur and tibia. These findings suggest that gains in abdominal adiposity during the pre- and early- pubertal years may contribute to suboptimal bone development and skeletal fragility later in life. The analyses also showed inverse associations between baseline muscle density of the thigh and calf with 2-year changes in bone strength and bone density of the metaphyseal and diaphyseal sites of the femur and tibia. This paradoxical relationship between SMF and bone outcomes was explained by subsequent analyses showing that girls exhibiting larger gains in muscle density experienced larger increases in bone density and strength compared to girls who did not significantly increase muscle density. These findings suggest that fatty infiltration of skeletal muscle contributes to suboptimal bone development in peri-pubertal girls. Further longitudinal analyses were conducted to examine the individual effects of the muscle-bone unit components on 2-year changes in bone strength. These results showed that muscle size contributed to gains in bone strength, independent of its mechanostat effect on BMC. These results underscore the importance of muscle size for promoting bone development and bone strength during growth. A final set of analyses were conducted to examine the effects of dietary fatty acids on bone development. The results of these analyses suggest that while decreasing intakes of AA n-6 FA may benefit bone health, higher intakes n-3 FAs may benefit tibia bone density development in young girls.

Our nation’s youth face health challenges today that are drastically different from the health problems of youth in generations past. The drastic rise in childhood obesity rates prompted the 108th Congress to look for an innovative solution to the problem, mandating that each school district receiving federal funding for Free and Reduced Lunch must create and adopt a local wellness policy. This study examines whether relationships exist between Georgia’s school districts’ wellness policies and specific demographic characteristics of the district. Dependent variables include compliance, phase of implementation, and presence of a school health council. This study conducted univariate analysis using chi square and odds ratio coupled with binary logistic regression. Analysis shows that percent of minority students, as an independent variable, is significantly associated with compliance with the Child Nutrition and WIC Reauthorization Act.

Bakgrund: Fetma är en folkhälsosjukdom som drabbar många barn. Barn som är överviktiga och feta förblir det också vanligtvis som vuxna. Fetma kan ge följdkomplikationer som diabetes, och hjärt- och kärlsjukdomar. Det gör att ansträngningar bör vidtas för att motverka barnfetman.  Skolor anses vara ett bra forum för att upptäcka och hjälpa barn med, eller med risk för, fetma. Syfte: Syftet med den här studien är att beskriva interventioner som gett positiva resultat vad gäller viktreducering och livsstilsförändring i samband med barnfetma. Studien har begränsats till att studera artiklar som rör barn i åldrarna 2-16 år. Metod: Studien är en litteraturstudie där tio vetenskapliga artiklar valdes ut för att analyseras och som sedan generade i ett resultat som presenterar interventionernas effekt mot barnfetma. Resultat: Interventioner som genomfördes i skolor tillsammans med elever och lärare och interventioner som involverade barn och föräldrar visade alla på signifikanta minskningar i BMI eller i ökad kunskap om nutrition och motion. Slutsats: Skolor bör bli bättre på att använda skolgårdar för fysisk aktivitet och lärare bör utbildas för att kunna ge barnen tillräckligt med kunskap för att göra bra livsval. Föräldrar bör iaktta sitt eget beteende till mat och fysisk aktivitet eftersom det leder till en minskad risk för att barnen drabbas av övervikt och fetma. / Background: Obesity is a public health disease that affects many children. Children who are overweight and obese, is usually also as adults. Obesity can cause complications such as diabetes and cardiovascular disease. Efforts towards that prevalence will increase must be done. Schools are considered a good forum to identify and help children with, or at risk for, obesity. Objective: Identify interventions and studies of interest to prevent childhood obesity, for children aged 2-16 years, with positive results in weight reduction or other lifestyle changes. Methods: The study is a literature review where ten scientific papers were selected to be analyzed and then generated in a result that presents the interventions' effect against childhood obesity. Results: Interventions were made in schools together with students and teachers, and interventions involving children and parents, they showed all the significant reductions in BMI or increased knowledge about nutrition and exercise. Conclusions: Schools should be better to use the schools playgrounds for physical activity and authority of the teachers to provide children with enough knowledge to make good healthy choices. Parents should observe their own behavior to food and physical activity for children to have a reduced risk of becoming overweight or obese.

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